[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                  DEPARTMENTS OF LABOR, HEALTH AND HUMAN
                SERVICES, EDUCATION, AND RELATED AGENCIES
                         APPROPRIATIONS FOR 2024

_______________________________________________________________________


                                 HEARINGS

                                 BEFORE A

                           SUBCOMMITTEE OF THE

                       COMMITTEE ON APPROPRIATIONS

                         HOUSE OF REPRESENTATIVES

                     ONE HUNDRED EIGHTEENTH CONGRESS

                              FIRST SESSION
                              _____________

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

                  ROBERT B. ADERHOLT, Alabama, Chairman

  MICHAEL K. SIMPSON, Idado	     ROSA L. DeLAURO, Connecticut
  ANDY HARRIS, Maryland		     STENY H. HOYER, Maryland
  CHARLES J. ``CHUCK'' FLEISCHMANN,  BARBARA LEE, California
   Tennessee			     MARK POCAN, Wisconsin
  JOHN R. MOOLENAAR, Michigan	     LOIS FRANKEL, Florida
  JULIA LETLOW, Louisiana	     BONNIE WATSON COLEMAN, New Jersey
  ANDREW S. CLYDE, Georgia	     JOSH HARDER, California
  JAKE LaTURNER, KANSAS
  JAKE ELLZEY, Texas
  JUAN CISCOMANI, Arizona


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

                 Susan Ross, Kathryn Salmon, Emily Goff,
            James Redstone, Laura Stagno, and Jonathan Norris
                            Subcommittee Staff

                              _____________
                              
                                  PART 1

                                                                   Page
  Members' Day..........................
                                  ------                                
                                                                      1
                                        
  Testimony of Interested Individuals 
and Organizations.......................
                                  ------                                
                                                                      9
                                        
  Department of Health and Social 
Services................................
                                  ------                                
                                                                    147
                                        
  Addressing the Challenges of Rural 
America.................................
                                  ------                                
                                                                    287
                                        
  United States Department of Education.
                                  ------                                
                                                                    399
                                        
  Centers for Disease Control and 
Prevention, Administration for Strategic 
Preparedness and Response, and National 
Institutes of Health....................
                                  ------                                
                                                                    475
                                        
  Provider Relief Fund and Healthcare 
Workforce Shortages.....................
                                  ------                                
                                                                    553
                                        
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
                                   
                              _____________

          Printed for the use of the Committee on Appropriations

                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
53-710 PDF               WASHINGTON : 2023   



                      COMMITTEE ON APPROPRIATIONS

                                ----------                              
                     KAY GRANGER, Texas, Chairwoman


  HAROLD ROGERS, Kentucky	     ROSA L. DeLAURO, Connecticut
  ROBERT B. ADERHOLT, Alabama	     STENY H. HOYER, Maryland
  MICHAEL K. SIMPSON, Idaho	     MARCY KAPTUR, Ohio
  JOHN R. CARTER, Texas		     SANFORD D. BISHOP, Jr., Georgia
  KEN CALVERT, California	     BARBARA LEE, California
  TOM COLE, Oklahoma		     BETTY McCOLLUM, Minnesota
  MARIO DIAZ-BALART, Florida	     C. A. DUTCH RUPPERSBERGER, 
  STEVE WOMACK, Arkansas	     Maryland
  CHARLES J. ``CHUCK'' FLEISCHMANN,  DEBBIE WASSERMAN SCHULTZ, Florida
  Tennessee			     HENRY CUELLAR, Texas
  DAVID P. JOYCE, Ohio		     CHELLIE PINGREE, Maine
  ANDY HARRIS, Maryland		     MIKE QUIGLEY, Illinois
  MARK E. AMODEI, Nevada	     DEREK KILMER, Washington
  CHRIS STEWART, Utah		     MATT CARTWRIGHT, Pennsylvania
  DAVID G. VALADAO, California	     GRACE MENG, New York
  DAN NEWHOUSE, Washington	     MARK POCAN, Wisconsin
  JOHN R. MOOLENAAR, Michigan	     PETE AGUILAR, California
  JOHN H. RUTHERFORD, Florida	     LOIS FRANKEL, Florida
  BEN CLINE, Virginia		     BONNIE WATSON COLEMAN, New Jersey
  GUY RESCHENTHALER, Pennsylvania    NORMA J. TORRES, California
  MIKE GARCIA, California	     ED CASE, Hawaii
  ASHLEY HINSON, Iowa		     ADRIANO ESPAILLAT, New York
  TONY GONZALES, Texas		     JOSH HARDER, California
  JULIA LETLOW, Louisiana	     JENNIFER WEXTON, Virginia
  MICHAEL CLOUD, Texas		     DAVID J. TRONE, Maryland
  MICHAEL GUEST, Mississippi	     LAUREN UNDERWOOD, Illinois
  RYAN K. ZINKE, Montana	     SUSIE LEE, Nevada
  ANDREW S. CLYDE, Georgia	     JOSEPH D. MORELLE, New York
  JAKE LaTURNER, Kansas
  JERRY L. CARL, Alabama
  STEPHANIE I. BICE, Oklahoma
  C. SCOTT FRANKLIN, Florida
  JAKE ELLZEY, Texas
  JUAN CISCOMANI, Arizona

              Anne Marie Chotvacs, Clerk and Staff Director

                                   (ii)

 
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED 
                    AGENCIES APPROPRIATIONS FOR 2024

                              ----------                              

                                          Wednesday, March 8, 2023.

                              MEMBERS' DAY

    Mr. Aderholt. Well, good morning, welcome. It is my 
pleasure to welcome everybody to the Subcommittee on Labor, 
Health and Human Services, and Education for our Members Day, 
and we are looking forward to taking testimony from Members of 
Congress this morning.
    This is an opportunity for any Member of the House to come 
before the panel and draw our attention to any particular 
issues of importance in both their district as well as across 
the Nation. And I look forward to hearing from our colleagues 
as they talk about some of the challenges they see and how this 
subcommittee can help address some of those challenges.
    Before we begin, I would like to turn to the ranking member 
and the former chair of this committee for any remarks that she 
may have, so, Ranking Member DeLauro, you have the mic.
    Ms. DeLauro. Thank you. Thank you so much, Mr. Chairman, 
and thanks for hosting Member Day, and congratulations on your 
first hearing as chairman of the subcommittee.
    And I want to welcome Representative Landsman for joining 
us, and thank you for joining us this morning.
    It is important for this subcommittee to gather input from 
Members as we begin the 2024 appropriations process. The 
subcommittee's bill is the largest of all of the nondefense 
appropriations bills.
    In 2023, Labor HHS that we passed and enacted in December, 
we supported middle-class and working families, helped to lift 
up vulnerable Americans, prepare the Nation for future crises.
    The achievements were possible with and because of the 
input--input of our colleagues provided throughout the process, 
including through Community Project Funding Requests.
    Because of the positive impact of the projects, these 
continue to have in our communities, and I would just say--the 
chairman has heard me say this before--I am saddened that the 
majority has chosen to exclude Labor-H from the process going 
forward.
    I think we should be really building on where we have gone 
in the last couple of years, and we ought to not decrease 
availability of resources that have benefited our communities.
    I also want to mention a worry that I have about a reported 
proposal by my colleagues on the other side of the aisle to cap 
the 2024 discretionary spending at the 2022 level. The cuts 
would be detrimental to the American people, to our economy, 
and essential government functions that our constituents rely 
on.
    But as we begin the 2024 appropriations process, we look 
forward to receiving the President's budget request. It really 
is critical that we work together to not lose ground on the 
progress we made in recent years.
    As we begin to draft the bill, it is important to continue 
to hear from our colleagues about their constituents' 
priorities, their priorities, as we put the bill together, 
because it is that input that really creates the bills at the 
end of the process. So thanks very much, and I yield back, Mr. 
Chairman.
    Mr. Aderholt. Thank you, and we will go ahead and get 
started. I would like to recognize our first witness who is 
Representative Landsman, and we welcome you and look forward to 
your testimony.
                              ----------                              

                                          Wednesday, March 8, 2023.

                                WITNESS

HON. GREG LANDSMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OHIO
    Mr. Landsman. Well, thank you, Mr. Chair and Ranking 
Member, I appreciate this opportunity to all the members of the 
subcommittee. I am a former teacher. My parents were teachers. 
I did child education advocacy most of my career and helped 
pass an effort in Cincinnati called the Preschool Promise, 
which provides 2 years of quality preschool for 3- and 4-year-
olds.
    And it is made a huge difference in terms of the number of 
our children that are showing up prepared, and who ultimately 
are reading successfully at end of third grade. These are 
children that will ultimately go on to graduate and do good 
things.
    So I wanted to provide some testimony on the way in which I 
think this Congress should approach investing in education, and 
that is, to shift the way we think about it to brain 
development. And so that our investments don't look like they 
do now, which really follow the K-12, to some extent, higher ed 
cycle.
    The vast majority of our spending begins when 90 percent of 
brain development has occurred. So we invest in kids when they 
get to kindergarten significantly--some would argue, including 
myself, that we should do more--and we don't do as much in 
those early years when the vast majority of brain development 
is occurring.
    And so, my argument is to shift that, and my testimony is 
just that, that we ought to start thinking about our 
investments in education the way in which brain development 
occurs.
    So that would mean that we would invest significantly in 
prenatal care, that every expecting mother, because the vast--
you know, a good chunk of brain development happens prenatally, 
that every single mother has access to high quality prenatal 
care, that they get it, that when they come home, they come 
home to a stable, safe house.
    So we are investing in housing stability, paid family 
leave, so that connection between the parent and the child is 
made. That helps with brain development, that we invest in high 
quality childcare, that helps with brain development, and 
preschool. All of that helps in brain development.
    If we make that shift where the vast majority of our 
spending on children is happening as brain development is 
occurring, we will see incredible results for children, for our 
schools. They will show up prepared. They will be doing better 
reading, as it relates to math.
    Across the board, our schools will get better. We will 
graduate way, way more students, and they will go on to do 
great things in college, career training, and be huge parts of 
our economy.
    And so that is what I hope to compel us to do, is to think 
about education differently and to invest in education as it 
relates to brain development and follow that trajectory which 
would have us investing significantly in prenatal care, 
childcare, housing, preschool, et cetera.
    And with that, I yield back, and thank you again for the 
opportunity.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Yeah, I had a quick question. You mentioned 
being an educator, as your parents were. Were you an early 
childhood educator or?
    Mr. Landsman. No, sir. Thank you for asking. Career was 
sort of two parts. One was, I was a classroom teacher in high 
school, but then was--I led an education advocacy group called 
the Strive Partnership, which is now a national group that 
looks at data and then uses data to say, Okay, what works, how 
do we best invest in children? And that got me very involved, 
for the better part of a decade, in early childhood.
    In these first 5 years when 90 percent of brain development 
occurs in these early years, kids who have everything they need 
in those early years, they show up to kindergarten--and most 
States have an assessment--they do great on that assessment.
    They know their numbers, they know their shapes, they 
behave the way you are supposed to behave in a classroom, and 
so they learn and they do great. Kids who don't show up because 
they didn't have any of those things, they struggle, and very 
few of them ever get back on track.
    Mr. Aderholt. Okay. Ranking Member.
    Ms. DeLauro. I would just say that I think there are enough 
studies and so much data that reflect what you have been 
saying, is that it is critical. Those early years is when kids 
are--they are absorbing. They are like little sponges.
    Mr. Landsman. Yes.
    Ms. DeLauro. They take all this information. And we can't 
afford to lose that time because you never get it back. It has 
its impact really on the future and on their future. So the 
investments in early childhood education, and as I say, we 
don't need any more studies, to be quite honest with you. We 
have enough data on early childhood, and the advantages of 
early childhood education for kids and how positive it is.
    So I encourage you to continue down this road. It is very 
critically important, and, you know, we have started to try to 
address that issue, and we need to continue to build on it. So 
thanks very, very much for being here.
    Mr. Landsman. Thank you very much.
    Mr. Aderholt. Yeah, thank you. Let me see if any of our 
other members have any questions or comments.
    Okay. Well, thank you, Mr. Landsman, for being here and for 
your testimony, and we look forward to working with you.
    Mr. Landsman. Thank you. Thank you for doing this.
    Mr. Aderholt. All right. Thank you.
    Mr. Landsman. I think it is a wonderful thing. Thank you.
    Mr. Aderholt. All right. Well, I don't think we have 
anybody on the list right now. We did have another member that 
was going to speak but was under the weather and was not able 
to be here.
    But we will take written testimony for anybody who wants to 
submit that to the committee, and so--do you have anything you 
want to say before we adjourn?
    Ms. DeLauro. No. I think that this is, you know, being able 
to deal with written testimony would be great.
    Mr. Aderholt. Yeah. Well, we will do that because I know 
this is a Wednesday that is a very busy day for members and 
multiple hearings going on. So I know it is sort of crazy, so 
we look forward to getting any written testimony that may want 
to be submitted.
    So with that, we are adjourned.

                                          Thursday, March 23, 2023.

         TESTIMONY OF INTERESTED INDIVIDUALS AND ORGANIZATIONS

                              ----------                              


                      COLLEGE OF SOUTHERN MARYLAND

                                WITNESS

YOLANDA WILSON, PH.D., PRESIDENT, COLLEGE OF SOUTHERN MARYLAND
    Mr. Aderholt. Well, good morning, everyone. It is good to 
have everyone here, having a nice roomful of witnesses and 
guests here for our committee on public witnesses today. And of 
course, we are here at the Subcommittee for the Labor, Health 
and Human Services Subcommittee of Appropriations.
    I am Robert Aderholt, honored to be chairing this 
subcommittee. And let me just say from the onset that we will 
probably have members that will be coming in and out during the 
hearing this morning. It is that time of year when all the 
subcommittees are having their hearings, and so they are all 
happening at one time. And so members are shuffling between 
subcommittees to come in and hear. So I know that some will be 
coming and going. So just bear in mind that is part of that 
time of year where we are.
    But this is our public witness day. It is, of course, an 
opportunity for members of the public to come before this panel 
and draw our attention to the issues that you deem important 
and that you want to stress to us. And we welcome that.
    I look forward to hearing from all of our public witnesses 
that will be sharing with us today, as we learn about some of 
the challenges that you face and what this subcommittee can do 
to try to be of assistance.
    Before we would begin, I will just remind everybody that we 
need to adhere to a 5-minute rule this morning, as we do have a 
lot of witnesses that will be coming before us and testifying, 
to make sure that we hear from everyone before we have to 
adjourn or a vote is called.
    For our witnesses, the 5-minute clock will count down on 
the microphone box that is going to be in front of you. You 
will have 1 minute remaining when the yellow light comes on, 
and at that point, start wrapping up your testimony. And then, 
remember, your full testimony will be able to appear in the 
hearing record.
    So before we begin, I would like to turn to my ranking 
member and, of course, former chair for many years of this 
subcommittee for any remarks, Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman, for hosting 
today's public witness hearing.
    And as you pointed out, this really is a highlight of the 
hearing schedule that we are engaged in. And really are so 
important helping us to craft the legislation as we go forward.
    I welcome all of you today, want to express our sincere 
gratitude, appreciation to all of you and to those who sent in 
written testimonies for the record. It is your experiences and 
your testimonies are invaluable to us and to the subcommittee's 
bill.
    It is one of the most important--today's hearing is one of 
the most important things that this subcommittee does. The work 
that we do together to fund the programs and services in this 
bill impacts every single American at every stage of their 
lives.
    In the 2023 Labor, Health, Human Services, and Education 
bill, we passed that in December, but we made critical 
investments in programs and services that our communities rely 
on. We created and we sustained better-paying American jobs by 
strengthening job training, apprenticeship programs, worker 
protection. We increased funding for the National Labor 
Relations Board for the first time since 2010.
    We invested in high-poverty schools, students with 
disabilities, postsecondary education. We supported middle 
class and working families with increased funding for 
childcare, Head Start, preschool grants.
    We strengthened lifesaving biomedical research with 
increased funding for the National Institutes of Health, and we 
bolstered America's public health infrastructure through the 
Centers for Disease Control and Prevention and our State and 
local governments. And we tackled our Nation's most urgent 
health crises, including opioid misuse, mental health, and 
maternal mortality.
    Our achievements of the past few years were possible 
because of the input like advocates like yourselves that you 
provided us throughout the process. So it is critical that we, 
in fact, work together so that we do not lose ground on this 
progress.
    I will intimate to you that I am worried about House 
Republicans' reported proposal to cap the domestic spending for 
the 2024 budget at the 2022 level. The cuts would be 
detrimental to the American people--my view--our economy, 
essential Government functions that our constituents rely on.
    So as we draft the 2024 bill using the President's budget 
request as a starting point and with direct input from 
stakeholders, including all of you, we will continue to fight 
for the programs that transform the lives of Americans all 
across this country, the programs that working and middle class 
families rely on.
    Looking forward to your testimony, and again, thank you so 
much for being here this morning.
    Mr. Chairman, I thank you, and I yield back.
    Mr. Aderholt. Thank you, Ranking Member DeLauro.
    And I would like to now recognize the gentleman from 
Maryland, Mr. Hoyer, for an introduction.
    Mr. Hoyer. Well, thank you very much, Mr. Chairman.
    There we go. Thank you very much, Mr. Chairman, for this 
courtesy, and I am very, very pleased to introduce Dr. Yolanda 
Wilson, a friend of mine who represents the College of Southern 
Maryland as its president. And she is relatively new to our 
college, but not relatively new to community colleges, which, 
as a member of the State Senate in Maryland, I was very pleased 
to have an opportunity back in the '70s to be one of the 
leaders in the community college effort. And I thank her for 
being here.
    Dr. Wilson received, Mr. Chairman, both her bachelor's 
degree and master's degree from the University of Maryland at 
College Park, and she earned a doctorate in education with a 
focus on adult and community college education at North 
Carolina State. She spent 23 years working as a professor and 
senior administrator in community colleges in both North and 
South Carolina.
    Just this year, she started an historic tenure, as I said, 
as president of the College of Southern Maryland. From the 
American Association for Women in Community Colleges to the 
Middle States Commission on Higher Education, a number of 
outside organizations have also sought her expertise. Dr. 
Wilson understands the impact that these schools can have on 
the lives of their students and on communities across the 
country.
    As someone who has long advocated, as I said, for greater 
Federal investment in skills training and workforce development 
as part of my Make It in America agenda, I am eager to hear her 
perspective. And I want to welcome her to this committee.
    Thank you, Mr. Chairman.
    Mr. Aderholt. Please.
    Dr. Wilson. Thank you for the opportunity, for your support 
to reform student aid for community college students 
specifically through Workforce Pell Grants for students in 
short-term programs. We must not overlook the critical role of 
community colleges in today's conversations about college 
affordability, both in helping our students to achieve their 
educational needs, as well as helping our communities thrive.
    As favorably reported by the American Association of 
Community Colleges, President Biden's budget proposal showcases 
a commitment to the Nation's community colleges and their 
millions of students. Particularly significant are the proposed 
funding allocations for the Department of Education and 
Department of Labor that provides resources for community 
college programs.
    Today, I direct your attention to additional funding to 
support much needed increases to the Pell Grant maximum and to 
further expand Workforce Pell Grants for students in short-term 
programs. Let us first consider who are our students. The rich 
diversity of our community college students cannot be neatly 
categorized.
    AACC reports that of the Nation's 10.3 million community 
college students, 4.1 million are considered noncredit or 
workforce development students. And of the students in credit-
bearing programs, 65 percent--or roughly 4 million students--
attend part time.
    Some of our students are considered dual enrolled, 
completing high school requirements while getting a head start 
on their higher education. Many are returning adults, balancing 
full-time employment with raising a family, all while taking 
one or two classes and studying 6 to 10 hours a week. And 
others are the underemployed who are working to gain the 
necessary licensures and credentials to boost their 
employability and stay current in their chosen profession.
    When we say college affordability, we are inclined to think 
of ensuring higher education is accessible and affordable for 
the traditional age full-time student on their path to a 
bachelor's degree. But for the part-time student or the student 
gaining workplace licensures, what does college affordability 
look like for them?
    The conversation about workforce Pell is a game-changer 
because it removes financial burdens for part-time and skilled 
trade students who seek our high-quality, short-term workforce 
development programs.
    In February, during the Association of Community College 
Trustees National Legislative Summit, we heard about efforts at 
the Federal level to expand Pell Grants for workforce 
development students. I have vigorously championed this wider 
net and the implications not only with our Members of Congress 
and our Maryland State delegation, but also with our county 
commissioners.
    During COVID, our county commissioners supported 1,798 
credit students in continuing their education. And of those 
recipients, almost a third have now graduated. When you 
consider that 87 percent of our graduates remain in our region, 
the local economic impact by our students is significant.
    In fact, Emsi calculated the total impact of CSM alumni, 
both credit and noncredit, at $196,000,000 in added income just 
in 2019 alone. That is the equivalent of supporting 2,822 jobs. 
But imagine this impact by extending support to workforce 
development students, enabling employers to more quickly meet 
their workforce and pipeline needs.
    Support of Workforce Pell Grants for students in short-term 
programs is critical. This will establish Pell Grant 
eligibility for shorter-term programs, accompanied by rigorous 
and relevant quality standards. Many students cannot 
participate in these programs because of their cost. Community 
colleges support lowering the threshold for Pell Grant 
eligibility, which would increase access to these programs.
    Our joint efforts to grow our trade programs and noncredit 
certifications are more important today than ever. In Maryland 
alone, our 16 community colleges annually provide customized 
training to more than 1,000 Maryland businesses and 
organizations, upgrading the skills of close to 100,000 
employees.
    In summary, you have it in your power to ensure all 
students have accessible, affordable education. On behalf of 
community college students everywhere, I ask your support for 
expanding Workforce Pell. With this, all community college 
students are better situated to be successful, and in turn, our 
families and our communities grow stronger.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Hoyer. Wow. [Laughter.]
    One second to go.
    Mr. Aderholt. Yes, impressive.
    Mr. Hoyer. I will tell you what. How about that?
    Mr. Aderholt. Thank you for your testimony.
    And like I said, anything else you would like to submit for 
the record, please feel free to, and we look forward to working 
with you. And thanks for being here today.
    I would like to go on to the next guest that will be 
speaking to us will be Mr. Michael Kutcher with the Cerebral 
Palsy Foundation. And so we would welcome you to the 
subcommittee today and look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

                       CEREBRAL PALSY FOUNDATION


                                WITNESS

MICHAEL KUTCHER, CEREBRAL PALSY AND DISABILITY ADVOCATE, CEREBRAL PALSY 
    FOUNDATION
    Mr. Kutcher. Chairman Aderholt, Ranking Member DeLauro, and 
distinguished members of the committee, thank you for allowing 
me to speak during National Cerebral Palsy Awareness Month on 
behalf of the more than 1 million Americans and 17 million-plus 
people worldwide living with cerebral palsy.
    My name is Michael Kutcher, and I was born with cerebral 
palsy, the most common lifelong physical disability, and the 
obviously more charismatic twin brother of actor Ashton 
Kutcher. [Laughter.]
    Mr. Kutcher. I am here as an advocate for the Cerebral 
Palsy Foundation, and with me is Cynthia Frisina, senior vice 
president of the Cerebral Palsy Foundation, a mother of a 
daughter with CP and the creator of National Cerebral Palsy 
Awareness Day.
    I know you have seen my submitted testimony with facts and 
figures, and I want to emphasize the fact that there is zero 
Federal dedicated cerebral palsy funding, which directly 
affects me and makes me personally feel that I do not matter. 
Even more importantly, I am speaking on behalf of the other 1 
million Americans who live with cerebral palsy and also feel 
that they do not matter either, especially those who do not 
have a voice to speak for themselves.
    Today, we ask Congress to take all steps necessary to 
establish baseline Federal cerebral palsy research investment 
and a national cerebral palsy research initiative. It is 
surprising that so little progress has been made in the 
understanding of CP over the last 45 years since I was born. 
With your leadership, we can invoke change.
    My story, and millions more like it, highlights the current 
reality that even in 2023, there is no consensus of best 
practices for a person with cerebral palsy. High-risk babies 
with brain injuries, and often, cases are shockingly still 
being discharged from the hospital with little more than a 
``wait and see'' attitude. It is tragic that there is not an 
aggressive protocol in place from the minute a brain injury in 
a baby or toddler is suspected. There should be.
    It is also important to point out that the estimated 
lifetime care and medical costs for all Americans with CP born 
in the year 2000 alone will cover--will total over 
$12,500,000,000. Right now, because of lack of research 
funding, there is actually no evidence-based best healthcare 
practices and treatments for CP throughout a life span.
    We can't let this continue to happen to other children and 
adults with CP. And the great thing is, we don't have to. 
Please wipe the image you have of what cerebral palsy is and 
know that change is possible. Outcomes can be improved. 
Lifelong healthcare costs of 10,000 babies born each year with 
CP can be reduced. Quality of life for more than 1 million 
Americans and their families will be better.
    It has been very difficult as an adult with the most common 
lifelong physical disability to understand why there hasn't 
been more Federal research support that would lead to better 
treatments, standards of care, and understanding of cerebral 
palsy across a life span.
    Mr. Chairman, Ranking Member DeLauro, thank you and the 
subcommittee for allowing me to testify today. I hope to see in 
my lifetime more research, treatments, and better quality of 
life for people with cerebral palsy. Your leadership will 
improve more than 1 million American lives.
    Thank you for your support and attention to this urgent 
public health issue. We would be happy to provide any 
additional information and answer any questions.
    Thank you very much.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. DeLauro. Thank you.
    Mr. Aderholt. Thank you very much. We appreciate your 
testimony here today, and thank you for the work that you do. 
And we look forward to how we can work with you and with the 
Cerebral Palsy Foundation.
    And again, we appreciate your testimony, and all the best. 
Thank you.
    [Discussion off the record.]
    Mr. Aderholt. All right. Next I would like to recognize the 
ranking member for introducing our next guest.
    Ms. DeLauro. Well, isn't this a pleasure, Jared? Listen, 
just really a very, very warm welcome.
    If I might say just to the two prior, I want to say thank 
you because we won't have time for questions with everybody. 
But thank you for the courage of speaking up on various issues 
like cerebral palsy and really the plea for what we do for 
community colleges, what we do for Pell, what we do for giving 
people opportunity.
    But it doesn't go unheard. It doesn't go unnoticed about 
what we should do, and thank you for letting us know that there 
is zero research for CP.
    But I want to, as I say, a very, very warm welcome to a 
former staffer. But Jared was on the Appropriations Committee 
and a fount of knowledge on all issues that deal with 
education, et cetera, and it was my honor to be able to work 
with him when he served with us.
    I became chair of the committee in 2019. He joined the 
subcommittee staff. He handled all of the higher education 
portfolio, as well as job training, employment services, those 
efforts under the Department of Labor. And during his time on 
the subcommittee staff, he helped to pass three omnibus 
appropriations bills, five emergency supplementals to respond 
to COVID in 2020, as well as the American Rescue Plan in 2021.
    He moved in 2021 to the Center for American Progress to 
become the Senior Director for Higher Education. And prior to 
his time on Labor-HHS Subcommittee, he served as senior policy 
adviser at the Department of Education. He was the lead higher 
education staffer on the House Committee on Education and 
Workforce.
    Earned a law degree at Temple University, master's from the 
University of Delaware.
    Welcome back, my dear friend. And this is, I think, your 
first time on the other side of the dais. So it is great to see 
you, and you know that you are always welcome in this 
committee.
    Thank you, Jared.
    Mr. Aderholt. Thank you.
    Please, we would love to hear your testimony, and thank you 
again for being here.
                              ----------                              

                                          Thursday, March 23, 2023.

                      CENTER FOR AMERICAN PROGRESS


                                WITNESS

JARED C. BASS, SENIOR DIRECTOR FOR HIGHER EDUCATION, CENTER FOR 
    AMERICAN PROGRESS
    Mr. Bass. Thank you. Mr. Chairman, Ranking Member DeLauro, 
and other members of the subcommittee, it is my pleasure to 
testify before you today about the needs for student aid 
administration funding for the Department of Education.
    And Ranking Member DeLauro, thank you so much for that 
introduction.
    Each year, the Department of Education processes millions 
of Federal financial aid applications, providing families with 
access to billions in Federal financial assistance. These 
crucial Government services provide access to billions in 
Federal financial assistance, and these crucial Government 
services provide educational economic opportunities for 
students throughout the United States, both Democrat and 
Republican alike.
    Through these programs, we train presidents and 
politicians, CEOs and small business owners, scientists and 
engineers, school teachers, medical professionals, and much 
more. Many of us in this room would not be where we are today 
without these services, myself included.
    The student aid administration account is crucial to the 
operation of these services, and when funding for this account 
is limited, so, too, are the services that rely on it. For this 
reason, I ask that the Labor-H Subcommittee consider the 
following.
    First, provide additional resources to support the 
operation of the Federal financial aid programs. Second, change 
how funding is appropriated for the account, including 
dedicated funding for program integrity activities. And third, 
consider using supplemental appropriations or CR anomalies.
    For fiscal year 2024, the Department of Education is 
requesting $2,650,000,000, an increase of nearly $620,000,000 
over fiscal year 2023. The Department needs these additional 
resources to meet pressing demands. After a 3-year student loan 
payment pause, borrowers will be returning to repayment later 
this year. In addition, the Department is on the verge of 
modifying the existing student loan servicing environment in 
meaningful ways.
    Resources are also vital to the implementation of the 
FUTURE Act and the FAFSA Simplification Act, key pieces of 
bipartisan legislation that will fundamentally change the 
operation of the Federal financial aid programs and require 
modernizing legacy systems at the Department.
    While student aid administration fund has been leveled 
before, the Department was not faced with the same set of 
circumstances. If this account does not receive adequate 
funding, the consequences could be dire. Already, the 
Department will miss an October 1 target for the release of the 
FAFSA this year, and it is not clear what other delays might be 
in store.
    To overcome any remaining political obstacles associated 
with this account this year, the committee could include set-
asides for specific functions and operations. For example, 
below the top line, the subcommittee can include funding 
specifically for IT modernization, student loan servicing 
improvements, and other services. Set-asides are used 
throughout the Labor-H bill, and this new change would help the 
Department prioritize how funding within the account should be 
used.
    In addition, the committee should prioritize funding for 
activities that will reduce costs, which is one of the main 
functions of the Office for Federal Student Aid. For example, 
dedicated funding for program integrity activities helps weed 
out fraud, waste, and abuse within Government programs.
    For that reason, Congress provides dedicated funding and a 
cap adjustment for program integrity activities under Social 
Security Administration in the Labor-H bill. This dedicated 
funding will produce net savings of $41,000,000,000 over 10 
years for SSA.
    Given the contractual complexity of FSA's work, it may be 
helpful to consider making advance appropriations for this 
account as well. This way, the Department will have advance 
notice of what resources may be available for the upcoming 
year. Advance funding may also help to overcome political 
challenges associated with this account.
    Lastly, the committee should consider other vehicles for 
funding student aid administration. Even if additional funding 
is provided in fiscal year 2024, those funds may come too late 
and may not help the Department meet pressing demands. 
Therefore, the committee should strongly consider using any 
supplemental appropriations opportunities that may arise this 
year to provide necessary funding for student aid 
administration.
    The committee should also consider including an anomaly for 
student aid administration funding if any continuing 
resolutions arise later this year as well. Anomalies have been 
provided for student aid administration before. For example, 
when mandatory funding for student aid administration was set 
to expire, the Appropriations Committee stepped in to ensure 
that adequate discretionary funding was provided under both 
short-term and full-year continuing resolutions. This critical 
funding ensured that students and their families could still 
apply for and receive Pell Grants, loans, and other forms of 
assistance.
    We are in a defining moment for higher education. And while 
the challenges confronting the Federal student aid programs and 
their administration may seem insurmountable, there is no other 
committee better suited to addressing these challenges than the 
Labor-H Subcommittee. From personal experience, I know that the 
Appropriations Committee will and can ensure that this moment 
defines the American higher education system for the better, 
not the worse.
    I look forward to working with the Appropriations Committee 
to ensure that the integrity of the Federal student aid 
programs is preserved.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Mr. Bass, for your testimony.
    And certainly, we understand the importance of higher 
education and funding. So we want to do what we can. So we look 
forward to working with you.
    Thanks so much.
    Mr. Bass. Thank you.
    Mr. Aderholt. At this time, I would like to recognize our 
member from the great State of Kansas, Mr. LaTurner, for an 
introduction.
    Mr. LaTurner. Thank you, Mr. Chairman. I appreciate it.
    Good morning, Katie. So glad you are here today.
    I am pleased to introduce Katie Hoff. She is an eight-time 
world champion, three-time world record holder, current 
American record holder, and two-time Olympian, competing in 
both Athens and Beijing, where she earned three Olympic medals 
in swimming. She has also twice won the United States Olympic 
Committee honor of Sportsman of the Year.
    Hailed as ``the female Michael Phelps,'' she withstood 
tremendous pressure and emerged after years of hard work with 
valuable lessons learned on what it takes to succeed and power 
through bitter disappointment.
    In 2014, Katie's career took a turn while she was making a 
comeback for the 2016 Rio Olympic games. Katie was diagnosed 
with a pulmonary embolism in her right lung, a diagnosis that 
ended her career. Since then, Katie has dedicated herself to 
advocacy with the National Blood Clot Alliance.
    In addition to her advocacy work, she is a best-selling 
author and an entrepreneur who works with aspiring young 
athletes all over the world.
    Katie, thank you for being here with us this morning, and I 
look forward to your testimony.
    Mr. Aderholt. Welcome, Ms. Anderson, and we look forward to 
your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

                      NATIONAL BLOOD CLOT ALLIANCE


                                WITNESS

KATIE HOFF ANDERSON, OLYMPIC MEDALIST AND PULMONARY EMBOLISM SURVIVOR, 
    NATIONAL BLOOD CLOT ALLIANCE
    Ms. Anderson. Chair Aderholt and Ranking Member DeLauro, 
thank you so much for holding this hearing and for the 
opportunity to ask Congress to provide $5,000,000 in funding to 
the Centers for Disease Control and Prevention to improve 
awareness and education----
    Oh. I will start over.
    Chair Aderholt and Ranking Member DeLauro, thank you for 
holding this hearing and for the opportunity to ask Congress to 
provide $5,000,000 in funding to the Centers for Disease 
Control and Prevention to improve awareness and education among 
the general public and healthcare professionals about life-
threatening blood clots.
    My name is Katie Hoff. I am a two-time Olympian, three-time 
Olympic finalist, eight-time world champion, and pulmonary 
embolism survivor.
    Swimming was my whole life. But I didn't get to end my 
career on my own terms. While training for my comeback for the 
2016 Rio Olympic Games, I began to feel tightness in my chest. 
The tightness progressed to a severe pain in my right rib, 
which felt like a Samurai sword in my ribs. Even laying on my 
back and sleeping was super painful, but I continued to push 
through the pain because my doctors were unable to identify any 
serious medical condition.
    Like many Americans, I had no idea what a pulmonary 
embolism even was. Actually, only about 6 percent of Americans 
know what a blood clot is, and this lack of awareness among 
patients and healthcare providers leads to preventable deaths.
    There are two types of blood clots, pulmonary embolism, or 
PE, and deep vein thrombosis, known as DVT. Every year, 1 
million Americans will develop blood clots, and more than 
100,000 people die from them. Blood clots can affect anyone, 
regardless of age, ethnicity, race, or level of physical 
fitness.
    It took 7 weeks for doctors to diagnose me with a pulmonary 
embolism. During that time, I continued to jump in the pool, 
unaware that I was in a life-or-death situation. I sought help 
from a variety of healthcare professionals, trying out every 
single remedy made available to me. I was desperate for answers 
because this undiagnosed condition affected my ability to race 
and engage in my life's passion and livelihood.
    Looking back, I can now identify some of the early onset 
signs. However, most Americans lack the knowledge to recognize 
these signs and advocate for themselves. In the time that I was 
seeking diagnosis, I felt like I was going crazy. Doctors 
thought I was fine because I was a young, seemingly healthy 
athlete.
    The mental toll of suffering from a blood clot is something 
that has actually continued to affect my life. To this day, I 
experience a trigger response when I get super out of breath, 
and I have an emotional breakdown and start crying. My husband 
also carries the burden of constantly looking for small signs 
that might be an indicator of a new blood clot.
    Even after my diagnosis, I felt isolated because I barely 
knew anyone who had suffered a clot or anyone who had bounced 
back from a clot, something that I was unable to do. I honestly 
felt like a freak.
    Sharing stories and being able to talk to fellow survivors 
is so important to helping people move through the experience 
of having a blood clot. If patients and healthcare providers 
have a better understanding about blood clots, the next person 
like me who suffers from one won't have to suffer alone. Not 
only will patients be able to advocate for themselves, but so 
will their loved ones.
    Raising awareness is key to prevention, diagnosis, and 
treatment. I truly believe that my condition would not have 
been as serious if I and my healthcare providers had the 
knowledge about blood clots to diagnose me earlier.
    In 2017, I joined the National Blood Clot Alliance, a 
patient-led health advocacy organization, as an ambassador, 
hoping that by sharing my story, I could raise awareness about 
the signs, symptoms, and treatment options for blood clots. The 
NBCA works closely with the CDC and receives funding to create 
programs designed to build awareness and educate both the 
public and healthcare providers about the risks of blood clots.
    Despite the significant toll of blood clots on patients and 
the healthcare system--an estimated $10,000,000,000--the 
Federal Government allocates few resources to the issue. It is 
for this reason that I urge Congress to direct CDC to provide 
$5,000,000 in funding to its public health approach to blood 
disorders and to budget and develop a comprehensive nationwide 
blood clot education and awareness campaign for the public and 
support for education and training on the signs and symptoms of 
blood clots for healthcare professionals.
    My life changed overnight when I developed a blood clot, 
and if I had the knowledge that I do now about blood clots, I 
could have spared myself weeks of agony as I chased a 
diagnosis. I appreciate your leadership and commitment to 
prevent deaths due to blood clots by providing dedicated 
funding.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Hoyer. Mr. Chairman.
    Mr. Aderholt. Yes.
    Mr. Hoyer. From now on, I am going to refer to Michael 
Phelps as ``the female Katie Hoff.'' [Laughter.] [Applause.]
    Mr. Aderholt. Okay. Thank you. Well said.
    Thank you for being here, and we appreciate your testimony 
and learning about blood clots. And we look forward to trying 
to work with you and helping make a cure for that.
    So next I would like to recognize Amanda Peel Crowley, and 
she is, of course, a passionate advocate, but also she is 
representing PANDAS.
    And so I am going to let you describe PANDAS a little more 
because it is a mouthful. So we look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

            NATIONAL ALLIANCE FOR PANS/PANDAS ACTION (NAPPA)


                                WITNESS

AMANDA PEEL CROWLEY, FOUNDING MEMBER, NATIONAL ALLIANCE FOR PEDIATRIC 
    ACUTE-ONSET NEUROPSYCHIATRIC SYNDROME AND PEDIATRIC AUTOIMMUNE 
    NEUROPSYCHIATRIC DISORDERS ASSOCIATED WITH STREPTOCOCCUS
    Ms. Crowley. Mr. Chairman, it is an honor to appear before 
the committee today on behalf of NAPPA, the National Alliance 
for PANS/PANDAS Action.
    I am grateful to be able to give a voice here on Capitol 
Hill to families across the country who have had their lives 
turned upside down by these terrible illnesses.
    We are asking you to provide $5,000,000 in your fiscal 2024 
report under the Department of Health and Human Services for 
childhood post-infectious neuroimmune disorders. These include 
PANS and PANDAS, conditions where an infection causes the 
immune system to ``go rogue,'' leading to inflammation and 
life-altering effects on the brain. The time is now to help 
parents like us who have watched helplessly for months, 
sometimes years, as our children lose everything that they once 
loved.
    Imagine for a moment that your happy, playful, 7-year-old 
boy goes to bed one night and wakes up a completely different 
child, terrified to be alone, unable to leave his room, and 
exploding into uncontrollable rages. He writhes in pain on the 
floor, sometimes for hours, and pleads with you to make it 
stop. Normal life becomes a nightmare. Leaving the house is so 
traumatic that he can't attend school or play with friends.
    As you desperately seek help over the next few weeks, the 
pediatrician refers you for a psychiatric evaluation, but the 
medications prescribed only seem to escalate symptoms. 
Agonizing months pass as your child cries and tells you he 
wants to die and attempts to jump off a third-floor balcony.
    Now imagine finding out the cause of this unbearable 
crisis. You meet with a new provider who asks, ``Has he been 
checked for infection?'' After tests are run, you discover that 
these months of devastating symptoms were actually the result 
of strep throat.
    Yes, you heard that correctly. Strep throat and other 
common infections, including flu and now COVID-19, can lead to 
behavioral and neurological symptoms that leave a child 
unrecognizable and destroy families' lives in the process.
    PANS and PANDAS are neuroimmune conditions that develop 
after infection. With the right screening and diagnostic tools, 
they are highly treatable. But sadly, many children and 
adolescents are missed. Undiagnosed and untreated kids can lose 
critical years of learning, and they are especially vulnerable 
to chronic mental illness and disability that can follow them 
into adulthood.
    When young people are diagnosed with PANS or PANDAS, they 
often still face lack of access to care. Families have to 
travel out of State to find providers, pay out of pocket for 
treatment, and find specialized schools for their children. The 
social, emotional, and financial costs to families are 
enormous.
    Dedicated scientists and clinicians are working to find 
novel biomarkers and treatments for PANS and PANDAS, but they 
cannot do this groundbreaking work alone. With funding, 
research can change outcomes for young people, something our 
patient community desperately needs.
    I have heard hundreds of heartbreaking stories from 
families impacted by PANS and PANDAS, of children who 
experience physical symptoms such as debilitating joint pain 
and stomach issues and have even lost the ability to walk. 
Teens with frightening compulsions who pull out every hair on 
their heads.
    Children with such an irrational fear of food that they 
become severely anorexic and have to be placed on feeding 
tubes. Adolescents who are wracked with impulsive feelings and 
thoughts of self-harm, and the unimaginable has happened. They 
have lost their lives.
    I share the next difficult story on behalf of one of 
NAPPA's founding members. Her daughter Louisa thrived 
academically and socially. She was a straight A student who 
aspired to become a doctor. The day that Louisa became ill was 
her last day at school, and she suffered horrific symptoms for 
2 \1/2\ years.
    Louisa's severe illness could have been treated far more 
easily had her original strep infection and OCD symptoms been 
recognized. Tragically, Louisa lost her battle with PANDAS at 
age 13.
    Her parents want young people to have access to early 
diagnosis and treatment. They donated Louisa's brain to a PANS 
and PANDAS research center at Georgetown University, and they 
have fought tirelessly to share the message that training the 
medical community, increasing vital research, and ensuring that 
all young people are routinely screened for PANS and PANDAS 
will save lives.
    My son Will is advocating with me today. We are here to ask 
for your help. Let us show Will how Congress can take action 
and partner with us, work with NIH, and be a force for change 
to finally make progress on PANS and PANDAS research. America's 
youth deserve the best that our healthcare system has to offer, 
not a lifetime of pain and symptom management.
    A funding commitment from Congress will help PANS and 
PANDAS families achieve a dream that we know is in reach--a 
healthy, happy future for all.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you for your testimony and for sharing 
with this subcommittee a little bit about some of the issues 
that this is very devastating.
    And thank you for bringing Will. He is a great advocate. So 
glad you had brought him today for us.
    And so, again, we look forward to working with you and how 
we can be of assistance from this subcommittee. And again, 
thank you for your testimony.
    Next I would like to recognize Mr. Kevin Longino, CEO of 
the National Kidney Foundation.
    Mr. Longino, we look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

                       NATIONAL KIDNEY FOUNDATION


                                WITNESS

KEVIN LONGINO, CHIEF EXECUTIVE OFFICER, NATIONAL KIDNEY FOUNDATION
    Mr. Longino. Thank you, Mr. Chairman. Thank you, 
Congresswoman DeLauro, for allowing us to speak, for me to 
speak.
    My name is Kevin Longino. I am the CEO of the National 
Kidney Foundation. I am also a kidney transplant recipient. I 
am one of the few that has been afforded a kidney transplant, 
given the long waitlist.
    Thank you for the opportunity to testify about the 
incredible burden of kidney disease, chronic kidney disease, 
and the need to shift our Federal approach from one that 
currently pays for kidney disease to the tune of 
$136,000,000,000 a year to one that emphasizes kidney health.
    More than 80 million adult Americans are at risk for kidney 
disease. A lot of the factors are diabetes, hypertension, and 
other risk factors. Approximately 38 million adults have 
chronic kidney disease, also called CKD, and an alarming 90 
percent of these individuals are unaware. They have not even 
been diagnosed.
    Many find out when it has reached more advanced stages. 
Often, in the worst case, they find out in an emergency room, 
and at that point, it is really too late to do an intervention. 
It is too late to slow progression. It is too late to 
oftentimes save the kidneys, and it is too late to even save 
their lives in many cases.
    And the costs of kidney disease are astronomical, as I just 
noted. One in four Medicare dollars are spent on individuals 
with chronic kidney disease, a condition that usually presents 
with an avalanche of comorbidities--diabetes, hypertension, and 
the big one, cardiovascular disease.
    You may be surprised to learn that 40 percent of patients 
with Stage 3 CKD die of cardiovascular disease before they ever 
get a chance to progress to kidney failure. And so for the 
lucky few that live long enough to experience kidney failure, 
dialysis is even more expensive. Patients with ESRD make up 
only 1 percent of Medicare beneficiaries, but they account for 
more than 6 percent of Medicare cost.
    This amounts to over $51,000,000,000 annually. I will say 
that again. One percent of Medicare beneficiaries account for 
more than 6 percent of Medicare costs, and this is 
$51,000,000,000 annually. And what is equally alarming is that 
acknowledging that 60 percent of kidney failure is preventable.
    So from a patient and a taxpayer perspective, what really 
makes these costs so tough to stomach is that we invest pennies 
in kidney-related research and prevention activities. We spend 
approximately $80,000 per year per patient with kidney failure, 
and we spend $26,000 per year treating people with CKD. But we 
only spend $19 per year on prevention, on research, and 
innovation.
    Moreover, investment in kidney research at NIH has lagged 
behind that of other institutes. While NIH overall has received 
averages totaling 4.6 percent per year, funding for kidney 
disease has lagged at 3.3 percent. So this is bad economics, or 
it is bad business, or it is bad policy, no matter how you look 
at it.
    But I wanted to share with you how things could be 
different if we invested just a bit more in early diagnosis, 
treatment, and management of CKD. In 2019, the National Kidney 
Foundation and CareFirst BlueCross BlueShield partnered on an 
effort to improve CKD diagnosis and treatment in the primary 
care setting. By increasing testing of at-risk patients and 
introducing modest interventions, such as medical nutrition 
therapy or increasing nephrology services, we were able to 
reduce ER visits, hospitalizations, and readmissions.
    The SAVINGS WERE FANTASTIC. We averaged $206 per member per 
month, or $408 per member per month, depending on whether you 
were Stage 3 or Stage 5.
    And thanks to a competitive grant from the CDC, and in 
collaboration with the National Association for Chronic Disease 
Directors, local Federally Qualified Health Centers, and other 
stakeholders, in 2022 NKA was able to further test the theory 
through CKD Intercept. CKD Intercept is our population health 
approach to transform CKD testing, prevention, diagnosis, risk 
stratification, management, and referral to nephrology.
    While this program is still in its early stages, we have 
already increased CKD screening and intervention by almost 30 
percent. So increased investment in these preventive activities 
will allow us to replicate this program in high-risk 
communities across the country.
    So for the cost of treating 50 dialysis patients per year, 
we can instead invest in programs that have proven they can 
slow disease progression and reduce costs in thousands of 
patients. This low-cost investment not only yields high returns 
financially, but improves quality of life for countless 
individuals.
    In closing, I would like to point out that in 2023 is the 
50th year anniversary of the Medicare ESRD benefits. As we 
consider where we want to go over the next 50 years, I would 
urge Congress to invest in a future where 60 percent of kidney 
failure is prevented, where dialysis is necessary only in 
emergency cases, and where every patient that has kidney 
failure can access a transplant or some other advanced therapy.
    To do that, we strongly urge you to preserve and increase 
our investment in kidney-related research at NIH, prevention at 
CDC, and in innovative initiatives like KidneyX.
    Thank you for your thoughtful and responsible consideration 
of this request.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Mr. Longino. We appreciate your 
testimony on behalf of the National Kidney Foundation.
    And again, we look forward to working with you and how we 
can--this subcommittee can work to find solutions and cures for 
kidney disease.
    So thanks so much for being here.
    Mr. Longino. Thank you, sir.
    Mr. Aderholt. Okay. Next our guest will be Mr. Jonathan 
Plucker, Professor of Education at Johns Hopkins University 
School of Education.
    So, Mr. Plucker, we look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

              JOHNS HOPKINS UNIVERSITY SCHOOL OF EDUCATION


                                WITNESS

JONATHAN PLUCKER, PH.D., PROFESSOR OF EDUCATION, JOHNS HOPKINS 
    UNIVERSITY SCHOOL OF EDUCATION
    Dr. Plucker. Thank you, Mr. Chairman, Ranking Member 
DeLauro, and members of the subcommittee. Thank you for 
inviting me to participate in today's hearing, and thank you 
for your attention to a topic that has been the focus of my 
professional career for over 30 years, developing children's 
talents and advanced skills.
    Today, I am specifically speaking to the need to increase 
funding available to the Jacob K. Javits Gifted and Talented 
Students Education Program.
    My name is Jonathan Plucker. I am a professor at Johns 
Hopkins School of Education. I am also immediate past president 
of the National Association for Gifted Children. I would like 
to state for the record that the opinions expressed here are my 
own and do not necessarily reflect the views of the Johns 
Hopkins University and NAGC.
    Academic excellence and talent development have strong 
relationships to economic and cultural growth. Yet ample 
evidence suggests that U.S. students achieve at advanced levels 
at significantly lower rates than students in other countries. 
Regardless of the content area, the percent of students who 
score in the advanced range tends to be below that of students 
in economically competitive countries.
    For example, in one study, there is evidence that our 
highest-performing fourth grade students underperform those in 
South Korea, Japan, England, Taiwan, Australia, and Turkey and 
perform at the same level as students in Russia in math. 
Results are similar for eighth grade math. Science performance 
tends to be better but is middle of the pack among major 
economic powers.
    One reason for this poor performance at advanced levels is 
the presence of large and growing excellence gaps. These gaps 
are differences in advanced performance associated with student 
race, gender, and class. For example, in fourth grade reading, 
only 3 percent of low-income students score advanced compared 
to 14 percent of higher-income students.
    Studies strongly suggest that much of the excellence gap is 
caused by students' lack of opportunity for advanced learning. 
Of special concern are bright students in both cities and small 
towns and also talented students with learning challenges whom 
are often described as being ``twice exceptional.''
    A study reported just last week that students in small 
towns have among the lowest participation rates for advanced 
learning opportunities. When students are provided with these 
opportunities, they thrive. But far too many do not get them.
    There is bipartisan concern about these problems, and 
educators are tackling them across the country. The issue is 
not a lack of desire to improve advanced outcomes for students. 
Rather, the issue is lack of resources and inadequate 
dissemination of strategies for achieving those outcomes.
    The Javits Act remains the Federal Government's primary 
program to promote educational excellence and close excellence 
gaps, and the program has made a clear, demonstrable 
difference. Javits projects have changed the way we train 
teachers to identify talent, created new models for high-
quality curriculum, improved strategies that helped teachers 
meet the wide range of various readiness levels in their 
classrooms, and designed and evaluated new techniques for 
helping twice exceptional students develop their academic 
strengths.
    A number of current projects are exploring the degree to 
which afterschool programs can promote advanced achievement 
across a range of school and community types. Available 
evidence overwhelmingly supports the conclusion that the Javits 
program is fulfilling its original goals, driving innovation in 
an area critical to the Nation's future well-being. The Javits 
Act has had an exceptional return on investment for the 
country's economy, culture, and taxpayers.
    I am grateful for the committee's ongoing support and last 
year's increase in funding. Yet Javits remains underfunded, 
given its importance to the country's economic growth and 
security. Even with the committee's generous increase of 
funding last year, the act only provides less than 30 cents for 
each of the country's 56 million K-12 students. This prevents 
the program from holding competitions for cutting-edge 
demonstration projects on an annual basis or funding a national 
dissemination center.
    Perhaps most importantly, the current size of the program 
prevents consistent funding opportunities for State 
dissemination projects. My colleagues doing cutting-edge work 
in several States, including Alabama, Colorado, and Texas, 
among others, show evidence of considerable innovation. 
Additional Javits support would allow those State Departments 
of Education to significantly increase services for students 
and educators.
    Increasing the funding to $1 per student or $56,000,000 
would provide ample resources for all these activities to 
occur. This investment in our children will pay significant 
dividends for the United States for years to come by increasing 
innovation, economic competitiveness, and cultural resources 
for a generation.
    Thank you for your time.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Professor, for your testimony here 
this morning. And as I have mentioned with our other guests, we 
look forward to working with you and how we, this subcommittee, 
can work with you to try to get some of the funding to try to 
help some of the issues that you have talked about in 
education, especially with the gifted.
    And so, again, we appreciate you being here.
    Dr. Plucker. Thank you, sir.
    Mr. Aderholt. Next I would like to introduce Dr. Brian 
Persing. He is the medical oncologist and hematologist, and he 
is here on behalf of the Association for Clinical Oncology.
    So, Dr. Persing, we appreciate your being here today and 
look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

                   ASSOCIATION FOR CLINICAL ONCOLOGY


                                WITNESS

BRIAN PERSING, M.D., MEDICAL ONCOLOGIST AND HEMATOLOGIST, ASSOCIATION 
    FOR CLINICAL ONCOLOGY
    Dr. Persing. Thank you very much, Chairman Aderholt. And 
thank you to the committee for the opportunity to testify 
before you today.
    My name is Brian Persing, and as a practicing medical 
oncologist and hematologist at the University of South Alabama 
and Mitchell Cancer Institute in Mobile, Alabama, I know 
firsthand the importance of investing in biomedical research.
    I am here representing the Association for Clinical 
Oncology, the world's leading professional organization 
representing nearly 45,000 medical oncology professionals. 
Thank you to each member of this subcommittee for your 
longstanding bipartisan commitment to the support of federally 
funded research at the National Institutes of Health and the 
National Cancer Institute.
    ASCO appreciates this opportunity to provide fiscal year 
2024 funding recommendations that will continue the scientific 
progress our patients depend upon. ASCO is requesting 
$50,924,000,000 for the National Institutes of Health, 
including $9,988,000,000 for the National Cancer Institute. We 
are also requesting at least $1,500,000,000 for the Advanced 
Research Projects Agency for Health, or ARPA-H, supplemental to 
the NIH base budget.
    Finally, ASCO requests $472,400,000 for the Centers for 
Disease Control and Prevention Division of Cancer Prevention 
and Control and $63,400,000 within that division for the Cancer 
Registries Program.
    In 2022, the NIH provided $36,680,000,000 in research 
funding to scientists in all 50 States and the District of 
Columbia, supported more than 568,000 jobs, and generated 
$96,840,000,000 in economic activity. Robust growth in NIH-
supported foundational research across the country is key to 
pushing the boundaries of innovation in both public and private 
sector.
    In July of 2022, the NIH celebrated 10 years since the 
first pediatric patient was treated with CAR T-cell therapy. 
This is groundbreaking therapy that works by training a 
patient's own body to destroy cancer cells. To replicate 
successes like this and to achieve cures, we must ensure the 
NIH has the capacity to support fundamental science across the 
full range of scientific disciplines.
    The cancer death rate fell 33 percent in the last 30 years, 
but it is still, sadly, the second most common cause of death 
in the United States. Over 1.9 million new cases will be 
diagnosed and approximately 609,800 people will die this year 
from cancer.
    The NCI is the largest funder of cancer research in the 
world, but its funding has not kept pace with opportunities for 
cutting-edge research. Today, only one in seven lifesaving 
research grants can be funded. Apart from these missed 
opportunities, we will lose early career investigators who may 
choose other careers if their grant submissions are not funded, 
disrupting the workplace pipeline.
    The Cancer Moonshot investment is paying off, increasing 
our understanding of how tumors behave, enhancing treatment, 
and identifying new approaches to pediatric cancer. We urge 
Congress to sustain the momentum by reauthorizing and funding 
the Cancer Moonshot and its infrastructure. With your support, 
the NCI can achieve its ambitious Moonshot goal of reducing the 
death rate from cancer by 50 percent in 25 years.
    In addition to the work done by the Cancer Moonshot, NIH-
funded translational research and clinical trials have 
significantly improved the standard of care in many diseases. 
As a practicing oncologist, I have seen the impact this has had 
on my patients. A few years ago, the NCI funded a trial 
evaluating cancer genes of women with breast cancer to 
determine whether patients were likely to benefit from 
chemotherapy after surgery. It showed that 60 to 70 percent of 
women were considered low risk and did not require 
chemotherapy.
    One of my patients, a woman in her 40s, had breast cancer 
and previously would have been given chemotherapy based on the 
size of her tumor. But thanks to the trial, we learned we could 
avoid chemotherapy. She was spared significant toxicity and was 
able to continue a busy life caring for her two teenaged 
children. Today, she is cancer free and has completed her 
hormone therapy.
    Over the last 40 years, adult trials conducted by the 
National Clinical Trials Network have extended the lives of 
patients with cancer by an additional 14.2 million life-years. 
That amounts to roughly $326 in Federal investment for each 
life-year added. An increase in the NCI's budget would enable 
the institute to achieve its goal of doubling patient accruals 
to clinical trials by giving patients an opportunity to extend 
their quality of life.
    As a complement to trials, clinicians need accessible data 
to understand cancer at a broader level. The Centers for 
Disease Control and Prevention Cancer Program play a critical 
role in prevention, detection, and treatment of cancers.
    The human and financial cost of advanced disease and about 
50 percent of cancer deaths could be prevented by using 
existing prevention and early detection strategies supported by 
the CDC's Division for Cancer Prevention. ASCO joins the cancer 
community in requesting at least $472,400,000 for the CDC DCPC 
and $63,400,000 for the CDC's Cancer Registry Program.
    We also reiterate our firm belief that the agency's funding 
should be additive for ARPA-H and not come at the expense of 
robust predictable funding for the NIH, NCI, and other existing 
entities.
    Thank you again for your continued support of patients 
living with, surviving, and at risk for cancer through funding 
these Federal agencies and programs. We look forward to working 
with you on a fiscal year 2024 budget that advances and 
accelerates U.S. cancer research and transformative health 
solutions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Dr. Persing. And----
    Mr. Hoyer. Mr. Chairman.
    Mr. Aderholt. Oh, yes, please.
    Mr. Hoyer. I want to make an observation. The payline for 
extramural grants approval is now in the middle teens, as I 
understand. I think you cited 14 percent on the NCI.
    When I was on this committee the first time, Joe Early was 
a congressman from Massachusetts, and he very much focused on 
the payline because experts tell us that at least 3 out of 
every 10 applications are very good science. But we are now 
down in the middle teens, and what you pointed out at the 
beginning, young people who may go into research, as they see 
this payline reducing, believe there is no future in that basic 
research. And if we continue that, we are going to lose to the 
rest of the world, including China.
    So your point, I think, is an extraordinarily important 
one. And Mr. Chairman, we really ought to look at that payline 
because we are leaving a lot of good science on the table.
    A former Governor of my State--famous or infamous, 
depending upon your perspective--Spiro T. Agnew, once said that 
the cost of failure far exceeds the price of progress. That is 
the profound reality of what you are talking about.
    Thank you, Mr. Chairman.
    Mr. Aderholt. Thank you. Ms. DeLauro.
    Ms. DeLauro. Mr. Chairman and Dr. Persing, I just want to 
tell that what we did in the 2022 appropriations bill was an 
overall increase in terms of NCI for $408,000,000, and 
$150,000,000 in terms of an increase in the payline. So you are 
on solid ground with where you are going, and it is an area 
that continues to be of extreme interest.
    And as a cancer survivor, just really can't tell you how 
much your work at the NCI means and allowing those of us who 
have been stricken with this illness to be able to survive.
    So, we are there. Thanks.
    Mr. Aderholt. Thank you. Thank you, Dr. Persing.
    And as a fellow Alabamian, we welcome you to the 
subcommittee. But also I had an opportunity to be on your 
campus a few months ago with your now president Jo Bonner, who 
we served with here, and who is now president of the University 
of South Alabama.
    So we look forward to working with you, and I think 
everyone agrees that, of course, all of these diseases that we 
are hearing about are devastating. But of course, cancer hits 
so many people and so many families. And so we appreciate your 
testimony, and we look forward to working with you, and thanks 
for your testimony.
    Okay. Next we will welcome Ms. Dorothea Staursky, and she 
is with the National Marrow Donor Program, and we look forward 
to your testimony.
    So, welcome.
                                          Thursday, March 23, 2023.

                     NATIONAL MARROW DONOR PROGRAM


                                WITNESS

DOROTHEA STAURSKY, VOLUNTEER AND BONE MARROW DONOR, NATIONAL MARROW 
    DONOR PROGRAM
    Ms. Staursky. Thank you.
    Chairman Aderholt, Ranking Member DeLauro, and committee 
members, my name is Dorothea Staursky of Birmingham, Alabama. 
On behalf of the patients, family members, donors, volunteers, 
and staff of National Marrow Donor Program, or NMDP, I want to 
thank you and the members of the committee for your support of 
the C.W. Bill Young Cell Transplantation Program and 
respectfully request $35,000,000 for the program in fiscal year 
2024.
    For over 35 years, Congress and the program have partnered 
to save lives. By establishing a National Bone Marrow Donor 
Registry in the mid 1980s, Congress promised patients with 
blood cancers like leukemia and lymphoma and over 75 other 
life-threatening diseases that they would have a way to find a 
lifesaving donor match. Thanks to this partnership, the program 
has facilitated over 120,000 transplants between an unrelated 
matched donor and a patient with blood cancer or disorder. This 
funding will not only save lives but will also improve access 
to cell therapies for thousands of underserved patients.
    I am proud and honored to be testifying today as a two-time 
NMDP volunteer bone marrow donor. I joined the registry because 
I saw a social media post about a young Greek-American child 
who needed a bone marrow transplant to save his life. This 
social media post encouraged people with Greek heritage, like 
myself, to sign up for the registry. I learned that ethnic 
background affects the patient's odds of finding a match.
    Thanks to congressional investment, NMDP has successfully 
developed targeted recruitment efforts, groundbreaking 
innovation, and continues to remove barriers to transplants.
    While patients' lives are changed through this program, my 
life was also forever altered when I received a call informing 
me that I had been identified as the best possible match for a 
patient. I was honestly a little overwhelmed and had so many 
questions, but NMDP was there to support me.
    The procedure itself was painless and easy, and the 
coordination was seamless. They were a great support system 
throughout the process. It was both an honor and a great 
responsibility to have matched with my recipient, Mario, and to 
offer him hope for a healthier life.
    After a full calendar year, we were allowed to connect. I 
am proud to know I was able to give Mario more time to spend 
with his family and give his two young children more time and 
memories with their dad. My donations to Mario have given my 
life and work new meaning. I continue to be involved by hosting 
donor registration drives in Alabama, Mississippi, and New York 
and recently completed my doctoral degree with a dissertation 
on bone marrow donation.
    Professionally, I have a career in hospital administration 
at the University of Alabama at Birmingham. Every day, I am 
surrounded by the bravery and strength of our patients, the 
spirit of our family members and caregivers, and the healing 
work of our providers. All this time I have Mario front of 
mind.
    Empathy starts with imagination. Throughout my donation 
journey, I imagined myself, a family member, a friend, or a 
colleague as a patient waiting for a match so they can live. I 
feel that it is my personal responsibility to work to ensure 
that every patient has a suitable donor available.
    In the Greek language, the word ``philotimo'' is a word 
that lacks a true definition. However, its meaning is great. 
The roots of the word ``philotimo'' include ``filos,'' meaning 
``friend,'' and ``timi'' meaning ``honor.''
    Philotimo extends beyond friendship and honor. It 
encompasses the desire in each of our hearts to do good work 
for others. This is what we should all aspire to achieve. Being 
a donor, being an advocate, and supporting the program is a 
perfect way to show our humanity by doing something out of love 
and honor for another human being.
    This committee knows the meaning of philotimo. More than 
any other committee in Congress, the programs you support save 
lives every day, including the C.W. Bill Young Cell 
Transplantation Program. I humbly request that you continue 
your support of this program by appropriating $35,000,000 in 
fiscal year 2024.
    Thank you for your time, consideration, and continued 
support of blood cancer and blood disease patients.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Hoyer. Amen.
    Mr. Aderholt. Thank you. Thank you. And again, as a fellow 
Alabamian, we welcome you here, and glad to have your 
testimony.
    And let me just say that I think everyone here on the dais 
served with C.W. Bill Young, and he was a great man and, of 
course, had a vision for this program. And so we appreciate 
your testimony, and we look forward to working with the 
National Marrow Donor Program.
    And thank you so much again for being here.
    Ms. Staursky. Thank you so much for having me.
    Mr. Aderholt. Okay. Our next guest is Ms. Sarah Rittling, 
who is executive director of the First Five Years Fund.
    And Ms. Rittling, we look forward to your testimony.
                              ----------                              

                                          Thursday, March 23, 2023.

                         FIRST FIVE YEARS FUND


                                WITNESS

SARAH RITTLING, EXECUTIVE DIRECTOR, FIRST FIVE YEARS FUND
    Ms. Rittling. Good morning.
    Mr. Aderholt. Good morning.
    Ms. Rittling. Chairman Aderholt, Ranking Member DeLauro, 
and members of the subcommittee----
    There we go, sorry.
    Good morning. Chairman Aderholt, Ranking Member DeLauro, 
and members of the subcommittee, thank you for the opportunity 
to testify on the need for all children, especially those from 
low-income families, to have access to affordable, high-quality 
early learning and care.
    My name is Sarah Rittling, and as the executive director of 
the First Five Years Fund, I am here recommending funding for 
Child Care and Development Block Grants, CCDBG; Early Head 
Start and Head Start; the Preschool Development Grants Birth 
through Five program; and IDEA Part B and C.
    I spent the early part of my career on Capitol Hill as 
counsel to Senator Lamar Alexander before the Senate HELP 
Committee and, before that, counsel to Representative Mike 
Castle before the House Committee on Education and the 
Workforce. Today, at the First Five Years Fund, also known as 
FFYF, we seek to build on the longstanding bipartisan support 
at the Federal level to expand access to high-quality early 
learning and childcare programs.
    First and foremost, I want to thank the subcommittee for 
your bipartisan efforts over many Congresses to strengthen the 
Birth through Five system in our Nation. I appreciate the 
support you have shown these programs in the past, which is 
also why I know no one on this committee needs a primer on the 
essential role that childcare plays for families, businesses, 
and the economy.
    And you know that for millions of working families and 
young children, childcare has become either unavailable or 
unaffordable. Childcare is hard to find. And even when parents 
can find it, waitlists are long, and costs are high.
    This has only gotten worse in recent years as the childcare 
sector is still down approximately 60,000 jobs from pre-
pandemic levels, leaving families with an even smaller supply 
of care even as nearly all other sectors have completely 
recovered. And this has an impact on families all across the 
Nation.
    For example, families like the single mom who had to give 
up her job and stay home because the cost of childcare would 
eat 75 percent of her take-home pay. Or the parents who have to 
leave their active toddler with an elderly neighbor because, 
like nearly two-thirds of all rural families, they live in a 
childcare desert with little or no options.
    We are here to talk about the child who will struggle to 
catch up with her peers once kindergarten starts because her 
parents didn't have access to affordable care and early 
learning options like the Judy Centers that would allow her the 
ability to develop and thrive.
    And finally, the small business owner who had to turn away 
work or close the restaurant this week because her staff had a 
hole in the patchwork childcare they rely on and couldn't come 
in. According to the Bureau of Labor Statistics, employees each 
year miss work because of childcare challenges. In fact, 
childcare challenges cause our Nation to lose as much as 
$122,000,000,000 every year in revenue, earnings, and 
productivity.
    Congress plays a key role in addressing these realities. 
Federal programs benefit families in all 50 States and every 
congressional district. Even with the growing support from 
committed Governors, local elected officials, businesses, and 
philanthropy, the Federal Government provides the funding to 
undergird an extremely complex childcare system that we have.
    Specifically, these programs are distinct and work 
together. I will go through them now. Child Care and 
Development Block Grant, CCDBG, helps parents work while their 
children receive quality care. States partner with the Federal 
Government on how to use these funds to best meet the needs of 
children, parents, and childcare providers in their community.
    This block grant focuses assistance on helping low-income 
working families with young children pay for care. Over the 
years, some States have also used these to raise payment rates 
for providers, improve health and safety standards, meet the 
childcare needs of families working nontraditional hours, and 
reduce waitlists.
    Head Start and Early Head Start deliver comprehensive early 
learning, health, nutrition, and family support services to 
families and children from birth through age 5. They are 
customized and modeled based on the needs of families and their 
communities, an approach that allows many programs to combine 
Head Start funding with other Federal and State funds from pre-
K childcare or other early care and education services to 
maximize their impact.
    Preschool Development Grants, in a nutshell, is the 
infrastructure that States--is the money that provides States 
the ability to build an infrastructure to make these programs 
talk together. And IDEA, I don't think I need to talk about. 
The committee is very well versed in that.
    Access to high-quality care is critical. We all know this. 
Thank you for your continued support, and we are ready to 
assist in any way we can.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Ms. DeLauro. Mr. Chairman.
    Mr. Aderholt. Wonderful. Yes. Ms. DeLauro.
    Ms. DeLauro. Thank you.
    I want to just applaud your testimony, but I also want to 
let you know that there are two sides to this, and this is what 
we were able to do last year in 2023. With regard to Child Care 
and Development Block Grant, it was $1,800,000,000. Head Start 
funding, $960,000,000. Preschool Development Grants, 
$25,000,000. Grants to States, $850,000,000. And grants for 
infants and families, $43,000,000.
    So this is what we have done. But I also want to just say 
one other thing. And I say this to all of my colleagues here on 
both sides of the aisle, and there is only some who want to 
apply the 2022 budget numbers for 2024. And with Head Start, if 
we did Head Start at the 2022 level, you are going to lose 
170,000 slots for children. If there is a 22 percent reduction, 
it is 200,000 slots.
    Low-income kids are not going to be able to get the 
opportunity to be educated. Childcare, if you fund at the 2022 
level, 105,000 childcare slots eliminated. 105,000 kids are 
eliminated from the program.
    So these are serious. And I say this to my colleagues on 
both sides of the aisle because I know my colleagues. When we 
passed the 2022 bill, we passed it. It has to be bipartisan, 
and it has to be the House and the Senate. So these were 
investments that were made. So I ask you to be mindful, and I 
obviously was talking to my colleagues about what is necessary 
for us to do. And I implore your advocacy on this issue, and I 
thank you for your testimony.
    Mr. Aderholt. Mr. Hoyer.
    Mr. Hoyer. Thank you, Mr. Chairman.
    I want to follow up, first of all, and say that there is no 
greater advocate for children in this Congress than Rosa 
DeLauro. I would like to think I am in the ballpark with her, 
but she is an amazing person.
    The American Rescue Plan that passed dedicated 
$38,000,000,000 to childcare. I visited a childcare center in 
Charles County, Maryland, in my district on Monday. And the 
director of that runs three childcare centers in and around 
Charles County. But for the American Rescue Plan, she would 
have had to shut down during the pandemic all three centers. 
That would have been some 200 slots that were not available for 
childcare.
    Childcare is a huge challenge in our country, and early 
childhood education is--you mentioned the Judy Centers, and I 
mentioned it earlier. There are now 69. There will be 100 in 
the next 2 years. They are going to add, so we will have 100 
Judy Centers. They are essentially 3- and 4-year-olds, but less 
than that as well. Infants as well.
    I quoted Ted Agnew. Let me quote somebody else from 
Maryland, born a slave on the Eastern Shore of Maryland, 
Frederick Douglass. And a profound quote that he made, ``It is 
easier to build strong children than it is to repair broken 
men.''
    That is what this is about. And Ms. DeLauro used this is an 
investment committee. It is not a spending committee, an 
investment committee, and there is a difference. And investing 
in our young children is as good an investment as any country 
will ever make.
    Thank you.
    Mr. Aderholt. Thank you.
    Thank you, Ms. Rittling, for your testimony, and we 
appreciate your testimony regarding the children like you 
mentioned that all need affordable, high-quality healthcare.
    I will just say we are impressed with your resume, that you 
mentioned you worked for Senator Lamar Alexander in the other 
body, and we were impressed with that. But we were even more 
impressed when I see in your resume that you worked for Mike 
Castle here in the House of Representatives. So we all served 
with Mike, and he was a great Member. So we appreciate your 
testimony.
    Mr. Hoyer. All of us share that view.
    Mr. Aderholt. Thank you.
    Our next guest, another Alabamian. We are glad to have Ms. 
Amy Templeton here today, who is president and CEO of McWane 
Science Center.
    And Ms. Templeton, we look forward to your testimony.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

                      AMERICAN ALLIANCE OF MUSEUMS


                                WITNESS

AMY TEMPLETON, PRESIDENT AND CHIEF EXECUTIVE OFFICER,
McWANE SCIENCE CENTER, ON BEHALF OF AMERICAN ALLIANCE OF MUSEUMS
    Ms. Templeton. Thank you. It is always nice to see another 
friendly Southerner. Yes.
    Mr. Aderholt. Thank you.
    Ms. DeLauro. I am going next Friday to Birmingham. Does 
that make me----
    [Laughter.]
    Mr. Aderholt. You are. You are. You will get the 
certificate when you get there.
    Ms. Templeton. Chairman Aderholt, Ranking Member DeLauro, 
and members of the subcommittee, thank you for the opportunity 
to testify today.
    My name is Amy Templeton, and I am president and CEO with 
the McWane Science Center in Birmingham, testifying on behalf 
of the American Alliance of Museums. I urge you to provide the 
Office of Museum Services within the Institute of Museum and 
Library Services with at least $65,500,000 for fiscal year 
2024, a much-needed increase of at least $10,000,000 accounting 
for inflation and public need for museum services.
    In light of museums being banned from this year's House 
Community Project Funding, which we strongly oppose, increasing 
funding for competitive grants for museums is all the more 
critical. IMLS is the primary Federal agency responsible for 
helping museums connect people to information and ideas. Its 
Office of Museum Services supports all types of museums, from 
art museums to zoos, by awarding grants to help them better 
serve their communities.
    Museums are economic engines and job creators. According to 
``Museums as Economic Engines: A National Report,'' pre-
pandemic U.S. museums supported more than 726,000 jobs and 
contributed $50,000,000,000 to the U.S. economy each year. For 
example, the total financial impact that museums have on the 
economy of Alabama is $473,000,000, including 9,410 jobs. For 
Connecticut, it is an $834,000,000 impact, supporting 10,229 
jobs.
    In fiscal year 2022, OMS received 716 applications, 
requesting nearly $109,000,000. But current funding has allowed 
the agency to fund only a small fraction of the highly rated 
grant applications it receives. $65,500,000 would allow OMS to 
increase its grant capacity for museums, funds which museums 
need as they continue to emerge from the pandemic and redouble 
efforts to serve their communities.
    In 2019, my science center received an OMS grant in the 
amount of $134,000 to strength science engagement experiences 
within our museum. It led to the development of new programs 
and exhibits that allow our visitors to learn more and to apply 
that new knowledge to their own everyday experiences.
    In 2021, we received an OMS grant in the amount of $222,000 
for the planning and design of a new exhibit that encourages 
visitors to learn STEM principles through the lens of popular 
music. We believe this exhibit will help us broaden and 
diversify our audiences, providing greater exposure to STEM 
among people of color, older teens, and young adults. The 
planning activities that were supported by OMS have allowed us 
to progress on this project to the point where private funds 
are now being committed, forming a true public-private 
partnership.
    Also in 2021, McWane Science Center received an OMS grant 
through the American Rescue Plan in the amount of $36,000 to 
support educational initiatives for the 2021-2022 school year. 
Initiatives included school-based outreach programs, virtual 
programming, teacher workshops that served 300 early childhood 
educators, and STEM kits for a variety of grade levels that 
teachers can check out for use in their classrooms.
    These OMS grants and many others like them to museums all 
across the country make a transforming impact on American 
museums and the teachers, students, and families they serve.
    I want to express the museum feels gratitude for the 
$55,500,000 funding for OMS in fiscal year 2023, and we applaud 
the 136 bipartisan representatives who wrote to you in support 
of OMS funding. This small program provides a vital investment.
    For the record, I also would like to endorse the upcoming 
written testimony on this issue of the Association of Science 
and Technology Centers, the Association of Science Museum 
Directors, and the Association of Children's Museums.
    In closing, I highlight recent national public opinion 
polling that shows that 95 percent of American voters would 
approve of lawmakers who support museums, and 96 percent want 
Federal funding for museums to be maintained or increased. 
Museums have a profound positive impact on society and are 
essential community infrastructure.
    Thank you again for this opportunity to testify today.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you.
    Ms. DeLauro. Mr. Chairman.
    Mr. Aderholt. Yes. Ms. DeLauro.
    Ms. DeLauro. I want to thank you, and we were very happy to 
make the increase in the museum services in the last budget. 
And I thank you for mentioning that.
    I, too, am saddened by the fact that museums are not 
eligible to apply for Community Project Funding because it is a 
real need. But in addition to everything that you have said 
about museums, I think fundamentally they really are the home 
of our humanity and are the soul of this country and what our 
history is about and what direction we want to go in, et 
cetera.
    And to shortchange museums I think it just is overall 
error, and really, this country and the people of this nation, 
knowing something about its history, about its current, 
present, and about its future.
    Thank you.
    Ms. Templeton. Thank you.
    Mr. Aderholt. We do appreciate you being here, and 
certainly, McWane Science Center is a great asset for the State 
of Alabama. Thank you for your work there and especially this 
morning, for being here for the American Alliance of Museums, 
and we look forward to working with you and with these grant 
programs.
    And thank you for being here, and look forward to working 
with you in the future.
    Ms. Templeton. Thank you so much.
    Mr. Aderholt. Thank you.
    Our next guest is Mr. Paul Schroeder. He is Vice President 
for Impact and Outreach with the American Printing House for 
the Blind.
    Mr. Schroeder, we welcome you to the subcommittee today, 
and we look forward to your testimony.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

                 AMERICAN PRINTING HOUSE FOR THE BLIND


                                WITNESS

PAUL W. SCHROEDER, VICE PRESIDENT FOR IMPACT AND OUTREACH, AMERICAN 
    PRINTING HOUSE FOR THE BLIND
    Mr. Schroeder. Good morning. Mr. Chairman, Ranking Member 
DeLauro, members of the subcommittee, thank you so much for 
the--oh, we didn't hit the button. See, we are already off to a 
bad start.
    Mr. Aderholt. You are good. You are good.
    Mr. Schroeder. They said it was the light button, I don't 
know.
    I do feel compelled, Mr. Chairman, since Alabama has come 
up several times, that I have been invited in May to come down 
to Talladega.
    Mr. Aderholt. Oh, my.
    Mr. Schroeder. I am not racing, just clarify that. I get to 
be the commencement speaker at the Alabama Institute for the 
Deaf and Blind and very privileged to have that honor.
    Mr. Aderholt. Congratulations.
    Mr. Schroeder. Look forward to going through your 
district----
    Mr. Aderholt. Yes, thank you.
    Mr. Schroeder [continuing]. On our way there.
    Mr. Aderholt. Yes, absolutely.
    Mr. Schroeder. I am here to talk about the American 
Printing House for the Blind and thank the subcommittee for 
your support for the APH over the many years that we have been 
at our work. With the support of Congress and the Department of 
Education, it has been our privilege to provide textbooks, 
tools, and technologies for the tens of thousands of students 
who are blind or low vision throughout the United States.
    Mr. Chairman, we have been at this for a little while, too. 
We have been doing this since 1879 with Federal support. So we 
are very privileged to have had that opportunity.
    My focus this morning is on a piece of Braille technology 
that here is with me at the table. I will hold it up briefly 
and hope to not drop it. That is a beta technology that is 
going to transform educational opportunities for blind 
students.
    We also hope, by the way, to be able to, working with 
Congress, expand the successful assistive technology training 
program that was inaugurated a few years back with the help of 
the Subcommittee on Appropriations for Labor-H.
    Braille is indispensable for those of us who are blind. It 
is a key success factor in employment and successful education. 
Braille textbooks are a key part of that. But I have to tell 
you, Mr. Chairman, members of the subcommittee, Braille 
textbooks are extraordinarily expensive and difficult to 
produce. They are very difficult to ship. And for the schools 
and students who work with them, they are also very difficult 
to manage.
    A lot of that has to do with the size and storage. We have 
got a picture that I think some of you have been handed, but I 
will also give you another example. A popular biology textbook 
that we produced in Braille takes up 47 volumes, each of them 
about 3 inches thick and 4 pounds in weight.
    So to do the math, that is about 12 feet of books at 190 
pounds. I think that is more than most backpacks will 
accommodate. So that is what our students are contending with.
    We have decided at APH that we needed to tackle this head 
on, and we needed to create a device that would allow books to 
be available to blind students in an efficient way, in a cost-
effective way, and in an immediate way. So that 190 pounds of 
books--12 feet of books--the picture that, if you have had a 
chance to look at it----
    Mr. Aderholt. Yes, we have.
    Mr. Schroeder [continuing]. The math book is taller than 
the young student who is using that book, they will all fit on 
this device. And every other book that that student would need 
pretty much throughout their school program will fit on this 
device.
    With this ``Monarch,'' as we have come to call it, our 
students are going to be able to explore the building blocks of 
life and the expansiveness of our universe. I am going to just 
hold up, for those of you who can see it, that could be the 
universe. It actually happens to be a boron atom, for those of 
you who didn't do the chemistry real fast. [Laughter.]
    Mr. Schroeder. It has got five protons, six neutrons, and a 
lot of electron shells. When I say the ``building blocks of 
life,'' this is what I mean. Our students will be able to have 
access to that material in a timely fashion, something we have 
never been able to do before.
    Just 6 months ago, I couldn't have presented this 
technology to you. It is a beta technology. But thanks to the 
work and the support from the fiscal 2023 appropriations 
legislation, we were able to do the research and are in the 
process of doing the training for our teachers so that they 
will be able to help their blind students learn this new 
technology.
    But who is kidding who? The blind students will be teaching 
the teachers. There is no question about that.
    Mr. Chairman, we are doing this in partnership with 
experienced organizations. Humanware, a company with long 
experience developing assistive technology, is part of this 
effort, and the National Federation of the Blind, the advocacy 
organization that works so hard on behalf of individuals who 
are blind or visually impaired, is part of the effort. This is 
a device that features multiple lines of Braille and tactile 
graphics on the same surface.
    I am holding another device that is the current state of 
the art in Braille. It has one line of cells, of 20 cells in 
this case. Mr. Chairman, I do not think that many of you would 
tolerate a laptop monitor or a smartphone with one line of 
Braille, and I am sure you would not want to read a book on a 
monitor or a smartphone with just one line of text and no 
pictures.
    Blind students are resilient. We have--and I say ``we'' 
because I was a blind student. We have had to learn many times 
without sufficient materials for the task at hand.
    What we are hoping is that the committee will be able to 
make an investment, as we have asked for in the request for 
$53,000,000 this year--$10,000,000 over 2023--an investment to 
put this technology into the hands of our students. Give them a 
chance to learn, to explore and, frankly, thinking of it as the 
monarch, to let their imaginations fly.
    Thank you very much for the opportunity. If there are any 
questions, I would be happy to take them.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Well, thank you. I appreciate, Mr. Schroeder, 
your testimony and your demonstration here of the Monarch, and 
it is fascinating to learn about the technology.
    And any questions or comments?
    Ms. DeLauro. I just want to make the point. Thank you for 
mentioning that we did increase the funding for the printing 
for the blind in the 2023 appropriations. But there was also 
language included to support the device, and we tried to deal 
with both the device and funding for the device.
    Also you said blind students are resilient. You certainly 
are, certainly are courageous. And thank you very, very much. 
That is just outstanding.
    Mr. Schroeder. Thank you, Ranking Member. We have put it to 
good use, and thank you for this.
    Mr. Aderholt. I do have a quick question. With the Monarch 
that you are talking about, how long has it been available?
    Mr. Schroeder. So this is a beta unit that is about a month 
old, and I will tell you that all of the technology people at 
APH were very frightened when they put it in my hands. 
[Laughter.]
    Mr. Schroeder. Because I am not a technologist, but I have 
done my best.
    Mr. Aderholt. But this, the vision is that it would be in 
the hands of every blind student that wants to learn?
    Mr. Schroeder. We are hoping beginning in school year 2024. 
So toward the end of the fiscal year 2024, to be able to start 
putting these devices into the hands of blind students, yes.
    And that is the purpose of the request is to make sure that 
this device that is going to be more expensive than the Braille 
devices we currently have, such as this one that I also have 
with me, that this device will be able to be available to 
students, and that State education agencies and schools will be 
able to start making them available to their students.
    Ms. DeLauro. So the request that you're making is for the 
funding for the device itself and the ability to get it out to 
wherever it is needed and so forth, so we can get it out the 
door.
    Mr. Schroeder. That is correct.
    Ms. DeLauro. That is right.
    Mr.  Schroeder. That is correct. Thank you.
    Mr. Hoyer. Mr. Chairman.
    Mr. Aderholt. Yes.
    Mr. Hoyer. I know I keep talking. I apologize for that.
    Mr. Aderholt. No.
    Mr. Hoyer. But I was a sponsor, as you know, of the 
Americans with Disabilities Act. This is what is called in the 
act a ``reasonable accommodation,'' and we have all experienced 
it. That is why the elevator tells you what floor it is rather 
than you are seeing it necessarily. That is why the elevator 
now has Braille so that a blind person can see it. It is a 
reasonable accommodation to make sure that people can be 
included fully.
    And you talk about capacity of that technology, I am always 
amazed, Mr. Schroeder--and I am holding up my iPhone. I am 
always amazed at the capacity. At some point in time during my 
life, which has been a long time, it is going to run out of 
capacity. But it sure hasn't, and I have been using it a long 
time.
    And this is a wonderful, wonderful device to make sure that 
we include everybody in the opportunities that America and the 
world has to offer. So thank you very much for bringing this to 
our attention.
    Mr. Schroeder. Mr. Hoyer, if I may, I want to thank you for 
your sponsorship of the Americans with Disabilities Act. I was 
with you on the day of the signing, got a chance to meet you 
for the first time. And I am told I look a lot older now, but 
you don't look any different to me. So----
    [Laughter.]
    Ms. DeLauro. You are terrific. Wow.
    Mr. Hoyer. You know, people say to me----
    [Applause.]
    Mr. Hoyer. I love that, but it is people say to me, say, 
boy, you don't look any older. And when I first met you, I 
said, you know, the good news is as I get older, my friends 
gets older and their eyesight gets worse. In your case, it is 
absolute. But thank you very much.
    Mr. Aderholt. Well, thank you, Mr. Schroeder. We do 
appreciate your testimony and look forward to--this 
subcommittee working with how we can try to help facilitate 
this program. And again, your testimony is very, very helpful.
    Thank you.
    Mr. Hoyer. Good job.
    Mr. Aderholt. All right. Well, our next guest is Dr. Anne 
Zink, M.D., president and chief medical officer, Association of 
State and Territorial Health Officials and the Alaska 
Department of Health.
    Dr. Zink, we welcome you to the subcommittee and look 
forward to hearing from you.
                              ----------                              

                                          Thursday, March 23, 2023.

   ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS AND ALASKA 
                          DEPARTMENT OF HEALTH


                                WITNESS

ANNE ZINK, M.D., FACEP, PRESIDENT AND CHIEF MEDICAL OFFICER, 
    ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS AND ALASKA 
    DEPARTMENT OF HEALTH
    Dr. Zink. Great. Thank you so much, Chair Aderholt, as well 
as Ranking Member DeLauro, as well to distinguished members of 
this committee, not only for the opportunity to appear before 
you today, but really for all of your tremendous support for 
public health.
    I come to you, as mentioned, as the president of the 
Association for State and Territorial Health Officers, but as 
also mentioned, I am the chief medical officer for the State of 
Alaska, a practicing emergency medicine physician, and a mom to 
two wonderful girls.
    Healthy economies are built with healthy people, and that 
is why the choice before you today is not a choice on spending, 
as mentioned, but a choice on investment--investing in public 
health, investing in the future of this great country, and 
investing in our children.
    I chose emergency medicine because I love the honor of 
working with people in their greatest moments of need, and we 
have heard many of them today. A teenager found in her room, 
vomiting after an attempted overdose, parents desperate for 
help, a child rushed by bystanders seizing after they were hit 
by a car on their way to school, or a gentleman with crushing 
chest pain whose heart stopped but was able to go home a couple 
days later with his family, thanks to a great team, amazing 
medical interventions, and some luck.
    However, I soon realized that my patients--if I had to care 
for my patients, I needed to care about health policy. Patients 
are my why. Public health is the how.
    The school counseling that may have allowed that teen to 
get help before the overdose, the safe routes to school that 
separated the child from the road, or the diabetes and 
hypertension management that might have mitigated the heart 
attack. Not to mention being able to eat food when I go to a 
restaurant or having clean water when I go home at night.
    Emergency medicine is the seawall of our healthcare system, 
and it is buckling under the weight of a lack of sustained 
investment in public health. People are boarding for days, 
weeks, even months in our emergency department, presenting 
sicker with unchecked or chronic diseases, and we are seeing 
rising numbers of patients with mental health crises and re-
emerging infectious diseases like syphilis, a disease I never 
saw in my training and now regularly see, as well as chicken 
pox, tuberculosis, measles. The vast majority of injuries and 
illness I see every day could be prevented or reduced by 
investment in public health and primary care.
    Good public health is a lot like the daily habit of diet 
and exercise. It doesn't always come easy. It is hard to 
prioritize with many other demands, but--and it is often 
invisible in the daily news cycle, but it pays dividends in the 
long run.
    The Association for State and Territorial Health Officers 
represents all 50 States and the territories. We manage many of 
the programs that you have heard about today, and we are united 
in our consensus that public health funding should be flexible 
and sustained.
    The funding requests for core public health work are 
detailed in my written testimony and cover a broad range of 
efforts, numerous Federal agencies from CDC to ASPR to HRSA. 
However, there are three funding asks I want to bring your 
attention to specifically within the CDC budget.
    The first is $1,000,000,000 for the public health 
infrastructure and capacity. The second, $153,000,000 for 
social determinants of health. And a third, $340,000,000 for 
data modernization.
    First, public health infrastructure and capacity. The 
challenges in Alaska are very different than that in D.C. or 
Ohio, and the people that we serve are more than one specific 
disease. But that is often how the funding comes to us. We are 
so grateful for this committee's creation and support of this 
program, which is disease agnostic, as well as flexible, 
allowing us to meet the critical needs and fill the gaps in our 
communities.
    Second funding for social determinants of health. Well, 
this may include housing and employment, education, 
transportation, and so much more. It is important to remember 
that 80 percent of our health is determined by things outside 
of the healthcare system. And this funding is not meant to 
solve all of these larger challenges, but it is to coordinate 
with agencies and partners to add to the body of knowledge how 
to maximize the impact of our limited resources and improve 
health, regardless of geography, race, or gender.
    And finally, the dire need for increased funding for data 
modernization. Our data systems are overstretched, outdated, 
and often siloed. Our lives, as mentioned with your phone, are 
enhanced by the daily use of data. Our weather forecasts, money 
securely transferred one place to another, or our driving 
routes that take into account a recent accident on our way 
home.
    Yet in healthcare, I look for the most recent public health 
alerts taped to the bathroom walls of our breakroom. I can't 
access medication lists or vaccine records when I am trying to 
care for a patient, and my team in Alaska had to use the 
National Guard to enter data into different datasets and then 
manually match them to understand and respond to a global 
pandemic.
    We appreciate the subcommittee, the funding for CDC Data 
Modernization, DMI, but we need robust, sustained, and yearly 
funding so that public health can support the patients that you 
have heard about, to support providers, and to support 
policymakers.
    As a nation, we have made tremendous stride in life 
expectancy with clean water and sewer. We have built upon that 
success with revolutions in diagnostic and therapeutic 
medicine. But our success is slipping. The U.S. has an average 
life expectancy falling to the lowest of all developed nations, 
yet we spend more per capita. Our funding depends and our 
future depends on stable, well-funded public health 
infrastructure integrated with healthcare.
    So thank you to this committee, to the Members of Congress 
for your time, and we look forward to the success of previous 
bipartisan agreements to increase the resources for the 
Nation's public health system in fiscal year 2024.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    I think this really is music because I think what we found 
in the pandemic was that our public health infrastructure 
collapsed. It collapsed.
    Our laboratories, the data wasn't there. CDC was not 
getting information as to what was happening, and it was 
catastrophic. So that I really am very, very proud of the work 
that we have done in this committee, and I am proud to have 
established--you know, my focus has been on public health 
infrastructure.
    And what we have done is focused in on the point you have 
made on data marginalization, on that initiative. The capacity 
of the funding line to be able to do that. And more than half 
of the increase in the 2023 budget was about allocating the 
funding to these kind of core activities.
    So I want to encourage you to advocate in this area because 
we need to build on what was done in 2023 without the numbers 
of--whenever a crisis comes up, we deal with the crisis for the 
moment. But then we go back to where it was, and all kinds of 
institutions have said to me, the medical profession said that 
is very nice that you are going to address--whether it is 
Ebola, Zika, whatever it is--but then you go away.
    What we need to do is to have consistent funding for public 
health infrastructure. So I know it is your goal. It is as well 
my goal, and it is this committee's goal as well.
    So, thank you.
    Dr. Zink. Thank you so much.
    Ms. DeLauro. Thank you very much.
    Mr. Aderholt. Dr. Zink, thank you for your testimony. We 
look forward to working with you on these issues.
    Next we, of course, have another Alabamian that is coming 
before our subcommittee, and we have Ms. Felicia Simpson, co-
director of the Alabama Expanded Learning Alliance. And not 
only from Alabama, but from the prestigious Fourth 
Congressional District of Alabama, Lake Guntersville, which I 
have the honor to represent.
    So, Ms. Simpson, we look forward to your testimony.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

                   ALABAMA EXPANDED LEARNING ALLIANCE


                                WITNESS

FELICIA SIMPSON, CO-DIRECTOR, ALABAMA EXPANDED LEARNING ALLIANCE
    Ms. Simpson. Good morning, Chairman Aderholt, Ranking 
Member DeLauro, and members of the subcommittee.
    I am Felicia Simpson, director of the Alabama Expanded 
Learning Alliance. On behalf of the Afterschool Alliance, 
afterschool and summer learning programs, and the families they 
serve, I would like to thank you for the increase in funding 
for 21st Century Community Learning Centers in the fiscal year 
2023.
    Today, I ask you to build on that investment in our 
communities and address the vast unmet need for afterschool and 
summer learning by providing $2,090,000,000 for this program 
for fiscal year 2024.
    21st Century Community Learning Centers allow Alabama to 
serve 18,643 students in afterschool and summer, and it ranges 
from pre-K to 12th grade. And we serve 1.5 million students 
across the Nation. These programs serve students in high-
poverty and low-performing schools. They are a tremendous 
support to underserved communities.
    They leverage community partnerships and faith-based 
partnerships. They keep children safe, provide meals, offer 
engaging hands-on learning experiences, apprenticeships, and 
mentorships. They improve school attendance, academic 
achievement, increase graduation rates, and so much more.
    In Alabama and across the Nation, for every one child in an 
afterschool program, there are four more waiting to get in. As 
a nation, we must to do more to ensure all children have access 
to high-quality afterschool and summer learning programs.
    I would like to note that partnerships at the State level 
are critical, and we are fortunate to have an exceptional 
Governor in Kay Ivey, who has committed funding and support in 
Alabama, which leverages our Federal investment, and a 
Lieutenant Governor who understands the importance of STEM in 
afterschool.
    Large industries across Alabama are implementing 
afterschool and summer programming for children of their 
employees. Research finds productivity decreases in industry 
after 3:00 p.m. as parents are more concerned about their 
children arriving home safely or simply being at home 
unsupervised.
    With jobs in STEM driving our economic growth, afterschool 
gives nearly 6 million students opportunities to explore STEM. 
However, funding remains a barrier for these rich resources. 
States can provide grants for only one in three applications 
for 21st Century funding.
    Before the pandemic, 24.6 million parents nationwide were 
wanting and needing to enroll their children in afterschool. 
Simply providing level funding or, even worse, a decrease in 
21st Century funding will mean fewer programs and fewer 
students served. Everyone in this room is here because there 
was a resource, a support system, a mentor, an opportunity 
which manifested in your life. All of these are offered in 
afterschool and summer programs.
    Allow me to share a story about a man named Phil. He grew 
up with a single mom and was considered a latchkey kid. In 
middle school, he found himself at a crucial place. His mom 
enrolled him in a local afterschool program. And with that 
program came stability and a safe place during a very turbulent 
time in his life.
    With the help of a high-quality afterschool program, Phil 
graduated high school, entered the United States Army Reserves, 
graduated from Birmingham School of Law, and went on to serve 
the Alabama State Senate. Phil was blessed to have a high-
quality afterschool program within his community and blessed 
with a single mom who rested in those resources. Not all 
children are so fortunate.
    This is why I urge you to increase funding for 21st Century 
Community Learning Centers by $750,000,000 in fiscal year 2024, 
to give more young people like Phil opportunities to learn, 
inspire, and thrive. Across the Nation, afterschool and summer 
program is a privilege afforded to few. Now is the time to deem 
it a nonnegotiable for supporting children and families. You 
can do this through your support for 21st Century Community 
Learning Centers.
    Thank you for allowing me this opportunity to speak on the 
importance of high-quality afterschool and summer programming 
on behalf of children and families. I am sincerely honored to 
testify before you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Thank you, Ms. Simpson.
    And I happen to know Phil, and he is a great individual and 
a good friend. So I am happy to know that we have a mutual 
friend there with the former senator.
    And we appreciate your testimony. This is an important 
issue--oh, yes, please?
    Ms. DeLauro. I just want to say many, many years ago, I 
volunteered in the afterschool program at the Conte Community 
School in New Haven, Connecticut. Taught modern dance and 
calligraphy. Couldn't do either one of them at the moment here.
    So, but this program, 21st Century Learning Centers, is 
named after Nita Lowey, who was the chair of the Appropriations 
Subcommittee, who was very, very much committed to the 
afterschool program, as I am as well. And we were able to deal 
with an increase, $40,000,000 increase, because we believe in 
this program.
    But I also, again, want to make my colleagues on both sides 
of the aisle knowledgeable that if we move to a 22 percent cut 
in the 2024 budget, your request of $750,000,000, what would 
happen to this program would be a cut of $293,000,000. So we 
need your advocacy because you are the boots on the ground. You 
see it. You know its value. And so thank you very, very much 
for your advocacy.
    Mr. Aderholt. Thank you, Ms. Simpson. We appreciate your 
testimony.
    Our next guest who will be speaking, giving testimony, will 
be Mr. Clarke Forsythe, senior counsel, Americans United for 
Life.
    So, Mr. Forsythe, we welcome you here to subcommittee and 
look forward to your testimony.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

                       AMERICANS UNITED FOR LIFE


                                WITNESS

CLARKE FORSYTHE, SENIOR COUNSEL, AMERICANS UNITED FOR LIFE
    Mr. Forsythe. Chairman Aderholt, Ranking Member DeLauro, 
members of the committee, I am Clarke Forsythe, and I serve as 
senior counsel with Americans United for Life.
    And I want to thank you for the opportunity to testify 
today in support of preserving pro-life appropriation riders, 
including the Hyde Amendment, Title X, the Weldon Amendment, 
and Medicare Advantage rider. I urge the subcommittee to keep 
these riders for three main reasons.
    Abortion funding aggravates the pressure on women to abort. 
Given massive Federal deficit, it makes no sense to use tax 
dollars to pay for elective abortion when private funding is 
readily available, as made clear in Robin Marty's book in which 
she documents it State by State.
    And tax-funded abortion violates the conscience of millions 
of American taxpayers, which a bipartisan majority of Members 
have recognized since 1976. All of the pro-life appropriation 
riders in the Republican bill that passed the House in 2018 
should be preserved.
    First, studies have found that coercion or pressure on 
women to abort plays a role in many abortions. One 2004 study 
found that 64 percent of women felt pressured by others to have 
the abortion. And coercion can take many forms, from intimate 
partner violence to subtle pressure to paying for the abortion.
    And early abortion rights advocate Daniel Callahan, a 
nationally recognized ethicist, recognized that legalized 
abortion has given men more choice because they now have, as he 
said, a potent new weapon in the old business of manipulating 
and abandoning women.
    Abortion increases the risk of intimate partner violence. 
In fact, the prevalence of intimate partner violence is nearly 
three times greater for women seeking abortion than for women 
continuing a pregnancy, and that is cited in the ACOG Committee 
opinion, page 2, in footnote 10 of my written testimony.
    Employers may also pressure women to abort. This problem 
became so obvious to Congress that Congress enacted the Federal 
Pregnancy Discrimination Act shortly after the Roe decision.
    Trafficked women are also at significant risk of coerced 
abortion. A 2014 study found that 66 trafficked victims had a 
total of 114 abortions. The victims reported that they often 
did not freely choose the abortions they had while trafficked.
    Coerced abortion has become so widespread in the United 
States since the Roe decision that at least 20 States have 
enacted some form of law to protect women from a coerced 
abortion. Public funding aggravates the pressure women feel to 
abort by weighting the financial scale in favor of abortion and 
eliminating a reason they may have against abortion.
    Second, given the massive Federal deficit, it makes no 
sense for Congress to fund elective abortion with tax dollars 
when more than enough private funding for abortion exists 
through numerous funders at the State and local level across 
the country.
    And third, funding restrictions are an important safeguard 
for taxpayers' conscience rights. The most prominent abortion 
funding restriction is, of course, the Hyde Amendment, which 
Congress has approved since 1976.
    Although Americans hold different views on abortion, 
polling data has shown a consistent consensus of Americans 
supporting restrictions on abortions, including public funding 
restrictions. In fact, in the 2023 Marist poll, 60 percent of 
Americans said they opposed taxpayer funding of abortion.
    A bipartisan majority of Members that has supported 
abortion funding restrictions for 46 years has understood that 
funding restrictions are critical to support for other social 
welfare appropriations. Instead of becoming embroiled in the 
abortion debate for every single social welfare program, 
Members have determined to restrict abortion funding, thus 
facilitating the passage of important social welfare 
legislation that won't also fund abortion.
    And pro-life riders also protect the conscience rights of 
medical professionals, in addition to taxpayers. The Weldon 
Amendment, for example, is an anti-discrimination provision 
that defends the conscientious objection of healthcare 
professionals, healthcare institutions, healthcare insurance 
plans that refuse to provide, pay for, or refer for abortion.
    So these appropriation riders are essential to protect 
conscience, and I urge the subcommittee to protect women from 
another layer of coercion and safeguard the conscientious 
objection of taxpayers and medical professionals.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Mr. Forsythe, for your testimony. 
And we--did you want----
    Ms. DeLauro. Yes.
    Mr. Aderholt. Yes. No, go ahead.
    Ms. DeLauro. I will just make a very, very simple 
statement. Mr. Forsythe, the decision to terminate a pregnancy 
is a very serious one. It is a very personal one. It is a 
decision, which women should be allowed to make with their 
families, with their doctor, with clergy, with the people who 
may be the closest to them that could help them in what is 
probably a very difficult time.
    I would also say that we need to respect the decisions that 
women make. We need to trust women. And I understand your 
position, and I think it is important for us to realize that 
paramount is the ability for women to make those decisions for 
their health, for their economic, financial security and 
stability of their family.
    And I trust them. It is about their dignity. It is about 
the respect that we should make.
    And I thank you, Mr. Chairman.
    Mr. Aderholt. Yes, well, thank you.
    And of course, the abortion issue is one that probably 
divides Congress more than anything else. But I think I 
appreciate your testimony from the aspect of talking about the 
public funding aspect, which is something that I think you 
mentioned 60 percent of Americans disagree with public funding, 
and no matter how you come down on the issue of abortion, the 
public funding is in a totally different category.
    So thanks for bringing that to our attention, and we look 
forward to working with you.
    Mr. Forsythe. Thank you. Chairman, may I respond very 
briefly?
    Mr. Aderholt. Yes.
    Mr. Forsythe. That picture you paint, though, is 
complicated by the medical literature that shows the many 
sources of coercion, the intensity of coercion, and the many 
women affected by coercion. So that needs to be factored in.
    Thank you.
    Mr. Aderholt. Thank you for your testimony.
    Next our public hearing guest is Katherine McGuire, chief 
advocacy officer of the American Psychological Association.
    And Ms. McGuire, we appreciate your testimony here today 
and look forward to it.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

              AMERICAN PSYCHOLOGICAL ASSOCIATION SERVICES


                                WITNESS

KATHERINE BRUNETT McGUIRE, CHIEF ADVOCACY OFFICER, AMERICAN 
    PSYCHOLOGICAL ASSOCIATION SERVICES
    Ms. McGuire. Good morning, Chairman Aderholt, Ranking 
Member DeLauro, and members of the subcommittee.
    I am representing the American Psychological Association 
and APA Services, the advocacy arm for the association. APA is 
the largest organization representing psychology in the United 
States, with 146,000 members and our affiliates. We are 
grateful for this committee's leadership in making bipartisan 
investments in mental health over the past several years, but 
more needs to be done.
    In my written statement, I point to a number of specific 
programs and recommended funding levels that we urge you all to 
consider. Today, I want to spend time talking about the human 
impact of these programs and why robust funding levels are so 
vital to ensure a healthier tomorrow.
    57.8 million U.S. adults are living with varying levels of 
mental health concerns. APA data show a population experiencing 
remarkably high levels of stress and anxiety. Psychologists 
report that demand for treatment for anxiety and depression 
remains high.
    Practitioners are seeing increased workloads and longer and 
longer waitlists, which have contributed to higher levels of 
burnout within the profession. Researchers responsible for 
ensuring new products are ethically designed, determining the 
impact of online platforms on children, or testing new 
treatments are left underfunded.
    Most alarming is the increase in the crisis we continue to 
see in youth mental health. Nationally, nearly 4 million 
children experienced depression in the last year, while the 
rate of suicide attempts increased by a disturbing 55 percent.
    Educators report increasing numbers of students seeking 
assistance for mental health issues, and hospitals continue to 
be overwhelmed by the number of children seeking care for 
mental health emergencies. Recent CDC data also show that 45 
percent of high school students are feeling consistently sad 
and hopeless, with teen girls and LGBTQ+ students showing 
disproportionate levels of concerning behaviors, all while they 
are bombarded by harmful online content.
    This is more than a mental health crisis. This is the 
accumulation of neglect, stigma, and unequal treatment of 
mental and behavioral health that we must turn the tide 
against.
    To meet these challenges, we need investments in a diverse 
and robust mental health workforce. The U.S. continues to face 
a nationwide shortage of mental healthcare providers, including 
psychologists, with Southern States having even less access to 
care. That gap of care is most evident in our new mothers, with 
over 50 percent of women with postpartum depression not 
receiving any mental health treatment at all.
    By 2030, these shortages will worsen significantly, 
particularly in rural communities. Of the over $15,000,000,000 
our country invests annually in the training of physical 
healthcare professionals, less than 5 percent of that amount is 
invested in building our mental healthcare workforce.
    Funding HRSA's Graduate Psychology Education Program at 
$30,000,000 and SAMHSA's Minority Fellowship Program at 
$36,700,000 will help increase our Nation's supply of 
psychologists trained to provide culturally competent, 
integrated mental and behavioral healthcare to underserved 
populations. In addition, we urge Congress to fund the 
enforcement of mental health parity.
    Finally, Congress must also support the treatment and 
prevention of mental health problems in our Nation's youth. An 
increase of at least $200,000,000 for youth mental health 
research at the National Institute of Mental Health, including 
$20,000,000 for the study of the mental health impacts of 
social media, is needed.
    This must also include a focus on meeting young people 
where they are. Schools and colleges are often on the front 
lines of the youth mental health crisis. They need the 
resources to deliver comprehensive services that support 
prevention and early intervention. Additionally, Congress must 
further invest in programs that promote all evidence-based 
models of integrated primary and behavioral healthcare, which 
is especially well suited for the pediatric population.
    Much of the recent funding for mental healthcare has been 
provided on an emergency basis, but we cannot address our 
Nation's mental health needs solely through crisis response, 
let alone go back to past funding levels. Instead, Congress 
must provide consistent, sustainable support to build the 
mental health workforce and to help champion the role of 
psychologists in all of our communities.
    I thank you again for the opportunity to speak with you 
today. The American Psychological Association and its members 
stand ready to find solutions to the critical issues that this 
committee has authority over.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Ms. McGuire.
    We appreciate your testimony, and certainly we--I 
understand that mental health is really a serious issue in this 
country, and sometimes it is the hidden illness that we don't 
see so much of the time. So your testimony is very well 
received.
    Ms. DeLauro.
    Ms. DeLauro. Yes. I just want to point out--thank you for 
bringing up the issues around mental health. It was a crisis 
before the pandemic, and it certainly was exacerbated by that. 
So it is front and center.
    But I want to be mindful of what the application of the 
2022 budget numbers to the 2024 budget would mean, a 22 percent 
reduction in the 988 Suicide Lifeline, cut responses by 
900,000. Nearly a million people facing suicidal, mental 
health, or substance use crisis would be unable to access 
support and stabilization services.
    State Opioid Response, more than 29,000 would lose 
admission to the opioid use disorder treatment. An estimated 
46.3 million Americans age 12 and older had a substance use 
disorder, 106,000 people died from a drug-related overdose in 
2021. And it would really cut back the opportunities for us to 
be able to provide a well-qualified mental health professional 
in every school in this Nation in order to deal with the 
increase of mental health problems that our kids are facing.
    And I will just tell you. I have a staff member at the 
moment who is watching her 12-year-old on a 24-hour basis, 
going in to see him every hour to make sure that he is all 
right because he is in danger of suicide.
    Serious problem. We can't afford the results of cutting 
resources, but we need to be increasing these resources.
    Thank you for what you are doing in your professional life 
and for your advocacy.
    Mr. Aderholt. Thank you, Ms. McGuire. Thank you.
    Our final testimony for today will be from Mr. Richard 
Stern. He is the director of the Grover Hermann Center for 
Federal Budget at the Heritage Foundation.
    And I see from your bio that you also have worked on 
Capitol Hill. So you are not a stranger to this place, and so 
we welcome you and look forward to your testimony.
                              ----------                              --
--------

                                          Thursday, March 23, 2023.

                        THE HERITAGE FOUNDATION


                                WITNESS

RICHARD STERN, DIRECTOR, GROVER M. HERMANN CENTER FOR THE FEDERAL 
    BUDGET, THE HERITAGE FOUNDATION
    Mr. Stern. Well, thank you. And thank you for including my 
testimony in today's proceedings.
    So, as many of the witnesses have come here today to ask 
for more taxpayer funding for this program or that, I have come 
here today to encourage that we reduce funding levels. I am 
here today for the 334 million Americans who are suffering with 
the economic and societal ills caused by over Federal spending, 
by runaway Federal spending, and overregulation.
    It is easy to point to where the Government sends dollars. 
It is much, much harder to point to the destruction wrought 
when Government takes that money out of the private sector.
    The intrusion of the Federal Government in our economy has 
likely cost average American households tens of thousands of 
dollars of annual income. But that income loss isn't about 
dollars and cents. It is about a loss that is much, much more 
profound--the loss of innovation, of technological progression, 
and scientific knowledge, the things that would have extended 
health and quality of life even further. Things that we can't 
imagine today that would have come if we had had a more 
efficient economy, if the Government had not had those burdens.
    It is the tragic reality that the Government's intrusion in 
the economy and its runaway spending has dimmed and denied the 
futures of hundreds of millions of Americans. And today, 
Americans face the scourge of inflation. They have seen their 
mortgage rates spike. They have seen their purchasing power 
drop.
    The Federal budget is set to consume more than a quarter of 
our economy in just a decade. Almost 82 percent of the debt 
that we have today has been created just in the last 
generation, just since 2000. And that debt now stands at 
$250,000 per American household. The debt is now truly 
America's second mortgage, and its burdens keep compounding.
    And it is not just mandatory spending that has caused this 
problem. Just since fiscal year 2017, discretionary budget 
authority has grown 66 percent faster than the overall economy. 
In fact, the annual level of discretionary spending since then 
is $604,000,000,000 higher. At the same time, the dollar 
increase in mandatory healthcare spending has only been 
$374,000,000,000. Congress' decision annually to add more and 
more to discretionary spending has actually outpaced even that 
mandatory spending category.
    Every dollar spent by the Government is a dollar that is 
taken from hard-working Americans, and it is a dollar that is 
taken out of our economy. It redirects the fruits of the labors 
of the Americans that earned it, that produced those resources. 
This destructive crowding out sucks the oxygen out of the room 
and denies the investments that would lead to more job 
opportunities, higher wage levels, more innovation and 
technological growth, and the production of the goods and 
services that enrich our lives, improve our health, and extend 
our life spans.
    Further, I believe that it is imperative for Congress to 
use its power of the purse to block overregulation and abuses 
from the Federal branch. The Founders envisioned that Congress, 
whose appropriations power was not merely to set funding 
levels, but it was also there to protect the American people 
from the abuses of Government regulation and the power of the 
Government. I would urge this subcommittee to write more 
limitation provisions into its base text to defund some of 
these onerous regulations and to prune these abusive behaviors 
from the executive branch.
    If we are to restore America's vitality and our economy, to 
end the scourge of inflation, to avoid triggering a debt 
crisis, we must cut the size and the scope of the Federal 
Government. We must return those resources back to the hard-
working Americans that produced it. We must respect their 
dignity, what they have put into it. We must believe in their 
ability to build a better future for us, and we must preserve 
their rights, their God-given rights that allow us to build--
that have built the society that we have today.
    Now I have in my written testimony that I submitted a long 
list of programs that I believe would be good to reduce funding 
levels for to achieve the things we have talked about here. To 
highlight just a few of them, so we believe that the Federal 
job training programs have failed American workers. They have 
backed unions. They have demonstrated, produced lower wage 
levels and job stability than private sector programs that they 
outcompete.
    Nearly half of CDC spending, nearly a third of the Health 
Resources and Services Administration spending is unauthorized. 
It is largely the work of earmarks and spending that is 
produced outside of the authorizing committees, stripping those 
Members of Congress and the authorizing committees of their 
power to direct how these programs are created.
    Further, of course, there is a whole slew of funding that 
goes to things like the Public Broadcasting Company, that go to 
the Endowment for Arts and Humanities, that go into education 
that are not used to help promote Americans' education or to 
help build lives, but goes to grants to various entities. We 
would like to see these cut.
    And of course, education spending overall, we have among 
the highest rates of education spending and middling results. 
This is a classic case of the inefficiency caused by Government 
intrusion.
    Thank you again.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Would you like to comment?
    Ms. DeLauro. Oh, sure. [Laughter.]
    Mr. Aderholt. Okay. You have the floor.
    Ms. DeLauro. Thank you.
    And Mr. Stern, really I am delighted that you are here 
today because I think it really is helpful to listen to and to 
see the disastrous cuts that are being advocated by the 
Heritage Foundation. And quite frankly, I plan to cite the 
proposed cuts in the future.
    If people--and I have mentioned some of the folks who would 
like to see us move back to 2022, what some of those cuts would 
mean. Now folks will just say, well, maybe that is just DeLauro 
speaking. No, there is a reality out there, with everyone in 
this room and beyond whatever networks you have, to understand 
what is being suggested.
    Sometimes the public just doesn't believe that anyone would 
advocate to eliminate health and education programs, slash 
billions of dollars from the NIH research, from Head Start, 
education for low-income communities. But the list goes on, and 
I am sure you may have a more fulsome, robust list that I would 
love to get a copy of it, to tell you the truth.
    Listen, and to our friend who is here from the Institute of 
Museum and Library Sciences, Heritage would eliminate, it 
would--funding would be eliminated. So there is a reality, my 
friends. Understand and use your voices. Use every ounce of 
your being in your advocacy to thwart this disastrous effort.
    I am proud having served as chair of this committee, and I 
have served as ranking member in the past of this committee, 
where and in a bipartisan basis, we have invested in these 
programs, and we have invested in making opportunity real for 
people. And this is the subcommittee that has the greatest 
impact on people's lives, bar none, at every step.
    And then for us to sit back and roll back the domestic 
investments that have been made to benefit the American people, 
and the stories, the stories are rife with what is happening to 
people today and where they can begin to get help. I never see 
anything that says where is the cut? Where is the end to the 
tax breaks for the richest one-tenth of 1 percent of the people 
in this Nation?
    And to make sure that the biggest corporations are paying 
their taxes. That is a waste of taxpayer dollars, not the 
investments that have been made in this subcommittee over the 
years.
    And I will really shout from the rooftop, Mr. Stern, about 
where you and Heritage would like to take this country.
    Thank you, Mr. Chairman.
    Mr. Stern. Congresswoman, and we certainly appreciate you 
doing that. So we will be happy to make the list available.
    We make your annual budget available to the public, too, 
because we believe that the tradeoffs I was talking about are 
real and important, and it is important that we reduce that 
burden of Government to promote a better future for Americans.
    So happy to make that list available, and we make it 
available to everybody we can.
    Mr. Aderholt. Let me just--did you have something to say?
    Mr. Hoyer. I just want to--when you provide that list, I 
would like your economist to compute the cost of not investing 
because I think all too often, we see this expenditure of 
money, and we put a dollar figure. You heard me quote Agnew. 
``The cost of failure far exceeds the price of progress.''
    NIDCR, which is the dental institute, Dr. Lowe, when I was 
first on this committee, pointed out that in 1 year, as a 
result of the investment in dental research in this country--
including fluorides--in 1 year, they saved all the money that 
had been spent since NIDCR was created.
    So I am concerned about the fiscal. As you may know, I have 
been always concerned about the fiscal posture of our country. 
I think we have to be very careful. I share Ms. DeLauro's 
feeling that if we all paid our fair share, and we spent money 
wisely not only on the nondefense discretionary side, but on 
the defense discretionary.
    I don't know, do you have any cuts on the defense?
    Mr. Stern. We actually do have. So they are not in the 
jurisdiction of this committee. So they are not on the list. 
But we do actually have them that we think would be for 
efficiencies that you could plug back into better national 
defense. Yes.
    Mr. Hoyer. We will be glad to receive those as well.
    Mr. Stern. Absolutely.
    Mr. Hoyer. But----
    Mr. Stern. And Congressman, I will say we have scored what 
you are talking about. From our position, and we are very 
convinced of it, that investment you are talking about from the 
Government means a deprival of investment that Americans are 
doing. It means that Americans are investing less in these 
things that they would innovate, that they would build.
    So that tens of thousands of dollars of lost annual income 
I was talking about, that is our score on the dangers of when 
Government steals that investment from hard-working Americans 
and redirects it the way that bureaucrats want.
    Mr. Hoyer. Thank you. Mr. Chairman.
    Mr. Aderholt. Thank you. And let me just say for those of 
our guests that are here that may not be insiders, so to speak, 
and may not--I think you have seen what makes this committee a 
tough job. As no doubt, there is so many needs out there that 
we can make investment in.
    But to Mr. Stern's point, we do have over a 
$30,000,000,000,000 debt in this country. And to dismiss that 
completely and act as if it is not an issue I think would be 
doing a disservice to the American people.
    Now that doesn't mean that from my perspective, I think 
that we need to do smart investing in these things and making 
sure that things that make a real bang for our buck for the 
American people. But again, for those of you who may not be on 
a daily basis, you now see what makes this job hard and what 
will make my job as chairman of this committee. But I feel like 
we can work together, and we can come to some solution.
    So, thank you----
    Mr. Hoyer. Before you----
    Mr. Aderholt. Yes? Yes, sir?
    Mr. Hoyer. I just want to make a comment because I came in 
early to talk. The fact that all of you stayed is incredible.
    Ms. DeLauro. They do all the time.
    Mr. Hoyer. That is what I am told. Now when I was first in 
this--my first incarnation, when I was 30 years younger, that 
didn't always happen, Mr. Chairman. People would go in and out. 
Understandably, they testified, and then they left. Seeing Dr. 
Wilson sitting here the whole time, she started, and she is 
still here.
    But I congratulate you because, as Ms. DeLauro said and as 
the chairman said, it has given you an opportunity to see how 
we make choices in a democracy, and it is tough.
    Because each one of you has a firsthand knowledge of the 
issue that you are involved with, whether it is your son or 
whether it is a more general population, and you need to inform 
the American people with whom you deal of how these--I have a 
favorite saying, life is series of tradeoffs. If you do one 
thing here in the hour, you can't do the other thing during 
that hour.
    And that is what this committee, that is what this 
Congress, that is what you have elected your representatives to 
do. But we can do it better to the extent that you are more 
knowledgeable, and therefore, you can advocate not just to the 
people who are involved in the interest specifically that you 
have testified on, but who are trying to figure out how--as a 
Congress--Republicans, Democrats, liberals, conservatives, and 
everybody in between make these decisions.
    And my experience over the 42, 43 years that I have been 
here is that almost every Member that we come in contact wants 
to do the right thing. Whether they are conservative, liberal, 
Democrats, Republicans, they want to do the right thing. And 
our democracy's premises, the more you know, the more you 
communicate to us, the better we are going to do.
    Thank you.
    Mr. Aderholt. Thank you, Mr. Hoyer.
    And again, like I said, this is--and thank you for staying 
around because I think it is important to hear from some of the 
other issues that you may not be familiar with. You are well 
familiar with your issue, but some of the other issues. But 
also to hear about--hear from the Heritage Foundation, which I 
think is important as well because, obviously, we don't have 
unlimited resources.
    And I would say for all of you who gave out a dollar 
amount, I said if we had unlimited resources, let us double it. 
But unfortunately, we don't live in that perfect world.
    But we will do the best we can. We look forward to working 
with you, and we will be following up with any questions.
    So thank you, and the hearing is adjourned.

                                           Tuesday, March 28, 2023.

                DEPARTMENT OF HEALTH AND HUMAN SERVICES

                                WITNESS

HON. XAVIER BECERRA, SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES

                      Chairman's Opening Statement

    Mr. Aderholt. Well, good morning. Good morning, Mr. 
Secretary. It is a pleasure to have you to the Subcommittee on 
Labor, Health and Human Services, and Education for our very 
first budget hearing of the year, which happens to be my first 
budget hearing as chairman. And we look forward to hearing your 
testimony today and thank you for being here.
    As I have been trying to come up to speed as the new 
chairman, I have been learning more about the incredible 
breadth of the programs that are under the jurisdiction there 
that you oversee from a day-to-day basis. From research that 
will, hopefully, cure diseases like cancer and Alzheimer's, 
providing childcare and early learning for the youngest 
Americans, training our next generation of medical 
professionals, and administering health insurance for our 
Nation's poor and aging population, it is clear that your 
responsibility and your departments are very many.
    There are many programs in your budget that I think we all 
agree are priorities, and we can collectively support. I share 
your concerns about maintaining our biodefense and preparedness 
for threats both from abroad and arising from natural means. I 
support biomedical research that will help cure cancers, 
dementias, and the other chronic health diseases that cut so 
many lives short, especially in rural America as well as across 
the Nation. I support programs that provide quality early 
education, access to quality healthcare, and programs to help 
people with disabilities live independent lives on their own 
terms.
    And then, of course, there are other policy areas that I 
know we will have disagreements on. It is the responsibility of 
this subcommittee to determine how we can support the most 
critical programs, identify the investments that will give us 
the greatest return, and face head on the challenges of limited 
resources that we have available to us right now.
    Unfortunately, hard decisions will have to be made. I look 
forward, though, to having a discussion with you this morning 
about the areas of top priority and what they are from your 
perspective so that we can invest the taxpayer dollars more 
wisely, given the expected funding constraints.
    I must say at the outset that it is disappointing to see 
that your budget continues to double down on out-of-control 
Government spending, which only adds to our already-high 
inflation rates. And I think we can all agree that inflation is 
a burden on every American, but it also hurts those on the 
margins of our society the most.
    Taxpayer spending for what many of us feel are partisan 
priorities like Sexual Gender Minority Research Office within 
the National Institutes of Health and nearly doubling the 
funding for the Title X program, which under this 
administration is making grants to abortion providers, does not 
seem to be the best use of taxpayer dollars.
    In addition, the President's failure to secure our Southern 
border is resulting in billions of dollars in taxpayer 
funding--or taxpayer spending, rather, to care for 
unaccompanied minors who illegally cross our borders to look 
for work. While border security is the jurisdiction of the 
Department of Homeland Security, these minors, as you know, are 
the responsibility of HHS through the Office of Refugee 
Resettlement.
    Sadly, many of them are ending up in dangerous and abusive 
situations at the hands of so-called sponsors, and your agency 
is releasing them to these so-called sponsors. Simply put, I 
think this has to end.
    I would also be remiss if I did not point out that many 
management challenges face you at the helm of HHS. From the 
continuing problems with administering the Provider Relief Fund 
to overseeing a public health agency that has almost totally 
lost the public's trust, there seems to be no shortage of areas 
in need of some improvement. I hope, as I know many of my 
colleagues do as well, that we can learn this morning of what 
you are doing to take positive steps in these areas.
    Finally, there are many external challenges facing the 
Department. Threats to cybersecurity, threats from new and 
evolving diseases, and the many challenges of poverty and 
access to care also land on your doorstep. I look forward to 
hearing your ideas to help combat these areas as well this 
morning.
    I am pleased that you agreed to send an agency witness to 
our hearing tomorrow on the challenges of what rural America is 
facing. This is an important topic for many members of this 
subcommittee, and your agency is responsible for many programs 
that can help these citizens. We look forward to learning more 
about them, and I am hopeful that we will continue to hear from 
your agency in the coming months on other timely topics that 
will inform our spending decisions.
    As a reminder for everybody this morning and to our 
witnesses, we will go by the 5-minute rule so that everyone 
will have a chance to get their questions asked and answered, 
and certainly including myself under the 5-minute rule as well.

                    Ranking Member Opening Statement

    But before we begin, I would like to yield the floor to our 
ranking member, who is certainly no stranger to this 
subcommittee. So the gentlelady from Connecticut, we recognize 
you for your opening statement.
    Ms. DeLauro. Thank you very, very much, Mr. Chairman.
    And I want to welcome the Secretary this morning, dear 
friend, a former colleague--Secretary Becerra--and thank him 
for testifying today.
    Just a shout-out to the Alzheimer's Association here. Love 
the purple shirts in here, but love the work that you do. Thank 
you. Thank you.
    Well, Mr. Secretary, when you came into office 2 years ago, 
our Nation was reeling from a painful health and economic 
crisis, making your job even more critical, but also more 
difficult. And over the past 2 years, you have made great 
progress to support working families and the health and the 
well-being of the American people.
    Alongside the administration, this committee made historic 
investments through the 2022 and 2023 appropriations packages 
to reverse decades of underinvestment in the programs that 
American families rely on. We lowered the cost of prescription 
drugs, supported working families, made healthcare more 
affordable, strengthened lifesaving biomedical research, 
bolstered our public health infrastructure, and addressed 
urgent health needs.
    And today, I look forward to discussing HHS' 2024 budget 
request, which builds on that critical progress. This budget 
takes important steps to continue tackling our Nation's most 
pressing health needs and supporting families while making our 
communities healthier and safer.
    An increase of $1,900,000,000 for the Centers for Disease 
Control and Prevention would bolster our Nation's public health 
and help State and local public health agencies strengthen 
their infrastructure, while making strides in maternal and 
infant health, behavioral health, gun violence prevention. My 
God, what happened yesterday?
    The maternal mortality rate in this Nation, especially 
among black and brown women, is unacceptable and, frankly, 
appalling. I thank you for taking steps to continue addressing 
it.
    This is not just about infectious diseases. This budget 
will also strengthen our public health agencies so we can 
support food safety, early detection and prevention of cancer, 
opioid prevention and surveillance. We must be ready for any 
current and future crisis. We must end the cycle of complacency 
that leaves us scrambling when a crisis hits.
    And with a significant increase for substance abuse and 
mental health services and the SAMHSA programs, we would 
provide more mental health services to children, strengthen 
recovery support services and opioid prevention and treatment, 
and continue the 988 Suicide and Crisis Lifeline.
    American families need our help. This budget acknowledges 
that reality. Families are facing a childcare crisis. This 
budget would lower costs, expand affordable early learning 
programs, with significant increases for Child Care and 
Development Block Grants, Head Start, and Preschool Development 
Grants.
    And with a significant increase for the Health Resources 
and Services Administration, the administration is prioritizing 
innovative ways to support the health of mothers and kids, 
strengthen community health centers, end the HIV epidemic, and 
increase access to contraceptive care.
    In the wake of the Supreme Court's disastrous decision to 
strike down Roe v. Wade, we need to support reproductive 
healthcare, and family planning has become even more 
pronounced. The President's budget includes an increase of 79 
percent for Title X family planning to provide affordable 
contraceptive services and healthcare to nearly 2 million low-
income women and men across the country.
    This program has helped nearly 195 million people over its 
more than 50-year history, many uninsured. This is a critical 
bedrock of our public health safety net, and we will never stop 
fighting for those who depend on it.
    I do want to mention my worry that the proposed increase of 
less than 2 percent for the National Institutes of Health is 
insufficient and threatens the progress this committee has made 
through significant sustained investments in biomedical 
research. The Advanced Research Projects Agency for Health, 
ARPA-H, would receive an increase of $1,000,000,000, a 
disproportionate increase, in my view, compared to the small 
increase at NIH.

                             SPENDING CUTS

    People depend on these programs, which is why I must 
mention how deeply concerned I am over extreme--some House 
Republican calls for massive spending cuts and even more 
extreme calls by some former Republican officials to eliminate 
so many of the programs that keep families healthy, safe, and 
prosperous. These cuts would be devastating to children, 
families, seniors, veterans. We should be doing everything we 
can to increase access to these programs, not cutting off vital 
services to the people who need them.
    I do not believe that some of my Republican colleagues 
realize the implications of these cuts. Just let me run through 
some of the scariest numbers that you shared in your letter to 
me.
    If these cuts were implemented, 200,000 children will lose 
access to Head Start; 100,000 children lose access to 
childcare, undermining the early education of our kids and 
their parents' ability to get to work.
    Perhaps even more staggering, amid a mental health and 
overdose crisis, nearly 1 million people facing a suicidal or 
mental health crisis would not be able to access support 
services through the 988 Suicide and Crisis Lifeline. Tens of 
thousands of people could be refused opioid use disorder 
treatment, denying them lifesaving healthcare.
    An estimated 2 million vulnerable individuals and families, 
including rural and underserved populations, would lose access 
to healthcare services through community health centers, like 
the Fair Haven Community Health Center in New Haven, 
Connecticut, that I visited last week. And despite the looming 
rise of food insecurity, nutrition services such as Meals on 
Wheels would be cut for more than a million seniors.
    I would also add that the cuts of this magnitude would 
dramatically impact the CDC's ability to support State and 
local health agencies, weaken our public health infrastructure 
and capacity. More than 70 percent of CDC funds go to public 
health partners, including our State and local health agencies. 
Such extreme cuts would be felt all over our Nation, would make 
our communities much more vulnerable to a public health crisis.
    The cuts are unrealistic, unsustainable, and unacceptable. 
They threaten so much of the progress we have made in recent 
years. They put people at risk. Like you and President Biden 
know, investing in families is how we make our economy stronger 
and our communities safer. I will never stop fighting these 
dangerous proposals.
    Mr. Secretary, I thank you for your dedication doing the 
same. I look forward to hearing your testimony.
    With that, Mr. Chairman, I yield back.
    Mr. Aderholt. Thank you, Ms. DeLauro.
    And Mr. Secretary, we look forward to your testimony, and 
you are recognized.

                     Secretary's Opening Statement

    Secretary Becerra. Chairman Aderholt, Ranking Member 
DeLauro, and members of the committee, thank you very much for 
the invitation.
    A lot has happened in the year since I last spoke to this 
body about the budget. More than 16 million Americans have 
secured health insurance through the Affordable Care Act 
marketplaces. That is an all-time high. Altogether, more than 
300 million Americans today now carry insurance to cover their 
healthcare. That is an historic high.
    The President's new lower-cost prescription drug law has 
capped insulin at $35 per month and made preventive vaccines 
like the flu, COVID, shingles vaccines available for free under 
Medicare. Moving forward, this new law gives us the right to 
finally negotiate lower prescription drug prices for Americans.
    And to cap it all off, the Biden-Harris administration has 
safely and effectively executed the largest adult vaccination 
program in U.S. history, achieving nearly 700 million shots in 
arms during the COVID pandemic without charge.
    The fiscal year 2024 budget proposes $144,000,000,000 in 
discretionary funding and $1,700,000,000,000 in mandatory 
funding for HHS. It positions us to tackle the urgent 
challenges we face, including a growing behavioral health 
crisis and future public health threats. It also funds 
operations and mission-critical infrastructure needed to build 
a healthier America, moving the Nation from an illness care 
system to a wellness care system.
    An illness care system leaves our most vulnerable families 
behind. A wellness care system invests in providing the full 
spectrum of healthcare to all Americans.
    Illness care allows the price of prescription drugs to 
skyrocket. Wellness care starts by prescribing fruits, 
vegetables, and exercise. It treats food as medicine.
    Illness care requires you to get a referral by your family 
physician to see a specialist for mental health services. 
Wellness care lets you get mental healthcare the minute you 
walk through the door of your family physician's office.
    Illness care forces hard-working Americans to deplete their 
life savings to be able to qualify for long-term care that they 
need. Wellness care invests early in long-term care like in-
home care, so our older adults and Americans with disabilities 
can thrive at home and in their communities.
    Our budget invests in wellness care. And we invest more 
than $30,000,000,000 to prepare us for the next COVID or public 
health crisis, including $1,000,000,000 to replenish our 
Nation's Strategic National Stockpile.
    On behavioral health, too many of our loved ones are dying 
from suicide and overdose. So we increase access to crisis 
care. We grow the behavioral health workforce, and we beef up 
substance use services. We are also gearing up to handle more 
than 6 million additional contacts from people who are 
experiencing a mental health crisis through 988, the three-
digit Suicide Prevention Lifeline we stood up last year.
    This budget covers 2 million adults left out of Medicaid by 
their home States and extends tax credits to make their 
healthcare more affordable for millions of Americans. It would 
also ensure that expanded postpartum Medicaid coverage for a 
new mom and her baby is here to stay. The President's budget 
not only strengthens Medicare for today's seniors, but it 
protects and strengthens it for the next generation.
    We also take care of our family members in this budget, 
investing $600,000,000,000 in childcare and preschool programs, 
and $150,000,000,000 to strengthen Medicaid home and community-
based services. This budget funds the Cancer Moonshot, ARPA-H. 
It invests in Title X family planning programs, so essential to 
so many of our families. It delivers on our commitments made as 
part of the National Strategy for Hunger, Nutrition, and 
Health.
    It opens more community health centers. And important to me 
as a former Attorney General, it bolsters our healthcare fraud 
and abuse detection and enforcement work.
    And the President's budget honors our responsibilities to 
Indian Country, with more than $2,000,000,000 in new resources 
in 2024. Last year, for the first time, you gave the Indian 
Health Service advance appropriation, providing the same 
protection against budget uncertainty that other health 
services receive. We hope to build on that progress this year.
    This budget reflects the President's and our values and 
commitments. It helps begin the move from a nation focused on 
illness care to one about wellness care, and most importantly, 
it ensures health and wellness are within reach for all 
Americans.
    On behalf of the women and men of HHS, we look forward to 
working with you. Mr. Chairman, I thank you, and I yield back.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                             5-MINUTE RULE

    Mr. Aderholt. Thank you, Mr. Secretary.
    Let me start out. And again, I just will remind everybody 
we will do the 5-minute rule. So we will try to abide by that 
today. So thank you all for understanding since we have a lot 
of folks here that want to ask questions.

                          UNACCOMPANIED MINORS

    But Mr. Secretary, it was disheartening to read the 
widespread reports of unaccompanied teenagers who enter through 
the Southern border without a parent, and they end up in the 
hands of human traffickers, and they are forced to work long 
hours in dangerous jobs. In previous statements, you have 
compared the Department's work in releasing minors into the 
U.S. as ``an assembly line'' and encouraged your staff to 
expedite the release of children.
    In light of these child labor violations, what changes will 
you be making to ensure that children are placed with suitable 
sponsors, and what efforts is the administration taking to 
address the flow of migrants into the U.S. after Title 42 is 
lifted in May?
    Secretary Becerra. Chairman, thank you for the question, 
and I hope to explore this with you and members in more detail 
because I think all of us, whether it is--I have three 
daughters that I raised. I have worked on immigration issues 
for the longest time. When I was a Member of Congress along 
with you, I had one of the largest populations of migrant 
families.
    And so I must tell you that this is very important. 
Children are children, regardless of where they are from. And 
so we do everything we can to make sure we protect those 
children while they are in our custody.
    I would say to you that what we have done with regard to 
the unaccompanied migrant children that come into our custody 
after Department of Homeland Security transfers them to us--
because they are not allowed to keep them by law for more than 
72 hours--is we provide them with the care that we can while we 
are in the process of trying to find a suitable sponsor who can 
provide care for them while these kids are waiting for their 
immigration proceedings to move forward.
    We in the process look for a responsible sponsor. We vet 
everyone who is coming through as a potential sponsor, and we 
don't release that person until they have gone through 
background checks and can pass those checks. Some of the 
stories that we are reading, I agree. It is unconscionable that 
there are companies, there are employers in America who are 
employing 12- and 13-year-olds to do work that even is 
dangerous for an adult. We have labor laws against that kind of 
child labor, and we should take action on that.
    But when it comes to the care of those children while they 
are in our custody, we do the best we can. And because every 
specialist on childcare will tell you, it is better to have a 
child in a home instead of in a large Government, federally 
sponsored congregate care setting, we do what we can to find a 
responsible sponsor. Usually that means a family member. Close 
to 90 percent of the cases, it is an immediate family member 
that we place these kids with.
    And so we do everything we can, and we try to do as much 
follow-up as we can. If you give us more authority and more 
resources, we could do more. But we will do what we can because 
kids are kids.
    Mr. Aderholt. Oh, in light of it with these reports, is 
there anything that you have been able to try to change to try 
to combat some of the things we are hearing?
    Secretary Becerra. One of the things that we are doing you 
may have heard is the Department of Labor and HHS, we are going 
to try to work a little closer. Because they are working on a 
number of investigations that might relate to child labor 
violations, and it may include some migrant kids.
    So we are trying to see if they can give us access to some 
of their preliminary information that they have been collecting 
in their investigations, clearly keeping it confidential, so we 
can see if somehow that might pinpoint to us the individuals 
who may be applying to be sponsors, but really shouldn't if 
they are engaging in labor law violations.
    But we are going to try to work closer in that respect. We 
are going to try to make use of some of the money that Congress 
has given us to see if we can do continued post-release follow-
up with the kids. We would need some authorities because those 
children nor their sponsors have any obligation to stay in 
touch with us once we have released that child.

                            LIFTING TITLE 42

    Mr. Aderholt. Can you talk a little bit about the efforts 
of the administration trying to address the flow of migrants 
after the Title 42 is lifted in May?
    Secretary Becerra. Yes. And I will try to stay to the 
unaccompanied migrant kids. That is the jurisdiction we have. I 
know that the administration has a whole-of-government 
approach, and the Department of Homeland Security could 
certainly tell you about the number of efforts that are 
underway to try to deal with those that are at the border 
itself.
    You are probably reading about reports about how the U.S. 
has reached an accord with Canada and is looking to reach an 
accord with Mexico and how we would handle people who were 
trying to cross the border. That is Department of State. That 
is Department of Homeland Security.
    What I can tell you with regard to HHS is we have done 
everything we can to make sure that if a child is--without any 
adult supervision is found at the border, that we are able to 
ensure that DHS, Department of Homeland Security, will not be 
in violation of the law by placing that child in what is 
essentially an adult detention facility not meant for children. 
And that is where we take on the responsibility to find a 
decent place to care for that child while we look for a 
responsible sponsor.
    Mr. Aderholt. Thank you. Ms. DeLauro.
    Ms. DeLauro. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary.

                              FUNDING CUTS

    A couple of questions. One, there are some in the 
Republican House majority that are demanding massive funding 
cuts in the fiscal year 2024 appropriations. It would appear it 
might be up to 22, 25 percent. It could go higher.
    Mr. Secretary, give us an idea about the real impacts of 
the cuts being proposed with regard to using those 2022 numbers 
for the 2024 budget. If you could describe the human 
consequences to children, families, seniors, veterans, and 
folks across the country?
    Secretary Becerra. Congresswoman, first, I have to thank 
you for all the work you have done to get us to a point where 
we had additional resources for programs like Head Start, for 
childcare, even unaccompanied migrant children.
    What we understand is that there is discussion here in the 
House of trying to keep funding at fiscal year 2022 levels. The 
Office of Management and Budget, which does the budget 
calculations for the administration, has asked us to formulate 
what would happen if we were to have a 22 percent reduction in 
these discretionary programs at HHS. What we can tell you is 
that it would lead to some 100,000 slots for childcare being 
eliminated from our funding opportunity, which means these 
families, most of these families would not be able to afford 
other childcare options.
    It would mean that there would be a loss of some 200,000 
slots for children in the Head Start program. And again, these 
are for low-income children. So very unlikely that their 
parents could find a different alternative for preschool 
support for their kid.
    The Indian Health Service, which I just mentioned--Congress 
did a phenomenal job of making sure we could provide some 
stability in their health services--it would cut off some 2 
million people in some of the most vulnerable communities that 
we have from access to healthcare. And in Indian health 
services itself, we would probably see a reduction in inpatient 
admissions at some of the IHS facilities by some 10,000 
inpatient visits and outpatient visits by nearly 4 million.
    The Low-income Home Energy Assistance Program, which helped 
a lot of families survive the winter by being able to afford 
their energy, the fuel they needed, would see their benefits 
cut from $529 to about $413 on average. Somewhere in there, 
$400 to $500. They would lose an ability to have additional 
help to pay for their energy, their heating needs, cooling 
needs, in summer and winter.
    I could go on. NIH, nutrition services, our behavioral 
health services. I could go on, but Congresswoman, I don't want 
to use up all your time.
    Ms. DeLauro. Well, thank you. And I would just ask you 
another question. Have my colleagues on the other side of the 
aisle made any similar request for information about the impact 
of the cuts they intend to make? It is kind of a yes or no 
question, Mr. Secretary.
    Secretary Becerra. I am not aware of a particular request 
for information on what the impact would be in terms of cuts. I 
know that we have had dialogue with a number of members.

                      988 SUICIDE CRISIS LIFELINE

    Ms. DeLauro. Okay. Quickly, on the 988 Suicide Crisis 
Lifeline, Mobile Crisis Response Teams, we increased the 
funding to $500,000,000 more because this was--we created the 
Mobile Crisis Response Team so that we could help those who 
were experiencing a mental health crisis be treated by 
healthcare professionals rather than law enforcement, and we 
created a $10,000,000 pilot program and increased it to 
$20,000,000.
    Tell me what kind of success have we had--or talk about the 
first 9 months of the 988 Suicide and Crisis Lifeline, as well 
as how the additional funds have ensured that individuals are 
connected to the proper healthcare service and what you have in 
mind for the increased expansion of the mobile crisis teams.
    Secretary Becerra. And Congresswoman, for folks who aren't 
fully familiar with 988--and I hope they will become as 
familiar with 988 as they are with 911, because 988 is 
essentially 911 for those who are experiencing a mental health 
crisis. It used to be you would have to know a 10-digit phone 
number to be able to call in, and it would be a different phone 
depending on what region of the country you were in.
    And so if you were on the verge of actually committing 
suicide, and you were deciding to make that final attempt to 
reach out to someone, if you didn't know the phone number, that 
would be tough. If you knew the number, but you happened to be 
in a different part of the country, it might not be the right 
number.
    And so you all had the wisdom of saying let us make this 
smart. Let us do it the way we do for 911. 988. What we did 
because it is not a Federal program--it is a State-operated 
system--is we tried to make sure that the States were ready to 
go. Because a lot of States are in need of infrastructure 
support, and COVID made it very difficult for everybody to 
figure all this out.
    So we did the best job we could to tie things together. We 
essentially were the glue for 988, and I thank all the States 
that actually stepped up.
    Some still have to do a little bit more work, but some have 
even gone to the point of coming up with a permanent funding 
stream for 988. The result, July 2022, we launched. Within that 
first 6 months, we saw a 50 percent increase in the number of 
people calling.
    That is great news. It is also terrible news. It shows you 
just how many people are calling and asking for help before 
they make the wrong call. And so we hope we could continue to 
move forward. That is why we want to do 6 million more 
additional contacts. We are going to help States, but we hope 
you will look at our budget and give us that support.
    Ms. DeLauro. Thank you.

                         HHS LETTER ABOUT CUTS

    Mr. Aderholt. Dr. Harris.
    Mr. Harris. Thanks very much. Thank you very much, Mr. 
Secretary, for being here.
    First, with regard to your letter about the cuts, it was 
pretty lazy work, to be honest with you. You just assumed a 
level cut all across the agency, which, of course, again that 
would be pretty lazy work on our part, if that is what we did. 
But I get it. I get the political point you made.
    For instance, you didn't assume that maybe we should ask 
our State partners under the expanded Medicaid program to just 
contribute the usual FMAP, and we could raise enough money from 
the States with that just to, oh, pay for all those--all those 
programs that you think are so valuable. But I get it. You 
don't want to ask our State partners to participate.

                       HHS REMOTE WORK PRACTICES

    I am going to ask unanimous consent to show a picture here 
that I think you have seen before, Mr. Secretary. I think you 
saw it on the other side of the Capitol. I am just going to ask 
you because this is, my understanding, a parking lot taken--a 
picture of a parking lot during business hours in Maryland at 
the CMS headquarters. Do you have any reason to believe this is 
not a valid picture?
    Secretary Becerra. Um----
    Mr. Harris. No, you don't.
    Secretary Becerra [continuing]. I will accept your 
representation.
    Mr. Harris. Okay. So maybe you can just very briefly 
explain why it is empty during normal business hours? Are we 
really paying employees not to be at work? And specifically, 
are we paying them locality pay not to be at work? Are we 
paying them actually perhaps even additional money not to be at 
work?
    Secretary Becerra. So I can't speak to the photo. I don't 
know where it comes from or when it was taken. But what I can 
do is speak to the workforce at HHS. We work full time. We do 
our best to make sure everyone----
    Mr. Harris. Mr. Secretary, my question is very specific. 
The locality pay question. Are you paying workers who are at 
home additional locality pay when they don't come to work.
    Secretary Becerra. Congressman, thank you for the question.
    We can only provide locality pay if someone is eligible for 
it.
    Mr. Harris. Okay. So you are. Thank you. All right.

                         GENDER AFFIRMING CARE

    Now, with regards to the President's comments about funding 
gender-denying mutilation surgery. That is all I can call it 
because, believe me, I have seen bilateral mastectomies. I have 
seen ``connectomies'' for trauma. These are gender-mutilating 
surgeries.
    You really want to pay for that under the CHIP program? Is 
the President serious? He wants to take our Childhood Health 
Insurance Program and pay for this?
    Secretary Becerra. I want to be----
    Mr. Harris. Yes?
    Secretary Becerra. I want to be careful how I answer this 
because I answer this as Secretary, but I also answer this as a 
father.
    Mr. Harris. Sir, I am just asking--be direct. This is a 
very simple question. Does the President want to use CHIPs 
money to pay for gender mutilation surgery?
    Secretary Becerra. If it is a simple question, I will tell 
you the simple answer is we want to make sure that everyone in 
America has access to the healthcare that they need, whether 
you are a child or an adult.
    Mr. Harris. So the answer is yes. So the President 
perceives and you perceive that that mutilation surgery is what 
the child needs? Not what the child might want, what the child 
needs. Is that your testimony today?
    Secretary Becerra. Congressman, my testimony is that, as 
you know, we cannot provide any dollar, taxpayer dollar for any 
service that is ineligible under Federal law. But we make sure 
that if it is eligible under Federal law, we will do everything 
in our power to make sure that child, that adult gets that 
care.
    Mr. Harris. So even in States where that underage surgery 
is illegal, your position would be that you should be paying 
for those surgeries?
    Secretary Becerra. We only comply with the law when it 
comes to the distribution of Federal dollars, and so, 
therefore, we make sure that any Federal dollar that goes out 
is to provide the care that medical professionals say that that 
individual needs.
    Mr. Harris. I see. Regardless of their age?
    Secretary Becerra. A medical professional has to make a 
decision, and then that individual would have to make a 
judgment.
    Mr. Harris. Even in those States where that would be 
illegal under State law?
    Secretary Becerra. Congressman, you are asking me to 
speculate on something that I am not aware of. And so if you 
could point out where there is an act that is occurring that is 
against the law, we can talk about that. But at the Federal 
Government, we spend our money complying with the law.
    Mr. Harris. Okay. Thank you very much.

                    NO SURPRISES ACT IMPLEMENTATION

    Now just in my remaining time, I am going to ask a little 
bit about the No Surprises Act implementation because it has 
been a fiasco. I get it. The insurers are in control at HHS. I 
fully understand it.
    And they have the Department, of course, which has lost the 
first Texas case. You know you lost it. You didn't even appeal 
it. I mean, obviously, you were caught dead to rights in really 
I would say conspiring with the insurance companies about the 
qualified payment amount and to be used as a benchmark for this 
No Surprises Act arbitrations.
    Now you raised the fee to ask for an arbitration on the 
part of a physician who feels they are being unfairly treated 
by an insurance company. A multi, multibillion dollar--these 
companies make tens of billions of dollars in profit. You 
raised the fee from $50 to $350.
    Now I was in State government before, and let me tell you 
something. I don't think we ever multiplied a fee by a factor 
of 7 ever. Yet you all did it. And you have also said that 
these claims are--too many of the claims are ``frivolous'' 
because there is ``no cost to file claims.'' This is before the 
Senate Finance Committee. This is your testimony there.
    Do you still feel that most of those claims are frivolous, 
and do you also feel that maybe a $350 fee might not be no cost 
to file claims?
    Secretary Becerra. Congressman, what I would urge you to do 
is talk to the judges, the arbitrators that have to go through 
these cases who, by the way, do not get paid for their service 
unless a claim goes all the way to an outcome. If a claim is 
frivolous, it does not go to an outcome, and those judges are 
spending vast amount of their time trying to adjudicate claims.
    There are any number--we are receiving exponentially more 
claims than you ever thought or we ever thought, more than the 
seven times you are saying that the rate of filing has gone up. 
We have to somehow make sure that no one thinks it is a free 
thing, a free ride to just submit a frivolous claim, bog down 
the system, and prevent the legitimate claims from being 
adjudicated so people can get paid.
    Mr. Harris. Thank you very much, Mr. Chair. I yield back.
    Mr. Aderholt. Mr. Hoyer.

                              TELEWORKING

    Mr. Hoyer. Thank you very much, Mr. Chairman.
    First, let me, as a representative of, I presume, a lot of 
those employees who are working at home, as they are at IBM or 
Costco--not Costco so much, but technical firms, other firms 
who are finding it as efficient because they work on computers. 
And where the computer is located is somewhat irrelevant.
    But they are paid locality pay not because of where they 
park, but because where they live. And if the cost of living is 
a very high cost of living, they are paid a differential, which 
the Congress and the President of the United States decided was 
okay under the Federal Employees Pay Comparability Act, which I 
introduced in 1990 and which was signed by George Bush. Let me 
just get that out of the way.
    Now, secondly, Mr. Secretary, thank you very much for your 
testimony. Thank you very much for your letter.

                              PROGRAM CUTS

    I have not heard anybody campaigning in America that says I 
want to have 200,000 less 3- and 4-year-olds in Head Start, 
notwithstanding the fact they are eligible. They simply say 
they want to cut the program.
    Nor have I heard anybody saying that they want 105,000 less 
children cared for while their parents are at work. What they 
say is they want to just cut childcare.
    Nor have I heard anybody say they want 900,000 less 
responses to people who call on the brink of suicide. Nor have 
I heard anybody say we want 29,000 less people admitted to 
opioid crisis programs. I just hear we want to cut.
    Nor do I hear that we want to have 2 million of the most 
vulnerable people in America not have access to healthcare 
centers. We just want to cut.
    Nor on, you mentioned, Indian health--1.6 million less 
visits, 120,000 less dental visits for Indians who have been 
shut out in many respects and whose land we stole from them 
many years ago. I just hear we want to cut.
    Now I could go on ad nauseam, I suppose, on so many 
different areas. Head Start has, since I served on this 
committee, almost invariably served about half of those 
children who were eligible. Why? Because there were not 
sufficient slots. I think that has a ramification. Because if 
you don't invest in those children, they become not necessarily 
taxpayers, but tax takers because they fall behind very 
quickly.
    So, Mr. Secretary, I appreciate the letter that you wrote. 
It is somewhat--I don't know about it being a lazy letter. I 
think really the problem with it, it is too accurate a letter. 
This committee, Mr. Secretary, as you well know, is a people's 
committee whose actions have an extraordinary impact on the 
well-being of our people, the education of our children, and 
the healthcare of our people.

                       MATERNAL AND CHILD HEALTH

    Mr. Secretary, let me ask you a couple of specific 
questions. First of all, I have been very interested in 
maternal/child health. We are the richest country on Earth. We 
perceive ourselves to be a very sophisticated country. I 
believe that as well.
    However, in terms of maternal health, particularly maternal 
health for minorities, we are not doing well. We are not only 
not doing well in terms of the wealthiest countries in the 
world, but we are not doing too well even among those in the 
middle. Would you explain that and tell me what impact a 
cutting of this maternal healthcare would have in America?
    Secretary Becerra. Congressman, thank you for the question.
    It is hard to believe. When you tell that to most 
Americans, they won't believe it that we have women dying 
shortly after birth, after giving birth at rates that would 
compare with developing countries and, in some cases, worse. We 
have children, newborns who are dying at rates that would 
compare to those of developing countries, and in some cases 
worse. Two to three times worse, especially in our black 
community. Two or three times worse, especially in our 
indigenous, our Native American community.
    Much of it is a legacy of lack of access. Much of it is 
difficulty affording the care. Much of it is just neglect. And 
that is why the President has taken this on with a great deal 
of fervor. And we are today, for example, offering States a 
challenge. We, at the Federal level, through Medicaid will make 
sure that we provide a woman and her new baby access to 
postpartum care after they deliver not just for 60 days, which 
is what is traditionally within Medicaid, but for 365 days.
    So far, some 30 States have taken us up on that challenge, 
and the President's budget will make that a permanent part of 
Medicaid. But so far, there are still 20 States who are 
unwilling to let the Federal Government pay for the vast 
majority of the costs in Medicaid for the care, postpartum care 
for that mother and her baby.
    We can do this, and we are going to try really hard. We are 
also making investments in programs that don't require us to 
pay a physician. But the doula programs that help a woman as 
she is getting ready to deliver and help her after delivery, 
those are very cost-effective programs that essentially give a 
woman and her baby access to someone who knows how to care for 
a woman and her baby.
    Mr. Hoyer. Thank you, Mr. Secretary.
    Mr. Aderholt. Mr. Fleischmann.
    Mr. Fleischmann. Thank you, Mr. Chairman.

                         ALZHEIMER'S TREATMENTS

    Mr. Secretary, thank you for appearing before us today.
    I do also want to honor and acknowledge all the wonderful 
folks from the Alzheimer's. Thank you for your persistence and 
all you are doing to try to cure this disease. Thank you.
    Mr. Secretary, my first questions are in the realm of 
Alzheimer's. One in three seniors die from Alzheimer's or a 
related form of dementia. Members of both parties have 
expressed concern to this administration regarding the national 
coverage determination policy and its impact on access to 
Alzheimer's therapeutics and diagnostics. This new class of 
Alzheimer's treatments gives families hope that they will have 
more quality time with their loved ones before the disease 
takes hold.
    The VA and the CMS have had the same trial data made 
available to them regarding these potentially life-changing 
Alzheimer's treatments. The VA chose to evaluate the available 
trial and data in open access, albeit with restrictions to 
patients. What is holding CMS back from taking a similar 
approach, sir?
    Secretary Becerra. Congressman, thank you for the question.
    And first, I think it is important to talk about how we 
have made so many advances, and we are getting to the verge of 
being able to treat conditions like Alzheimer's. And FDA took 
that step and said that they were moving forward with approval 
of that Alzheimer's drug, finding it safe and effective. They 
are still waiting for additional clinical trials to come in 
with further evidence to find out if their actions can be left 
with a standard approval, which would be the full approval 
needed within FDA.
    Medicare services are received under the Centers for 
Medicare and Medicaid Services, and those are treated 
differently than the way FDA treats the issue of whether a drug 
should be put on market, as you know. And CMS goes through a 
different analysis.
    What I will note is that CMS did create a coverage path for 
this new Alzheimer's drug. It is a limited path because CMS is 
also waiting to receive more evidence of the utility of the 
medicine, and as soon as FDA collects some of that evidence 
they are trying to get and gives standard approval, then you 
will see CMS quickly move as well to try to qualify that drug 
for coverage within the CMS standard.
    You have to remember there are two different standards by 
two different agencies, but the most important thing is to 
remember that whether you are at FDA, you are at CMS, or at 
that dais, or sitting here, all of us know someone who is 
suffering from dementia, Alzheimer's, and it is incumbent upon 
us to move as quickly as we can.
    Mr. Fleischmann. Thank you, sir. A follow-up to that.
    How many times has CMS provided coverage for drugs or 
therapeutics approved under the FDA's accelerated pathway?
    Secretary Becerra. And so it is not so much that they have 
provided coverage based on the FDA's approval based on an 
accelerated pathway, it is that the CMS has gone through its 
analysis, separate analysis, and made a determination that 
based on the requirements that Congress has set for CMS by law, 
that those requirements have been met.
    Mr. Fleischmann. Understood.

                         DOMESTIC MANUFACTURING

    I want to switch to my last question on PPE. Mr. Secretary, 
during the pandemic, a number of companies made a substantial 
investment toward domestic manufacturing of personal protection 
equipment. I am aware of one American manufacturer that 
actually produces 1 gown per second 7 days a week, 24 hours a 
day, and has engaged with 6-year contract agreements with over 
30 U.S. health systems.
    My question, Mr. Secretary, is what is being done by HHS to 
shore up these domestic manufacturers such as this company I 
have actually alluded to that is doing that? One gown per 
second they can do in America to avoid our dependence on China 
or any other outsource.
    Secretary Becerra. And here, the President has tasked us to 
do everything we can to use domestic manufacturing. We saw what 
happened when we couldn't find masks during the beginning of 
COVID. It is crazy that we had to go to places like China to 
find masks.
    And so we are trying to invest in more domestic 
manufacturing capabilities. The difficulty here is trying to 
have the resources. We need money to just replenish the 
Strategic National Stockpile, but we are trying to promote 
domestic manufacturing. What the manufacturers are looking for 
is a consistent, a thread of certainty that if they jump in the 
game, it won't just be because the Federal Government helped 
this year, but that in 5, 10 years, there is still a market 
that they can compete in.
    And that requires us to make investments up front. We are 
trying to do some of that, and we are going to use every 
opportunity we can and every authority we have to try to make 
domestic manufacturing more possible.
    Mr. Fleischmann. Thank you. And I look forward to working 
with you in that endeavor, Mr. Secretary.
    Secretary Becerra. Absolutely. Absolutely.
    Mr. Fleischmann. Mr. Chairman, I will yield back. Thanks.

                  GOING BACK TO 2022 LEVELS OF FUNDING

    Mr. Aderholt. Mr. Pocan.
    Mr. Pocan. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here.
    I would like to get to a couple subjects. Okay, I am moving 
mikes. A couple different subjects.
    First one, though, I am concerned in listening to the 
Republican leadership with their talk about going back to 2022 
levels of funding, the cuts that that would have. It is the 
politics of the budget versus the people benefiting the budget. 
And two programs in particular. One is Meals on Wheels. Senior 
nutrition, obviously, if you look at that cut going back to 
2022 levels, about an $80,000,000 cut, 1 million less seniors 
getting meals.
    My mom, in her late 80s--she passed away last year--but 
late 80s was getting Meals on Wheels. They came in. It was 
someone that she had a chance to see every day. I have 
delivered Meals on Wheels in multiple communities in my 
district, and that may be that one little check that some 
people need. I am really concerned about what those cuts mean.
    Also in the State Opioid Response Grant program, the cut 
there would be about $350,000,000. A lot of us talk about 
fentanyl. Rightfully so, but more than talk, we need to do 
something. I think the President is trying to do something.
    Can you just talk about very briefly these two areas and 
what the impact of that kind of a cut would mean?
    Secretary Becerra. Congressman, and like you, I have a 
mother who depends a lot on some of the services that are out 
there that we make available. I would say this.
    Fentanyl, opioids, there is no doubt that if we don't get 
ahead of this, we are going to lose loved ones. We have seen 
that already. And the States are making a yeoman's effort. When 
I was Attorney General, the States, we were part of an effort 
to sue many of those manufacturers of opioids to get them to 
pay for the damage they have committed.
    For us to walk back those commitments would make it 
difficult for a lot of these people who are willing to come 
in--and opioids are very addictive, but they are willing to 
come in and try to get off of that stuff. Before we lose them, 
we should be providing them with the access to the treatment 
they need. Before they start to use, we should have access to 
preventive programs that keep them from going there.
    And before our children start to use what some other young 
adult is doing, we have to have the programs in place to help 
them. And so it would be a travesty to give up on the funding 
in the fight against opioids and drug addiction.

                           MEDICARE ADVANTAGE

    Mr. Pocan. Thank you. A different subject and one I think 
that we have written you on and I know we have talked about 
previously is Medicare Advantage.
    I agree with Mr. Harris about the excessive profits 
insurance companies make. Medicare Advantage in particular is 
twice as profitable as regular health insurance. These 
companies are making a killing on this. And yet it has tripled 
just from 2011 to 2021 from $124,000,000,000 to about 
$361,000,000,000. A lot of money out there.
    Two questions. One, why do we let them use ``Medicare'' in 
their name? We don't allow anyone to use U.S. Postal Service 
Delivery. We don't allow someone to call themselves the U.S. 
Treasury Investment Fund. Why are we allowing Medicare 
Advantage, which is private insurance, to be called Medicare?
    And secondly, CMS did do some things recently to try to 
help go after some of the collection of overpayments, which I 
think virtually every company has done to the U.S. Government. 
Can you talk just a little bit about those changes? But name 
why, and then I would love to hear more.
    Secretary Becerra. Yes, and Congressman, you are bringing 
up a really important point. Because Americans watch these 
commercials, and they hear the name ``Medicare,'' and they 
think, oh, okay, gosh. I got to look at this.
    And then when they hear the pitch, the sell pitch, they 
think, well, I got this great deal with Medicare. I will take 
it.
    You got to look behind the curtain, and that is what we are 
trying to do by doing additional work to scrub the way that 
managed care program within the Medicare system works. Because 
we want to make sure that not just the seniors and disabled 
folks who are on the Medicare program get their money's worth, 
but we want taxpayers who are helping pay for some of those 
Medicare services get their money's worth.
    I have to tell you that at this stage, it is hard to 
believe the amount of money that is being spent lobbying and 
doing commercials to try to prevent us from being able to do 
the type of work that any oversight agency should do to get 
returned to the taxpayers' money that was overpaid. We are 
going to continue to do it.
    Mr. Pocan. And if I could just add, the most recent 
advertising is assuming your 1 percent increase is cutting 
Medicare. They are not Medicare. Only Medicare is Medicare. So 
if we really want to take their advice that we are cutting 
Medicare, then they shouldn't have Medicare in their name at 
all.
    Secretary Becerra. Yes.
    Mr. Pocan. And I have introduced a bill to do that, but if 
there is anything the agency can do to go after this false 
advertising because I know way too many people, seniors in my 
district, who signed up for this and then can't get actual 
benefits because they are in a network.
    And even my mom was impacted. A nice salesman sold her 
this. Couldn't get the care she needed because she couldn't get 
to the facility. The building she lived in, she would have got 
care if she was on Medicare.
    So if they are going to claim this is a cut to Medicare, 
then let us just allow Medicare to use ``Medicare.''
    I yield back, Mr. Chairman.
    Mr. Aderholt. Mr. Moolenaar.

               PREPARING FOR THE NEXT INFECTIOUS DISEASE

    Mr. Moolenaar. Thank you, Mr. Chairman.
    Mr. Secretary, good to see you, and thanks for being here 
today.
    In your role, you have the responsibility to ensure that 
the United States is prepared for the next infectious disease 
outbreak. A critical component of being prepared is ensuring 
that we are actively conducting, monitoring, and surveillance 
of these pathogens in both the hospital and community setting. 
And how will HHS ensure the correct diagnostic testing is being 
done to quickly identify infectious pathogens?
    Secretary Becerra. That is a great question. And you will 
understand that I ended up going to law school, not to medical 
school. So I am going to be as concise in my response as I can 
be.
    We are going to rely on the scientists, the medical 
professionals, especially those that deal with disease and 
virus, to give us the best evidence. We were able to generate, 
create a lifesaving vaccine in record time because we relied on 
the scientists to give us their best work.
    And if we continue to rely on those who have spent their 
life training and studying this and doing the research, we 
should be able to move forward. Because some of the discoveries 
that have been made with the technology and the science that we 
have are going to allow us to reach Americans with lifesaving 
treatments and vaccines in ways that we have never seen before.
    Mr. Moolenaar. Were you surprised, when you mentioned the 
scientific community, how slowly they recognized natural 
immunity or infectious-based immunity? Because one of the, I 
think, tragedies is that people were very slow to recognize the 
importance and the contribution of infectious-based immunity.
    Secretary Becerra. I don't think it was so much slow, 
Congressman. I know where you are heading on that. But I would 
look at it this way. They are saying people are dying in 
numbers, great numbers from COVID. We don't yet have a direct 
solution. We shouldn't wait until more people get infected and 
then survive and create that natural immunity to figure out how 
to help those who may not be as strong and as fit and won't 
survive it.
    No one wants to see the scenes again of people in hospitals 
having to use a ventilator who a month ago were walking 
upright, going to work, and today are barely alive because a 
mechanical ventilator is doing their breathing for them. And so 
I think they are trying to get there as quickly as we can, but 
everyone is aware that you do gain some natural immunity if you 
survive that virus.

                     COVID PUBLIC HEALTH EMERGENCY

    Mr. Moolenaar. Would you agree that the health emergency 
COVID is over now?
    Secretary Becerra. So I would agree that we are certainly 
at a different place, and that is why we are pulling down the 
public health emergency that was declared shortly after COVID 
started hitting in this country. But if I were to tell you, 
Congressman, that the news just came out an airliner carrying 
250, 300 passengers just crashed in America and everybody 
perished, you would gasp.
    And if I told you it was going to happen tomorrow and the 
day after that and the day after that, you would say what is 
going on in the aviation industry? COVID is killing 200 to 300 
people a day still. So we still have to protect against it, but 
it is certainly not what it was before.
    Mr. Moolenaar. And is there something special about, what 
is it, May 11th or when the President says the emergency----
    Secretary Becerra. Yes, I get asked----
    Mr. Moolenaar. I mean, it is kind of like, okay, the 
weather on May 11th will be what?
    Secretary Becerra. Yes. Fair question. Fair question.
    One thing we did was we promised, we made a commitment we 
would give especially our providers, especially the industries 
that are working off of the protections and flexibilities that 
you all gave us. You let us do things like on telehealth that 
we could otherwise not do. Rather than just yank back that 
authority to do those things, we said we will try to give you 
lead time, 60-day lead time before that public health emergency 
comes down.
    Mr. Moolenaar. Okay. I am told the Committee for a 
Responsible Federal Budget estimates that there is somewhere 
between $70,000,000,000 and $90,000,000,000 that was going to 
be spent to address the emergency, the health emergency. Are 
you familiar with that? Unobligated dollars in Federal agencies 
directly related to the American Rescue Plan that was supposed 
to be addressing an emergency?
    Secretary Becerra. I am not familiar with that number. I 
can give you the accounting of the monies that we have got from 
the American Rescue Plan and how we have spent it. But I----
    Mr. Moolenaar. Do you have any unobligated dollars that 
were designed to be spent during the emergency?
    Secretary Becerra. More than 90 percent of the monies that 
Congress made available to HHS--I am speaking of HHS--has been 
obligated. There is about 6 percent of that money that has not 
been obligated. But if you were to talk to some of the States, 
some of the providers that are out there, they would say wait a 
minute. We have got the request in. They just haven't signed on 
the dotted line. We are expecting some of those funds.
    Mr. Moolenaar. Right. I just--we have spent a lot of money 
these last 2 years, over $6,000,000,000,000 on this emergency, 
and it just seems to me when you have got $70,000,000,000 to 
$90,000,000,000 still in the Federal Government that was 
designed to be spent there, and we got a $32,000,000,000,000 
debt, and we are concerned about a fiscal cliff, it just seems 
that spending dollars towards an emergency where there is no 
longer an emergency would be wasteful.
    Secretary Becerra. Congressman, I can guarantee you that 
some of the hospitals in your district, some of the providers, 
some of the manufacturers of that protective equipment would 
say to you, wait a minute, we are still being asked to prepare 
some of this stuff. That is what that money that is left is 
going to be used for.
    It is still related to COVID. We may not be in a public 
health emergency the way we were 3 years ago, but there is 
still a need for us to protect against----
    Mr. Moolenaar. But wouldn't those be considered obligated?
    Secretary Becerra. Well, they are--as I said, they are in 
the pipeline, and you said to be obligated. I wanted to be--I 
wanted to be honest. Have we signed on the dotted line and said 
it is now committed? No. But is it in the pipeline to be signed 
on the dotted line? Yes, it is.
    Mr. Moolenaar. Okay. Thank you.
    I yield back, Mr. Chairman.
    Mr. Aderholt. Ms. Frankel.

                            SERIOUS CUTBACKS

    Ms. Frankel. Thank you.
    There is something wrong with our time--oh, there we go. 
Okay.
    Good to see you. Thank you for your service.
    I want to quickly first just talk about seniors because I 
have a very big senior population in Palm Beach County. And as 
I know you know that Democrats are putting people over 
politics, especially when it comes to reducing the cost of 
prescription drugs and putting a cap on insulin to help our 
seniors.
    I am concerned about a potential large cutback that would 
reduce our efforts in Meals on Wheels, housing for seniors, 
causing longer waits for Medicare services. So I hope that--and 
also potentially cutting things like research for Alzheimer's. 
And thank you folks for being here.
    So I hope that we do not do those serious cuts, but I want 
to change direction a little bit because our distinguished 
chair raised my ears to it. My ears, maybe I will say that. My 
concerns when he mentioned potentially cutting Title X. And I 
would like to ask you this.
    Would you explain to everybody what the impact of serious 
cuts to Title X would mean?
    Secretary Becerra. Congresswoman, let me start by giving 
you the best advice I got growing up from my mother. She said, 
``Mi hijo, siempre va a ser major prevenir que remediar.'' It's 
always going to be better if you can prevent than remediate.
    Family planning is important because it helps a couple, an 
individual make decisions ahead of the event occurring. And the 
more we plan out our families, the more we are ready to have 
them not only come to this Earth, but also go to college, the 
better off we will be versus trying to remedy what we didn't 
take care of.
    And so family planning, Title X is simply that. It helps 
families, especially families who don't have a lot of income, 
be prepared. Do the things that probably you and I, with better 
incomes, can take care of. And that means going early to get 
the preventive healthcare services. It means if you are 
pregnant, going in for service now, not waiting until you 
deliver.
    Ms. Frankel. So, and let me just add to that for the folks 
who don't know what Title X does. I mean, and they are serving 
millions and millions especially of young people, young adults 
who have no access to healthcare. There are wellness exams, 
lifesaving cervical and breast cancer screenings, birth 
control, contraception education, testing and treatment for 
sexually transmitted diseases.
    Something like this isn't quite a--6 million STD tests per 
year under Title X, which brings me to another subject. The 
Republicans are on a mission to ban abortion across this 
country. And we have seen, unfortunately, State after State, 
including my home State of Florida, which is about to pretty 
much ban abortion.
    I know you have been looking to see what the impact has 
been, and I will ask you what have been your findings?
    Secretary Becerra. Well, let me give you one that is, I 
think, stark. Pregnant women in States with abortion bans are 
nearly three times more likely to die, regardless of their 
income or their education, during the process of trying to 
bring that child into the family. Three times more likely to 
die.

                          BIRTH CONTROL ACCESS

    Ms. Frankel. That is pretty scary. So let me get to another 
subject because I think we could go on and on with that. And 
that is getting back to birth control, which I think we should 
all try to support, if it is voluntary. Correct?
    Over a decade ago, the Affordable Care Act promised 
coverage for birth control with no out-of-pocket cost. 
Unfortunately, the current guidance allows insurance companies 
to pick and choose which type of birth control they want to 
cover, as long as they cover one within each category or 
method. So insurance company, for example, gets to choose which 
kind of birth control pill somebody--that they will cover, and 
this is a problem. And my question to you is whether HHS would 
consider requiring insurance plans to cover all unique birth 
control products?
    Secretary Becerra. Congresswoman, we have taken action to 
make sure no insurance company denies or deprives a woman of 
the healthcare she is entitled to under the Affordable Care 
Act, and that includes reproductive. That includes abortion 
care services, and that, of course, includes birth control 
services.
    And so we have brought in insurance companies. The 
Department of Labor, Department of Treasury, and Department of 
Health and Human Services, we asked insurers to come and speak 
to us because we were receiving reports that they were 
depriving women of payment for those services, coverage for 
those services.
    We have also brought in pharmacies throughout America to 
make sure that they know they have to dispense those products 
as well, and we are going to do everything we can, including 
regulations, to make sure that we implement the statutory 
requirements of the Affordable Care Act because everyone in 
America, regardless of your gender, is entitled to have access 
to the care that you need for health.
    Ms. Frankel. Thank you. Mr. Chair, I yield back.
    Mr. Aderholt. Ms. Letlow.

                        RURAL HEALTH DISPARITIES

    Ms. Letlow. Thank you, Mr. Chairman.
    Thank you, Mr. Secretary, for being here today.
    One area of great concern for my constituents--I represent 
24 parishes in Louisiana--is the health disparities and access 
to regular and specialized care in my rural district known as 
the Delta region along the Mississippi River. Within the Delta, 
according to the CDC, Louisiana is now the third-highest State 
in new cancer cases and among the top five for cancer deaths, 
and there seems to be little progress in slowing the morbidity 
rates down. This region has far too long been subject to lack 
of care comparative to its urban peers.
    As a member of this subcommittee, I would love to work with 
HRSA in investing in the health of the nearly 10 million people 
residing in the Delta region. So my question is this, How is 
the Department addressing the health disparities, especially 
around cancer rates, in the Delta region? And how can the 
Department and this committee work together on developing a 
regional plan to address these high cancer rates and 
cultivating a healthcare workforce so individuals living in 
rural areas can have an earlier diagnosis and adequate 
treatment?
    Secretary Becerra. Congresswoman, first let me start by 
saying that I hope you will follow up with this. Carole Johnson 
is the head of HRSA. I will--after this hearing, I will let her 
know that you asked specifically about that. And if it is okay, 
I will ask her to call you.
    Ms. Letlow. That would be wonderful.
    Secretary Becerra. Yes. Because I think it is important. We 
are trying to do what we can to reach into communities that 
have been left behind.
    The reason so many people died of COVID is because they 
didn't have easy access. Chances are you don't have a pharmacy 
or a medical office within a mile or two of a lot of your 
residents, a lot of your constituents, and that makes it 
tougher for them to get connected.
    And so we are trying to create--shrink that access gap. And 
so on top of having Administrator Johnson reach out to you, let 
me mention a couple of things that we are doing.
    We are trying to advance rural health in different ways. We 
talked a little earlier about the fact that the public health 
emergency is coming down. We think the telehealth opportunities 
that came from COVID, where you don't have to leave your home 
and still have access to a doctor, should continue. And we 
thank Congress for giving us an extension of those 
flexibilities, but we need them permanently. And that is where 
your help will come in handy and your support.
    The other thing we are trying to do is ensure that on 
cancer specifically--because, I mean, how many of us haven't 
lost someone to cancer? What we are trying to do is improve 
access to screening. About 9 to 10 million Americans missed 
their cancer screening tests during COVID because they couldn't 
go out. We want to get those folks back in because those are 
the folks who we will catch before it becomes a terminal 
illness. And so, help us.
    One of the things we are trying to do, the First Lady, Dr. 
Biden, has been aggressive on this in the Cancer Moonshot to 
say it is not just about coming up with cures. It is about 
getting people the preventive--my mom, I said it, right? 
Prevent versus remediate. We want to do those preventive 
screenings. Help us get to those folks who haven't done the 
preventive screenings.

                        MATERIAL HEALTH OUTCOMES

    Ms. Letlow. Thank you. Another area of importance to me is 
maternal health outcomes. I know you talked about it today, but 
especially for rural moms.
    Louisiana is one of the original recipients of the HRSA 
Maternal and Child Health State Grant and has used this grant 
to set up a perinatal psychiatric access line and better train 
providers throughout the State. However, there is a long way to 
go in improving postpartum care, which you have already talked 
about.
    I am discouraged that several of the HRSA programs that 
cover maternal and child health were flat funded again for a 
third year straight within the President's budget request, 
despite a huge demand for these grants. Those programs include 
the Maternal Mental Health Hotline, the Innovation for Maternal 
Health, and the Screening and Treatment for Maternal 
Depression.
    So while we have seen some improvement based off recent 
data, Louisiana still has one of the highest maternal mortality 
rates in the U.S. And the U.S. spends $4,200,000,000,000 on 
healthcare annually, and we are failing to adequately address 
the health needs of our moms and our babies. I believe we can 
and we must do more.
    So what steps--I know you have addressed some of them--is 
HHS taking to address the fact that maternal mental health 
conditions are the leading cause of maternal mortality in the 
U.S., and how can the Department and, again, this committee 
work together on directly assessing those maternal needs? I 
know you have talked about Medicaid expansion for 365 days. I 
am particularly interested in RMOMS program and how that works 
in conjunction.
    Secretary Becerra. Yes. So I think you are going to be 
talking to Administrator Johnson quite a bit.
    Ms. Letlow. Okay.
    Secretary Becerra. And so we will try to make sure she 
connects with you on this issue as well. Secondly, I believe--I 
don't want to misspeak--but I believe your State has adopted 
the challenge----
    Ms. Letlow. Right.
    Secretary Becerra [continuing]. To move towards 365 days of 
coverage for a woman postpartum care and also for their child, 
and so I hope that is the case. Because that is probably the 
most direct way that we can make sure that your providers, your 
doctors will get reimbursed for the care that they provide to 
some of these folks.
    The other thing we are doing is some of the programs we are 
doing that are specific to rural America, you will want to make 
sure you are talking to Administrator Johnson about those. We 
will follow up with you because if you want to tackle this in 
your district, we want to be right there with you.
    Ms. Letlow. Okay, I would love some more information on the 
RMOMS specifically and how that is helping in rural.
    Secretary Becerra. We will get back to you.
    Ms. Letlow. Okay, thank you for your time.
    Secretary Becerra. Thank you.
    Mr. Aderholt. Mr. Harder. Mrs. Watson Coleman.

                    DISPARITIES IN HEALTHCARE ACCESS

    Mrs. Watson Coleman. Thank you, Mr. Chairman.
    Good to see you, sir, Mr. Secretary. Thank you for your 
work.
    And I want to thank my colleague for raising an issue that 
I am very concerned about, and that is disparities in access to 
healthcare, be it maternal mortality, infant morbidity and 
mortality, or just healthcare in general.
    I am particularly concerned about mental health. I had been 
prompted by just Facebook many years ago to head a special task 
force on looking at the impact of mental health and suicidal 
issues with young people, particularly young black youth, and 
we held a series of hearings.
    That hearing and those findings led to a piece of 
legislation pursuing equity in mental health, but in addition, 
it came at a time when the whole issue of mental health started 
exploding in this country because of the pandemic and what was 
happening. So I want to ask you about mental health issues. The 
proposals that you all have to deal with mental health, 
particularly getting treatment and services in the schools and 
places where young children are impacted because we recognize 
that mental health is showing up at very young ages.
    I want to know what your kind of budget proposal is right 
now, and I want to know just how damaging would a 10 percent or 
a 20 percent or a return to 2022 funding levels have on your 
ability to deal with this escalating need of mental health in 
this country?
    Secretary Becerra. Congresswoman, and first, thank you for 
the work that you have done on this issue of maternal mortality 
and morbidity, and whether it is in the Louisiana Delta or 
whether it is in urban areas of New Jersey, women are dying. 
And it is incredible to believe in this country that women are 
dying right after giving birth, and their babies oftentimes as 
well.
    On the issue of mental health, this budget, the President's 
budget invests some $4,000,000,000 in discretionary funding to 
help meet some of those behavioral health needs that you 
mentioned. That would include funds to increase access to 
crisis care services. We are putting more money into the 
Certified Community Behavioral Health Centers. These, as you 
know, are the 24/7 crisis centers that many times are not 
available throughout the country.
    You don't have a mental crisis only between the hours of 
9:00 to 5:00, and you need to have access to care. And if that 
center is closed, where do you go? And so these critical care 
centers are open 24/7 to meet those needs. We are expanding 
services and access to those kinds of centers.
    We are putting in an additional $334,000,000 to ensure 
capacity of the Suicide Prevention Lifeline, and that would 
give us a chance to have some 9 million contacts under 988 for 
fiscal year 2024. That is about 6 million more than we had 
before. We know the need is there, and so we are going where we 
know we could make a big difference.
    I could go on and on if you would like, but I know your 
time is limited.
    Mrs. Watson Coleman. Well, I know that we are trying very 
hard to catch up and to be able to in real time deal with the 
issues. And so I am concerned, I would like to know from 
someone like you, what would be the impact of the diminishing 
of those resources either back to the 2022 level of funding, 
continued flat-funding, 10 or 20 percent cut. What does that 
mean in terms of saving lives, quality of life, ensuring our 
children grow up with healthy minds and appreciate living as 
opposed to thinking that suicide or other damaging things are 
alternatives to their problems?
    Secretary Becerra. Well, as I mentioned, rather than being 
able to make all those additional contacts under the 988 
program, we would probably, if there were about a 22 percent 
cut in services at 988, that would likely mean a loss of 
contact with about 900,000 individuals who are calling at a 
time of mental health crisis.
    That would mean that that 300-and-so additional--330 or so 
additional dollars in funding for 988 from $500,000,000 to 
about $836,000,000 would essentially be erased as well. It 
makes it very difficult to believe we could really reach 
America.

                           PROVIDER SHORTAGES

    Mrs. Watson Coleman. One of the other issues that we face 
during this period of time is that we recognize that there 
aren't the kind of service providers that we need. There aren't 
enough psychiatrists, psychologists, social workers, other 
kinds of healthcare workers. And I know that you all have as 
part of this budget a priority to increase capacity, increase 
understanding, also recognize compensation levels as well as 
other things that these workers need in order to be healthy and 
do their jobs.
    What would a 10 or 20 percent cut in what you are proposing 
result in, in terms of the workforce needs that have been 
demonstrated that is so direly needed?
    Secretary Becerra. Well, it would not only result in the 
need to cut or reduce services, but it would probably make it 
almost impossible to continue forward some of the programs that 
are out there to try to help increase the size of our 
workforce. Because we have to essentially move to dedicate 
whatever money is left after these devastating cuts to actual 
services.
    So, for example, the investments we are making in workforce 
would probably have to disappear. They would have to be 
relegated to the need for actual service, and that is a 
travesty. And we know, for example, in childcare, you could 
probably make more money if you abandon your work as a 
childcare worker and go flip burgers at the corner burger 
stand.
    Mrs. Watson Coleman. Thank you.
    Thank you, Mr. Chair. I will yield back.
    Mr. Aderholt. Mr. Clyde.

                         GENDER AFFIRMING CARE

    Mr. Clyde. Thank you, Chairman Aderholt, for holding this 
hearing today.
    And thank you, Mr. Secretary, for attending.
    Secretary Becerra. Thank you.
    Mr. Clyde. Secretary, under the Department of Health and 
Human Services, do any taxpayer dollars go toward sex 
reassignment surgeries or hormone blockers for those attempting 
to change their birth sex?
    Secretary Becerra. Congressman, we make sure that----
    Mr. Clyde. A simple yes or no will work.
    Secretary Becerra. I am sorry?
    Mr. Clyde. A simple yes or no will be fine.
    Secretary Becerra. Well, I have to make sure it is clear 
because the services that someone receives at their doctor's 
office or in a hospital in a particular State may differ from 
other places, and we must make sure that whatever we do, we are 
abiding by the law. So we provide resources and support to make 
sure that any services that are provided fall within Federal 
guidelines and the Federal law.
    Mr. Clyde. Okay. So, and Federal law allows that. Is that 
what you are saying?
    Secretary Becerra. Federal law allows a number of services 
to move forward, and we make sure we monitor to make sure 
providers are using their monies that they get from the Federal 
Government properly.
    Mr. Clyde. Okay. How many taxpayer dollars have gone toward 
paying for sex reassignment surgeries or hormone blockers since 
you have assumed office in 2021?
    Secretary Becerra. I could try to take a look to see if we 
can find that kind of information, but I don't have anything--
information on that available with me.
    Mr. Clyde. Okay. The HHS does track the amount of money 
spent on various treatments?
    Secretary Becerra. Again, it depends because you are 
talking about 50 States and their different ways, but we do 
track the money because we have to come back to you to report 
that it was responsibly----
    Mr. Clyde. Absolutely. I am sure the ladies back here that 
are supporting Alzheimer's funding would want to know that as 
well, that you do track the amount of money that is used on 
various treatments.
    Secretary Becerra. We absolutely track the money that we 
send out to States and to providers.
    Mr. Clyde. Okay. All right. Have any of these sex 
reassignment surgeries or hormone blockers been given to 
children, minors under the age of 18?
    Secretary Becerra. Again, you are asking me a question. We 
don't actually administer programs directly at HHS. We fund 
services from States and from providers. So you would have to 
give me more insight into what you are referring to because----
    Mr. Clyde. So you don't have a restriction on that then?
    Secretary Becerra. Our restriction is by statute, what you 
all set for our parameters on how we can use the dollars you 
give us and under what conditions.

                        TITLE X FAMILY PLANNING

    Mr. Clyde. Okay. According to the Department of Health and 
Human Services fiscal year 2024 budget, HHS proposes to 
increase funding for the Title X family planning by 76 percent. 
This is after the Biden administration repealed the Trump era 
rule, which, as you know, prohibited the use of Title X funds 
to perform, promote, refer for, or support abortion as a method 
of family planning.
    Is any money in the 76 percent increase in Title X family 
planning going towards referrals for abortion services for 
women?
    Secretary Becerra. The increase in funding--and by the way, 
Title X has not received an increase in funding in, I think, 
close to a decade. And obviously, family planning services are 
more needed than they were 10 years ago. What we do is make 
sure that the money is spent appropriately under the law and 
which is provided to those different centers, who provide a 
number of services, not all of them----
    Mr. Clyde. I am specifically asking about abortion 
services. Would you please address your answer to that?
    Secretary Becerra. So we would only allow monies to be used 
in ways that the Federal Government permits, and any grantee of 
Title X funding understands that they must use Title X dollars 
in the way that Title X allows.
    Mr. Clyde. Okay, please answer the question.
    Secretary Becerra. Which is?
    Mr. Clyde. Which is--I have said it twice now, all right? 
Does any money of the 76 percent go towards referrals for 
abortion services for women? A simple yes or no is fine.
    Secretary Becerra. Again, you are asking me to put myself 
in the position of those centers throughout the country that 
provide services.
    Mr. Clyde. Well, I mean, you track what money goes for, 
right? The services that it goes for?
    Secretary Becerra. Those centers have to make sure they 
have spent the money according to Federal law.

                   AUTHORIZATION FOR FEDERAL PROGRAMS

    Mr. Clyde. Okay. All right. Prior to becoming Secretary, 
you spent many years as a Member of Congress on the Ways and 
Means Committee, very powerful authorizing committee.
    Secretary Becerra. Great committee.
    Mr. Clyde. Uh-huh.
    Secretary Becerra. This is pretty good, too.
    Mr. Clyde. Do you think unauthorized Federal programs 
should be funded?
    Secretary Becerra. I am sorry. Say again.
    Mr. Clyde. Do you think unauthorized Federal programs 
should be funded?
    Secretary Becerra. There is no way within the executive 
branch that we can spend money that hasn't been allocated for a 
particular use.
    Mr. Clyde. Authorized.
    Secretary Becerra. If it has been authorized, we can spend 
it.
    Mr. Clyde. But if it has not been authorized, it can't be 
spent. Is that what you are telling me?
    Secretary Becerra. We would have to have legal authority to 
spend it. Otherwise, we couldn't.
    Mr. Clyde. Okay. Do you know when the last time the Title X 
family planning program was authorized?
    Secretary Becerra. Every year, there is a family planning 
program that is made available. When you all provide money in 
the budget, you give us authority to spend money on family 
planning.
    Mr. Clyde. Well, authorized. Not appropriated, authorized.
    Secretary Becerra. Oh, so now you are trying to--you are 
being a little technical here.
    Mr. Clyde. No, I am not being technical. It is very, very 
distinct between authorized and appropriated.
    Secretary Becerra. Congressman----
    Mr. Clyde. From my research, it is----
    Secretary Becerra [continuing]. You sit on the 
Appropriations Committee.
    Mr. Clyde. Yes, I do. It seems that Title X has not been 
authorized since 1985. And when it was last authorized was the 
98th Congress Public Law 98-512. That would be this one right 
here.
    Secretary Becerra. Then explain to me why you grant us 
dollars to spend in those ways.
    Mr. Clyde. I am the one asking the question here, sir, Mr. 
Secretary.
    Secretary Becerra. Well, I am trying to answer the 
question. The reality is that we cannot spend money----
    Mr. Clyde. Okay. Over the last 2 years in your tenure as 
Secretary, why have you not asked for an authorization?
    Secretary Becerra. We would love to have the authorization. 
Let me see you try to get it through this Congress.
    Mr. Clyde. So you are here today asking for money to fund a 
program that is currently not authorized?
    Secretary Becerra. This program has existed for decades, 
and we can only spend money that you allow us to spend on it. 
Having a fully authorized program is ideal, ideal. Think about 
the Children's Health Initiative that couldn't get 
authorization for many years. We still spent money trying to 
keep our kids healthy.
    Mr. Clyde. So you still spend money on unauthorized 
programs.
    Secretary Becerra. Only because you grant us the authority, 
Congressman.
    Mr. Clyde. But you have to ask for it, and I yield back.
    Mr. Aderholt. Mr. Harder.

                            ASTHMA PROGRAMS

    Mr. Harder. Thank you so much, Mr. Chairman, and thank you, 
Ranking Member.
    Thank you, Secretary Becerra, for being here.
    I know we are talking a lot about the impact of particular 
cuts. I wanted to focus especially on programs that I think 
really need to grow to serve the health needs of our community.
    As you know, I represent the San Joaquin County in 
California. Having grown up in Sacramento, you know it well. 
Been spending a lot of our time in our district, and I know 
that you understand some of the issues and the health 
challenges that the Valley faces.
    One of those is asthma. I grew up with childhood asthma in 
my area. My brother did. I know exactly what it is like to make 
sure that you have to put your inhaler in your backpack before 
you go to school. We have the highest rates of childhood asthma 
in the entire Nation. We have asthma-related emergency room 
visits 300 percent higher than the national average.
    Programs like the National Asthma Control Program make a 
huge difference in areas like mine, and yet I don't think we 
are funding those programs adequately. The funding was 
$33,000,000 nationwide for the Asthma Control Program last 
year. The budget that you are asking for is the same, which is 
actually, given inflation, a reduction in the type of support 
that I think families like ours need.
    Can you talk about why you are requesting level funding for 
this program, and what we can do to make sure that asthma and 
kids with childhood asthma are given the appropriate healthcare 
they need?
    Secretary Becerra. Congressman, I know you know this issue 
well, and I thank you for posing the question. And I 
congratulate you. In fact, I encourage you to do exactly as you 
are doing, and that means advocating for the folks back home. 
Because I think a lot of folks forget that that breadbasket of 
the world, the Central Valley, also has some of the worst air 
in the Nation, in the world.
    And I thank you for the work that you are doing. A lot of 
my family lives in your district.
    We would love more money to do even more on asthma, and we 
are grateful for the money you helped us get in the last bill 
in the omnibus that increased by $3,000,000 the amount of money 
we had. And if I could answer every Member of Congress' 
question to say how come you are not committing more, I would 
need a ton more money.
    But what I will tell you is this. You are on the right 
course, just as the folks that are behind me who are really 
pushing hard for asthma treatments availability are doing 
absolutely what they should do. I would hope that you would 
continue that effort, and I hope that the next time I come, I 
will say thank you because you were able to secure more money 
for asthma programs in this country.
    Mr. Harder. Well, thank you for your support on that.
    I think what is particular about asthma is that the 
National Asthma Control Program has proven that every dollar 
spent on it saves $71 in healthcare costs. It is 71 to 1. I 
used to spend my career in business before I came to Congress. 
If I ever saw a 71-to-1 return, I would be doing a very 
different set of things with my life on a beach somewhere.
    Secretary Becerra. Congressman, I want to introduce you to 
my mom. I mentioned how she focused me on prevention versus 
remedy.
    Thanks.
    Mr. Harder. Absolutely. And I think that is why this 
program is so important. But that is only one tool in the 
toolbox for HHS. What else do you think we could be doing to 
tackle asthma? And what especially are you focused on, on home-
based interventions or self-management education, to make sure 
that we are focusing on that side of prevention?
    Secretary Becerra. There is no doubt that we need to do a 
much better job of giving people access early, especially for 
children, to the type of preventive services that let people 
detect right away that their child might be suffering from 
asthma. We have to make sure that in our schools we are making 
more of those healthcare services available.
    That is why at HHS we are trying to move to help schools 
actually apply to be providers under the Medicaid program, 
which is difficult. They are not healthcare providers, per se. 
But if they check enough of the boxes and do the right thing, 
we could probably get healthcare provided more in our schools, 
and those schools would get reimbursed for having done that 
because they can't afford to spend precious education dollars 
on that.
    We are going to do everything we can, as my mom said, to 
prevent rather than to remediate. Look forward to working with 
you. But certainly, screening and access to preventive 
healthcare services for all our families regardless of their 
income would be crucial.
    Mr. Harder. Thank you. Thank you for your attention on 
this, and I know you have a lot of heart for my district and 
our community. So thank you for that.
    If you ever want to come and visit your family and then do 
some public visits and talk about asthma or any of the other 
issues----
    Secretary Becerra. If that is an invitation, I am there.
    Mr. Harder [continuing]. We would love to have you.
    Secretary Becerra. Okay.
    Mr. Harder. Well, thank you so much.
    And with that, I yield back.
    Secretary Becerra. Thank you.
    Mr. Aderholt. Thank you. Mr. Ciscomani.

                         UNACCOMPANIED CHILDREN

    Mr. Ciscomani. Thank you, Mr. Chair.
    And thank you, Secretary Becerra, for being here with us, 
and thank you for making time to answer our questions.
    I represent Arizona's Sixth Congressional District.
    Secretary Becerra. I know it.
    Mr. Ciscomani. And I hope I can cover two quick areas here 
on my questions to you, but on the first one, we will be going 
actually back to what the chairman mentioned at the beginning.
    So, on February 27, HHS announced that it will be 
conducting an audit over the next 4 weeks on the vetting 
process for potential sponsors of children in the Office of 
Refugee Resettlement, including the vetting requirements for 
potential sponsors. It has been 4 weeks since that 
announcement. When can we expect Congress and this subcommittee 
also to--when can we--can Congress and the subcommittee expect 
the results from that audit?
    Secretary Becerra. We will probably be able to check in 
with you in the coming weeks. One, we are trying to make sure 
that we are looking closely at the entire process, but we 
should be able to get back to you pretty soon.
    Mr. Ciscomani. Okay. We are really looking forward to those 
results.
    Also, the Office of Refugee Resettlement also conducted 
safety and well-being calls with both the sponsor and the child 
after the child is released from ORR custody. How long after a 
child is placed with a sponsor family does this call take 
place?
    Secretary Becerra. Congressman, we try--because we lose 
jurisdiction over the child once we have placed them with a 
sponsor, we try to do a check with them within about 30 days to 
make sure everything is moving forward. And so we reach out to 
the child. We reach out to the sponsor and hope to hear back 
from them.
    Mr. Ciscomani. I am trying to get a sense of the nature of 
the calls. How often do you think the calls actually happen? Do 
they get answered, or do they go unanswered? Or do you make 
additional attempts to connect with them? What is the success 
ratio there?
    Secretary Becerra. Thank you for asking that. You are 
probing, which is what others haven't done.
    We reach out to the child directly. And because the person 
is a child, a minor, we also reach out to the adult who is 
responsible for the child. That means the sponsors as well. We 
make three attempts with the child and with the sponsors to try 
to reach out to them.
    Mr. Ciscomani. Okay. Appreciate that.

                                FENTANYL

    Let us move on to the second topic I wanted to cover, which 
is the area of fentanyl. Again, I cover a district that is 
highly hit by this, and I think I keep saying that regarding 
fentanyl every State has become a border State in that sense, 
given the tragedies that we see.
    In my county of Pima County, where I live, fentanyl deaths 
is now the number-one cause of leading death among teenagers. A 
tragedy for sure. So with my district being on the Southern 
border, the opiate overall epidemic is a major concern for me. 
As you know, over 100,000 drug overdose deaths occurred in 
2021, and with the flow of fentanyl and other illicit drugs 
across the Southern border, I expect these numbers to be 
exponentially higher.
    Unfortunately, for 2022, we are definitely seeing again if 
you are counting the level of numbers that I mentioned. 
Unfortunately, the administration hasn't released these numbers 
yet. And as you can imagine, I am actually waiting for results 
for 2022. When do you think we could have some data and some 
numbers on the drug overdose poisoning of fentanyl?
    Secretary Becerra. Yes, and I know that the numbers usually 
lag a little because we have to rely on the States to provide 
us the information, and we are collecting it as best we can. We 
know everyone is interested to see where they are doing well 
and where they are not. We will try to get those out as quickly 
as we can.
    And Congressman, if you want, we can follow up with you if 
you want a more precise date?
    Mr. Ciscomani. Yes, I would like that, Mr. Secretary. I 
appreciate that.
    The last question I have is around in the same area here. 
The reports have shown that drug traffickers are now mixing 
fentanyl with other drugs as well. Xylazine specifically being 
one of them, which is a veterinary tranquilizer, which 
increases the effects of fentanyl and makes it deadlier.
    Another concern is that this new mixture is not an opioid, 
so Narcan does not have the same effect on preventing the drug 
poisoning. How is HHS preparing for more cases like this of 
drug poisoning involving this mixture, and what is HHS doing to 
develop Narcan options that can treat these mixtures, 
especially now that the DEA has seen the mixture in 48 out of 
the 50 States?
    And I got to tell you, small business owners in my district 
are being trained by local law enforcement on how to distribute 
Narcan and apply it to people overdosing and poisoning on their 
own businesses. So this is truly tragic, tragic, and keeps 
increasing. So what is your response on that?
    Secretary Becerra. Yes, and you have raised something that 
I think a lot of folks miss. We are asking our men and women in 
uniform to actually do more than they were trained for in the 
academy. And they have to because, otherwise, some of these 
folks are going to die right in front of them.
    And so it is crucial that we have access to the types of 
treatments that can revive you, keep you alive, and provide the 
training where it is possible.
    And so what we are trying to do is make sure that working 
with law enforcement, we try to make sure that what the 
evidence proves works and make it more available. Because our 
laws are still based on 1980s, 1970s, 1990s, and sometimes we 
don't give access to the kind of treatment--naloxone and other 
things--that could save a life.
    And so we want to make sure we are using best evidence and 
also making sure that we don't put it on just our law 
enforcement because sometimes they don't have the access to 
that information. Sometime they are not trained up on that, but 
yet they are the first ones to have to respond.
    And so we have to understand that this issue of drug use 
goes way beyond just waiting for that person who is overdosing 
to try to save them. It is making sure we provide the support, 
including for our law enforcement officers, so that we can make 
sure we do this the right way.
    Mr. Ciscomani. Thank you, Secretary.
    Madam Chair, I yield back.
    Ms. Letlow [presiding]. Mr. LaTurner, you are recognized 
for 5 minutes.
    Mr. LaTurner. Thank you, Madam Chairwoman.
    Welcome.
    Secretary Becerra. Thank you.

                          PROVIDER RELIEF FUND

    Mr. LaTurner. Good to see you today. I want to talk about a 
few issues related to healthcare access----
    Secretary Becerra. Okay.
    Mr. LaTurner [continuing]. Back home in Kansas. First is an 
issue related to the Provider Relief Fund that I know you have 
addressed in previous congressional testimony, but I would like 
to get some additional clarity on it today.
    There were several acute care hospitals that opened in 2019 
and 2020, including Rock Regional Hospital in Kansas, that 
received significantly less financial support from your 
Department than other legacy providers. You have committed in 
the past to work to help these new providers so that they are 
not forced to close their doors and move us backwards on access 
for those who need it most.
    However, I am deeply concerned that whatever actions you 
have taken is not sufficient to date. What specifically has 
your Department done to help support these new providers?
    Secretary Becerra. And Congressman, let us do this. 
Administrator Carole Johnson at HRSA is the one who administers 
that Provider Relief Fund. If you want, we can try to follow up 
because I am not going to be able to give you a quick, concise 
answer. So let me keep it at this.
    One, when we came in, the formula had already been baked on 
how to distribute the money from the previous administration. 
That formula used one aspect, a variable, Medicare 
reimbursement to sort of drive dollars to those providers. 
There are a lot of providers--including, of course, a new 
provider--that won't have a record of having gotten Medicare 
reimbursement because they are new. So guess what? The formula 
weighs against them because they can't show that they had large 
expenses.
    When we came in, we decided we don't want to use that 
formula. We came up with a different formula for what would be 
the fourth tranche of funding in the Provider Relief Fund. But 
by then, by the fourth tranche, very little of the money was 
left. Most of that money had already gone out.
    And so chances are the answer for those providers you are 
talking about is that they didn't qualify because they weren't 
around to qualify in the first three tranches. We changed the 
formula, and in the fourth tranche, they probably received 
something. But because that tranche of money was so small 
compared to the others, and it had to go around to a lot of 
folks who were new providers or who got--who didn't get a fair 
share in the first three tranches, it has become less than some 
people would have expected.
    But to give you specifically for those providers, if you 
want, we can follow up with Administrator Johnson and her team.
    Mr. LaTurner. I certainly understand the issue, but I just 
want to make clear--and I think you understand this--that even 
though they didn't have the record under the formula, it is 
still very much impacted.
    Secretary Becerra. Absolutely.
    Mr. LaTurner. And so when you get a new provider, you 
certainly don't want to see them close their doors.
    Secretary Becerra. Absolutely. Congressman, put yourself in 
my shoes. Am I supposed to yank back the money that all those 
providers got before and say we now find a provider that didn't 
get anything or very little and is worthy, and so, therefore, 
give me back some of the money we gave you?
    Every one of those providers would be coming to your door 
saying they are about to try to take the money I already used.
    Mr. LaTurner. Let us talk about those specifically offline, 
if we can.
    Secretary Becerra. Sure.
    Mr. LaTurner. And we would welcome that conversation.
    Secretary Becerra. Look forward to that.

                              340B PROGRAM

    Mr. LaTurner. HRSA has previously taken some action to 
ensure proper enforcement of the 340B program when it comes to 
PBMs, as some safety net providers have reported that PBMs are 
undermining the intent of the 340B program by effectively 
pickpocketing the 340B savings that were intended to support 
those providers and using them to boost their own profits 
instead.
    I believe it is vital that we have more information about 
the operation of PBMs so that we know how best to address the 
problems instead of operating in today's opaque reality. 
Outside of HRSA enforcement of the 340B statute, what is your 
Department doing specifically to promote additional 
transparency of PBMs practices?
    Secretary Becerra. And thank you for the question. Look 
forward to your help on this one.
    We are, as you said, trying to create a more transparent 
operation. We don't want to find that the middlemen are 
skimming money unnecessarily off the top that should be going 
to help make drugs, prescription drugs affordable for folks.
    And so we are trying to open up, move the curtain, but here 
is the difficulty and one of the reasons why I can only say so 
much. We get sued every time we try to have more transparency 
and more accountability by these middle managers. And so, right 
now, we have been taken to court on a number of occasions as we 
try to move forward with regulations that would open up 
transparency and provide more accountability.

                    NIH OFFICE OF NUTRITION RESEARCH

    Mr. LaTurner. The budget request for the National 
Institutes of Health includes a $120,000,000 increase for the 
Office of Nutrition Research----
    Secretary Becerra. Yes.
    Mr. LaTurner [continuing]. Within the Office of the 
Director from a current funding level of just $1,300,000. I 
can't see any justification for why we need to be providing a 
9,000 percent increase for research that can already largely be 
conducted by other agencies like USDA that will likely result 
in Kansas farmers being told by D.C. bureaucrats what we can 
and can't grow.
    Could you give us specific examples of what the budget 
envisions the office doing with an additional $120,000,000?
    Secretary Becerra. Yes. And Congressman, I hope we have an 
opportunity to discuss this because I hope I can dissuade you 
in the feelings that you have. Because today in America, you 
can buy a bag of potato chips with a certain level of salt, and 
if you were to go to a country in Europe, same bag of potato 
chips, and you turned around and you looked at the amount of 
sodium in that bag, you would find that it is about 50 percent, 
maybe more than that, less salt.
    Why a difference? Because our standards don't allow us to 
go in as quickly to try to provide for the nutrition of 
Americans. The money that we are including is so we can start 
to treat nutrition the way we should, as part of health. And 
that we treat food as we should, as medicine to help people 
stay healthy.
    Mr. LaTurner. My time has expired. Madam Chairwoman, I 
yield back.
    Ms. Letlow. Mr. Ellzey, you are recognized.
    Mr. Ellzey. Thank you, Madam Chair.

                              PREPAREDNESS

    And first of all, I would like to say thank you to the 
folks here from the Alzheimer's Association. All of us know 
somebody who has suffered from this very cruel disease, and I 
appreciate you being here.
    Thank you very much.
    And I agree with my friend, Mr. Ciscomani, about the 
Narcan. And from my perspective, Mr. Secretary, Narcan should 
be the defibrillator of the modern era. And everywhere there is 
a defibrillator, we should have 10 Narcan doses--school buses, 
high schools, aircraft--everywhere across the country. Because 
it takes a matter of seconds to save it. It is harmless, and we 
need to be looking at it as a nationwide issue.
    Because we are losing wartime numbers of Americans every 
day, 200 every day, to fentanyl overdoses, and it is extremely 
important.
    Thank you for being here, sir. I have got a couple of quick 
questions for you.
    Number one, let us talk about COVID and the next infectious 
disease. We need to be prepared both at the community and the 
local hospital level. How is HHS ensuring that we have quick 
diagnostic testing done to quickly identify infectious 
pathogens?
    Secretary Becerra. We continue to work and make investments 
in the diagnostics. I was asked earlier about the money that 
was provided to address COVID and how most of that money has 
been spent, about 94 percent. There is still about 6 percent 
that remains.
    Some of that 6 percent would go precisely to what you just 
mentioned. Is to make sure we continue to stay prepared. We are 
able to fund the types of programs, whether it is for treatment 
or testing, that will be needed. And we want to replenish our 
Strategic National Stockpile, which was reduced so we could 
meet this need during the pandemic.

                           HUMAN TRAFFICKING

    Mr. Ellzey. Thank you, sir.
    Shifting gears to human trafficking, it is my belief--and I 
am from Texas 6. We have three interstates going through my 
home county, Ellis County just south of Dallas, where we know 
human beings are being trafficked for the sex trade throughout 
the United States from the Southern border.
    Human trafficking and sex trafficking is evil as modern-day 
slavery. The number of unaccompanied alien children encountered 
at the Southwest border has increased over the last 2 years, 
with over 146,000 in fiscal year 2021, 152,000 in 2022, 37,000 
in the first 3 months of fiscal year 2023. Under Federal law, 
HHS is responsible for ensuring the safety of all unaccompanied 
alien children referred to HHS by CBP, an entity within DHS, 
which means ultimately you are responsible for protecting these 
children through the Office of Refugee Resettlement.
    In 2021, HHS and DHS signed an MOA, a Memorandum of 
Agreement, which replaced a previous 2018 MOA between HHS and 
DHS, removing some requirements for background checks for 
potential sponsors of unaccompanied alien children. 
Specifically, the 2021 MOA removed the requirement that the 
Office of Refugee Resettlement must provide biographic and 
biometric data for all adult members of a sponsor's household 
in order to check the FBI's national and statewide criminal 
history, child abuse, neglect, and sex offender databases prior 
to placement of the UAC.
    Leaves those children vulnerable, in my mind. I am new to 
this committee and new to this issue other than knowing that it 
exists. It seems like it is making it easier for those children 
to be put at risk than harder.
    So my question is, was there a rationale for removing the 
biographic and biometric data?
    Secretary Becerra. I appreciate the question, Congressman.
    And by the way, I appreciate the way you have approached it 
because I know in your State, you see it every day.
    Mr. Ellzey. Yes, sir.
    Secretary Becerra. I believe what you are referring to is 
our decision, based on the work with the advocates for these 
families and for these children, who said if you know there is 
a parent for which that child can be released in sponsorship, 
then why would you need to do as vigorous a check as you do 
generally when you are trying to find out who would be an 
eligible sponsor?
    And we decided that if it is to a parent that the child 
would be released, who is going to care more about that child 
than the parent himself or herself? And so because at that 
point in time that you are referring to, we were getting more 
kids than we had capacity to absorb, we decided that at least 
with regard to a child who had a parent waiting to become the 
sponsor, that we would assume that having done checks, that the 
people in the household with that parent should be responsible 
as well.
    And so, based on having a parent available, we said that if 
we could find a parent--and most of the time we can find a 
parent--that to be able to move that child to a better setting 
than having them in these congregate care settings where you 
have got hundreds of kids, we would do something like that. But 
otherwise, everyone goes through a background check.
    Mr. Ellzey. Thank you for your time, Mr. Secretary.
    Secretary Becerra. Thank you for posting that.
    Mr. Ellzey. My time has expired. I yield back, Madam Chair.
    Secretary Becerra. Thank you, Congressman, for that 
question.
    Ms. Letlow. Mr. Secretary, we are going to start a second 
round. Thank you, Mr. Secretary. We are going to start with a 
second round of questions.
    I would like to acknowledge Ranking Member Ms. DeLauro for 
5 minutes.

                           BACKGROUND CHECKS

    Ms. DeLauro. Thank you very, very much.
    If I can just take a second of my time because I lived 
through the issue of the background checks. To my colleague Mr. 
Ellzey, it was found by the prior administration that the 
expanded background checks did not increase the safety of these 
children. So it was under the prior administration, under the 
Trump administration that what they began to do was roll back 
on the entire household.
    Because what they found was that doing the entire household 
tripled the amount of time that children were in the 
Government's care. And so it really brought unification to a 
halt, et cetera.
    Secretary Becerra. Yes.
    Ms. DeLauro. So it was the prior administration that rolled 
back. Be happy to talk to you more about it. Lived through it, 
and you know, it made good sense what the actions were.

                               CHILD CARE

    Childcare. Speaking of childcare, two questions here.
    This is--we know that childcare is essential. It is a 
crisis. More kids need access to childcare. But the childcare 
facilities struggle to retain staff. The staff is underpaid, 
and this is women in disproportionate numbers, women of color, 
underpaid.
    And so, Mr. Secretary, what is included in your 2024 budget 
to address the staffing shortages and underpaid workforce in 
childcare and in early childhood education?
    I am going to ask my second question at the same time, 
which is a trick, I know. With the block grant, the Child Care 
and Development Block Grant, there is a $1,900,000,000 increase 
we secured for the CCDBG in 2023, and I appreciate and support 
the $1,000,000,000 increase you are requesting. What does the 
$1,000,000,000 increase for the block grant mean in terms of 
the number of additional children that would be able to access 
childcare? What does it mean for the economy if we are able to 
expand access to affordable childcare?
    Secretary Becerra. And Congresswoman, I am going to give 
you numbers, but that doesn't tell the story when we are 
talking about kids. The numbers are the President is requesting 
$600,000,000,000 for childcare. That is a lot of money. It is 
still not enough because we know that only 1 in every 7 
children in America is receiving the childcare that they need, 
and that is keeping a lot of parents from having the ability to 
really do their utmost, be the most that they can be, because 
they have to worry about care for their children if they try to 
go to work.
    I will tell you that if we weren't to get the dollars to do 
the expansion of the Certified Community Behavioral Health 
Centers, there would be a whole bunch of folks after the hour 
of 5:00 p.m. who won't know where to go to get help, and in 
many cases--we had conversation earlier about what happens to 
these folks that don't get care? And if they are on a drug, if 
they are on opioids, chances are they will end up overdosing, 
and we will find them, but now we will find them no longer 
alive. And so it is desperately needed that we make these 
investments.
    When--as I said earlier, when a worker in America--mostly 
women, mostly women of color--are taking care of our next 
generation of leaders, and they could probably go across the 
street at that burger joint and apply for a job and make more 
money flipping burgers, something is wrong with our priority 
about how we treat the workers who take care of our kids.
    And some of the money that the President is proposing would 
go not just to increase and expand the number of slots for kids 
to get care but would increase the ability to pay more.
    Ms. DeLauro. Mr. Secretary, is that money that you are 
speaking about the proposal for the--the mandatory proposal for 
the----
    Secretary Becerra. Yes.
    Ms. DeLauro. Okay. But within the one, so dealing with the 
shortages, does that $1,000,000,000 increase for the Child Care 
and Development Block Grant include the opportunity to deal 
with expanding of the opportunity for childcare, but also being 
able to deal with the underpayment and the shortage of staff?
    Secretary Becerra. Yes, it does.
    Ms. DeLauro. So that $1,000,000,000 will provide that. In 
the meantime, we do need to get the authorization for the 
mandatory program to increase 16 million kids being able to get 
access to childcare.
    Secretary Becerra. Yes. And it does it with flexibility 
because it is different for some States than in other States, 
but we do provide dollars so they can deal with their 
workforce, increase the pay, increase the numbers.
    Ms. DeLauro. Okay. So that is within that $1,000,000,000 
that you have requested----
    Secretary Becerra. Yes.
    Ms. DeLauro [continuing]. To deal with the Child Care and 
Development Block Grant? Thank you, and I yield back.
    Ms. Letlow. Dr. Harris, you are recognized.

                             AUTHORIZATION

    Mr. Harris. Thank you very much.
    Let me follow up a little bit on what Mr. Clyde asked 
about, the appropriation versus authorization.
    Secretary Becerra. Yes.
    Mr. Harris. Because you were sitting on this side of the 
divide at one point. So you know that the Rules Committee makes 
a rule every time we bring an appropriation bill to the Floor 
that it can't be challenged because it is not authorized. That 
is right? It disallows that point of order, right? Or maybe you 
didn't read the rules that closely?
    Secretary Becerra. I know that there are various ways to 
make sure that at the end of the day, if you all tell us there 
is dollars available, we get to spend it.
    Mr. Harris. Right. Because there could be an assumption 
that when we appropriate, it is a de facto authorization. But 
then again, why would the Rules Committee put a point of order 
rule in the appropriation when we bring appropriating bills to 
the Floor, not allowing that point of order?
    But your answer was intriguing because what you said is, 
well, let us see if you could get the authorization through. So 
what you are implying is that this committee should act 
contrary to what we could actually pass out of an authorizing 
committee. That is what your answer implies, right? We should 
actually----
    Secretary Becerra. No, that is not true.
    Mr. Harris. We should appropriate money when we kind of 
feel that the authorization committee could never pass an 
authorization. It would be unsuccessful.
    Secretary Becerra. No, that is not my----
    Mr. Harris. Well, can you explain your answer? Can you 
explain why you answered--and I forget the exact quote, 
although I will pull it out of the transcript.
    Secretary Becerra. And I am responding based on my time as 
Secretary, where I am obligated to make sure that any dollar I 
spend is legally spent. And I am also responding based on my 24 
years having sat where, Congressman, you are. And that is that 
I understand the process. At the end of the day, we may 
execute, but we cannot execute unless you dispose of that 
particular program.
    Mr. Harris. Sure. And yes, just reclaiming my time, I mean 
the bottom line is that it certainly seems we can do it because 
we have done it. But my opinion is, like Mr. Clyde's opinion, 
is that we actually take some authority from authorizing 
committees by doing it year after year after year. And in the 
case of Title X, I don't know what he said, it was a decade 
since that has gone through an authorization committee.

                           MEDICAID EXPANSION

    But let me ask you because you were here longer than I am. 
I was not here when the ACA Medicaid expansion was passed. It 
always intrigues me that our FMAP toward the expansion is at 90 
percent, but the average FMAP for traditional Medicare, which 
is what we think of Medicare--the poor and elderly, the 
pregnant women----
    Secretary Becerra. That is----
    Mr. Harris [continuing]. Is at 56 percent.
    Secretary Becerra [continuing]. For Medicaid.
    Mr. Harris. For Medicaid. I am sorry. For Medicaid, yes. 
For Medicaid. So the FMAP is higher for the expansion.
    Now if we brought that FMAP for the expansion just into the 
same FMAP that we have for traditional Medicaid, how much do 
you think we would recover from the States? Because my 
calculation is about $50,000,000,000, on that order. Maybe even 
more. In other words, you understand my question?
    Secretary Becerra. I do, but it relies on a premise that I 
think is faulty because in order for these States to receive 
those Medicaid dollars under expansion, we are by law required 
to offer them an FMAP----
    Mr. Harris. Right. So that was my question. Why did we 
choose a much higher FMAP than the traditional FMAP? And maybe 
you don't know. Maybe you weren't involved in that negotiation.
    Secretary Becerra. I was certainly involved in the drafting 
of the ACA and in passing the ACA. And what we were trying to 
do is get as many people as possible in this country coverage 
because some folks were falling into the gaps.
    Mr. Harris. Let me reclaim my time again. Covered under 
Federal dollars, using Federal dollars. But what was the--you 
might not remember. What was the deficit in the year that the 
ACA was passed? Was it over $1,000,000,000,000? I don't think 
so. My best recollection it was not over $1,000,000,000,000, 
but it is now.
    So the situation has kind of changed. I mean, when we 
passed that bill that was overly generous with the States, we 
didn't have a $1,000,000,000,000 deficit. I would suggest that 
we should consider having the States pay their ``fair share'' 
of the expansion, and that would help us get out of the fix we 
are in.

                           DIETARY GUIDELINES

    Finally, the Dietary Guidelines. Because you know, the HHS 
and Department of Agriculture share the Dietary Guidelines, or 
constructing those Dietary Guidelines. And I chair the 
Agriculture Appropriations Subcommittee. You pointed out 
sodium. Great example. The Dietary Guidelines realized that we 
probably have too much sodium.
    You are aware there is no restriction on the use of SNAP 
benefits to restrict the sodium content of what you can obtain 
under SNAP benefits. Is that right?
    Secretary Becerra. So you are asking--I could give you an 
answer. I can volunteer an answer, but I would probably let 
Secretary Vilsack----
    Mr. Harris. Let me just tell you, Mr. Secretary, there is 
no restriction. So in a strange way, we actually are funding 
over $100,000,000,000 a year into a program that actually does 
nothing to adhere to the sodium guidelines that the Department 
of Agriculture and the Department of HHS promulgate.
    I yield back.
    Ms. Letlow. Mr. Hoyer, you are recognized.

                             AUTHORIZATIONS

    Mr. Hoyer. Thank you very much.
    First, let me say that when the Congress passes a bill and 
appropriates money, it does, in fact, authorize that 
expenditure by the Federal Government. We do have a rule, of 
course, that requires authorization. The Rules Committee 
regularly waives the point of order against that rule so that 
expenditures perceived as necessary, but unauthorized because 
for whatever reasons it has not passed an authorization can, in 
fact, be effected.
    And when the entire Congress passes that bill and the 
President signs it, it is law. And therefore, any implication 
that somehow the Secretary or any other Department would be 
spending money that was not authorized by the House, but 
nevertheless the appropriation was passed is doing something 
that is not authorized is incorrect.

                           MEDICAID EXPANSION

    Secondly, the ACA, the reason we did 90 percent is because 
we want to encourage people to get under--get insured. And one 
of the incentives we gave was to say that we would pay 90 
percent of the cost to the States. Because the States are being 
pressed very hard by the increase in their medical expenses. 
And so we did not believe they had the resources. So we made 
the resources themselves.
    And I would remind everybody, the Affordable Care Act was 
paid for, period. And we made a very great effort to make sure 
that it was paid for.

                               HEAD START

    Lastly, Mr. Secretary, those of us who advocate for 
spending ought to also advocate for accountability. Head Start, 
which I am a strong supporter of, existed from 1965 to 1995 
without any Head Start effort having been canceled. Donna 
Shalala, who was then the Secretary, canceled one for 
nonperformance.
    Let me ask you something. In terms of accountability for 
the expenditure of Federal dollars on programs that are highly 
supported--President Bush highly supported this, as did I and 
many, many others. You did as well. Do we have an 
accountability? Because we owe it to the American taxpayer to 
say we want your money spent effectively.
    Can you tell me about that? I used that one program, but 
there are other programs as well.
    Secretary Becerra. And again here, Congressman, I 
appreciate the question. But I will also tell you not just as 
Secretary, but as a former Attorney General, it is important 
that we have accountability. And if you look at some of the 
past actions of HHS, recent actions, we are going to enforce 
accountability because it is important that if you are going to 
get a Head Start dollar, you are using it for those kids.
    And so if you are not--if you can't prove that that is how 
you are using that money, then that center is going to be 
subject to action, enforcement action to make sure that we 
don't provide more dollars in ways that aren't helping kids.
    Mr. Hoyer. Thank you very much for that.
    And I would like a follow-up from your folks on how that 
has been affected in terms of because I think there are 
programs that are not functioning as we want them to do so, to 
the detriment of our children. So that we need to make sure 
those children are getting what we think we want them to have.
    Thank you, Mr. Secretary.
    Secretary Becerra. Thank you.
    Mr. Hoyer. I yield back.
    Ms. Letlow. Thank you. Mr. Ellzey, you are recognized.
    Mr. Ellzey. Thank you, Madam Chair.
    Thanks again, Mr. Secretary.
    I just have a couple of quick questions.
    Secretary Becerra. Okay.

                        HHS WORKFORCE PRACTICES

    Mr. Ellzey. One is, as I look across at the building across 
the street, it looks kind of empty. So my question is simple. 
How many folks were working in your Department in office before 
the pandemic to now, and how many were working remotely before 
the pandemic and now? And the reason I ask this is I just got 
out of another hearing. I am asking everybody this question. 
Nobody is exempt from it. I am just curious.
    Because everybody else kind of has to go back work. My 
constituents from time to time will complain that they are not 
able to get a hold of anybody at various departments. Not 
pointing any fingers here. So just a flat-out number, if you 
got it.
    Secretary Becerra. Yes. I will tell you that our folks are 
working full time. And because of the new flexibilities that we 
have learned that COVID made possible, we are continuing to 
have not just full-time work, but our performance, I mean there 
are more people today who have access to healthcare than ever 
before. There are close to 16.5 million people who got their 
healthcare directly from our marketplaces under Obamacare. 
There are close to 40 million people that we helped gain access 
through the Affordable Care Act altogether.
    There are, as I mentioned before, close to 300 million 
Americans who have gotten vaccinated. That is all because the 
folks at HHS have been working. A lot of our folks, as you 
know, don't just work at a desk. A lot of our folks are actual 
practitioners who are out there in the field.
    Some are the investigators that we need, and some of them 
do have an opportunity to have a more flexible work 
arrangement, and we are going to do everything we can to keep 
them because we have to stay competitive. Because the other 
guys who pay way more than we do are doing everything they can 
to attract the great folks that we have. And we are going to 
keep them with us.
    By the way, we are ranked as the number-two agency to work 
for in the Federal Government, and we are big. And the only 
reason we are not number one is because we don't send people 
into space who work for us because that is what NASA gets to 
do. But otherwise, if we got to send people into space, we 
would be number one.
    Mr. Ellzey. Well, that was an artful dodge. I appreciate 
your answer. [Laughter.]
    I am not going to keep continuing to poke that bear and see 
if I can get an answer. I don't think I will, but that is all 
right.

                            BORDER IN TEXAS

    When I was a State legislator just 2 years ago, I went down 
with a bunch of fellow State legislators and a congressman down 
to the border in Texas at night. And I watched as a coyote 
brought a family--two sets of families across. As we watched 
them, and I watched this coyote set foot on American soil, 
which as a warrior, a formal naval aviator, I really wanted to 
act on that because I knew what was going on here.
    And this family that came across, they got off the raft 
right in front of me. I am wearing night vision goggles, 
watching them walk right in front of me. They left an 8-year-
old on the boat. And in Spanish, they said, ``You forgot her.'' 
And the father in me at that point really wanted to act.
    And so, oh, they went back and got her because I know full 
well that they will bring children across that aren't a member 
of the family so that they can get across and then get 
processed, and we are finding kids in the ditches in Texas.
    I am not pointing fingers here, but what I will point out 
is Border Patrol agents have claimed how traffickers are 
recirculating those kids from family to family. Are you aware 
of any of that happening?
    Secretary Becerra. We have heard a number of stories. But 
could I just say from me you are going to hear nothing but good 
stuff about the Border Patrol agents that have been out there 
working really hard. They are doing a lot of stuff that they 
didn't think they would have to do in trying to help some of 
these unaccompanied migrant kids, and we have heard stories 
otherwise.
    But I will tell you that there are men and women serving in 
Border Patrol who are having to be the first contact for some 
of these children who are unaccompanied. And it can be very 
traumatic. I want to say here thank you to those men and women 
who are doing the work. They got a pistol on their side, but 
they are also picking up those kids.
    And so I think it is important that we recognize the work 
that is being done. It is tough work. It is a challenge. And I 
would say to you that we should do everything we can, whether 
in U.S. or working with Mexico to go after those coyotes 
because they are the real culprits in this.
    They charge these folks to come across. They make a 
killing, and they know it is safe with these unaccompanied kids 
to do it. They probably make more money than trying to carry 
drugs across the border. It is easier, safer. And so I think 
what we have to do is double down in our efforts to try to make 
sure that we stop this stuff, especially when it deals with 
trafficking kids.
    Mr. Ellzey. But would you say that the traffickers are 
recirculating those kids for this purpose? Are you aware of any 
of those? You are HHS. You may or may not.
    Secretary Becerra. I am not aware of it because a child 
that we hear about, we care for.
    Mr. Ellzey. Okay.
    Secretary Becerra. And so that kid will not recirculate. 
But it wouldn't surprise me, but I can't tell you that for a 
fact. And DHS, the Department of Homeland Security, probably 
could answer that question.
    Mr. Ellzey. Okay. Well, thank you very much for the answer. 
You know, I think we can all agree that the cartels are the 
epicenter of evil in the Southern Hemisphere. And they are a 
clear and present danger to national security, but they are 
also an evil force that must be reckoned with.
    Secretary Becerra. By the way, thank you for your service.
    Mr. Ellzey. Thank you, sir.
    Madam Chair, I yield back. Thank you.
    Ms. Letlow. Ms. Frankel, you are recognized.

                         MENTAL HEALTH OF GIRLS

    Ms. Frankel. Thank you very much.
    Mr. Secretary, it is very sad that Republicans are obsessed 
with bullying and bashing transgender people. You know what I 
not have heard one peep about, not even a little peep, that is 
about the over 45,000 Americans who in 1 year were killed by 
gun-related injuries. The biggest killer of our children are 
guns.
    And you know that, Mr. Secretary? You don't have to answer. 
I know that. But I want to go to another topic.
    One thing, I will say this. You learn a lot here. I learned 
today that some of my colleagues--and I don't know whether they 
are right or wrong about this--but they do not want us, the 
Federal Government, to tell farmers what vegetables to grow. 
However, they do want to tell the women of this country when 
and if they should bring a family into this world.
    And at the same time, Mr. Secretary, they want to cut Title 
X for family planning. They want to cut childcare, Head Start, 
nutrition programs, maternal health. Should I go on and on? 
Other than to say I think it is crazy.
    All right. Let me get to my question because I do think 
what we are leading to and what we now know is that there are 
horrifying rises in the mental health issues of adolescent 
girls, and what we are doing in this country is going to make 
it worse. I would like to know what your agency is doing on 
this subject.
    Secretary Becerra. Congresswoman, we make a more than 20 
percent increase in investments on these issues of mental 
health because we know that America tells us 90 percent of 
Americans feel that we are in--experiencing a mental health 
crisis in this country, and we know the numbers are exploding 
of our young, including those who are even younger than teens. 
And so we are making a major investment in that.
    I could mention one particular program that is focused on 
children. It is called Project AWARE. We go into the schools. 
We try to provide kids with an opportunity to have access to 
mental health services, including just finding out about what 
is available to them. We are trying to provide some 
$244,000,000 for that project because we have seen how 
successful it has been in places throughout the country where 
it has been employed.
    Ms. Frankel. Thank you, Mr. Secretary.
    I yield back.

                           Concluding Remarks

    Ms. Letlow. Thank you. I would like to recognize Ranking 
Member Ms. DeLauro for closing comments.
    Ms. DeLauro. Thank you very, very much, Madam Chair.
    I just wanted to make a couple of points first, if I can, 
just for the record.
    A number of my colleagues have talked about child labor, 
unaccompanied kids, and we all read the horrific stories in the 
papers about underage kids in meat plants and working late 
hours or working during the middle of the night. But the issue 
is that child labor in the United States, it is not just 
unaccompanied kids. It is an exploitation of vulnerable 
children regardless of where a child is from.
    Let me mention this to you. It is something that this 
committee--and not everyone is here, but this committee is 
uniquely positioned to address. We can fund investigators at 
the Department of Labor Wage and Hour Division, which comes 
under the purview of this committee. So we need to crack down 
on the companies that exploit kids, that place them in 
dangerous workplaces.
    A number of my colleagues this morning have also talked 
about the Southern border. They have talked about drugs and 
fentanyl, et cetera. And I just say to folks look at what is 
being said about going back, and looking at 2024, looking back 
at what 2022 numbers are. And if you deal with the scale of the 
cutbacks or what I call the lack of investment, you are going 
to see it is there. Read about it.
    We are looking at cuts to the Border Patrol. We are looking 
at gutting border protections. That means that there is even 
more of an opportunity for fentanyl, for trafficking to 
continue to happen. I just ask people to please look at what it 
means. It is just not a phrase to say we are going to cut, go 
back to 2022 for 2024. It has real-life consequences, and I 
think we need to educate one another about what those 
consequences are.
    I couldn't be more pleased with the 2024 budget request for 
HHS. Strong funding increases for public health, for maternal 
health, which I know the chair cares deeply about, behavioral 
health, mental health, childcare, early learning, so many other 
areas. And what our job at this committee particularly is to 
build on the investments that we have made in the past here.
    I won't--but I worry about what is being said about the 
cuts, and I was pleased, Mr. Secretary, I have your letter, and 
we have the letters from every one of the agencies. But you 
outlined 200,000 slots. It is not a slot. It is a kid. It is a 
little kid that is not going to be able to be put into 
childcare or into Head Start.
    Childcare, I will tell you parents are not going back to 
work, what that does to the economy. You are not going back to 
work if your kid is not in a safe place during the day.
    Suicide has been mentioned, and you talked about that. I 
just would say opioids, we care about that. We talk about that. 
But look at what it has done to our ability to respond to the 
opioid crisis.
    Health centers, 20--almost 25 million people in the United 
States get their primary healthcare from community health 
centers. What happens to their folks in those?
    And you talked about Indian health services. Writ large, we 
continue to put them at a disadvantage, and they already are 
for so many issues.
    So I would just say let us educate ourselves on what these 
cuts mean. Let us think about where the opportunities are for 
us to continue to make investments in the issues and the 
services that we provide to the American people every single 
day.
    Should we take a look? Should we have accountability? There 
is no question about that. That is what the job of the 
Appropriations Committee is about as well.
    So I thank you for your testimony today, Mr. Secretary. 
Thank you for the work that you are doing. It is just not your 
testimony today. Thank you for a career that has focused on the 
issues that really are front and center for the American 
people.
    Thanks very much.
    Ms. Letlow. I would like to recognize Mr. Hoyer.
    Mr. Hoyer. Thank you very much, Madam Chair.
    I just want to congratulate our former colleague and the 
former Attorney General of California. He has got a big agency. 
He has got a lot of programs.
    Mr. Secretary, I thought your answers were honest, 
knowledgeable, and respectful of those who asked the questions, 
and I think you are serving the American people well. But more 
importantly, you are serving the people that this Congress 
wants HHS to serve well.
    So thank you very much.
    Ms. Letlow. Thank you, Mr. Secretary, for joining us today.
    Our staff will be following up with some questions for the 
record.
    The subcommittee stands adjourned.
    [Questions and answers submitted for the record follow:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

                                         Wednesday, March 29, 2023.

               ADDRESSING THE CHALLENGES OF RURAL AMERICA

                               WITNESSES

TOM MORRIS, ASSOCIATE ADMINISTRATOR FOR RURAL HEALTH, HEALTH RESOURCES 
    AND SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN 
    SERVICES
RUTH RYDER, DEPUTY ASSISTANT SECRETARY FOR POLICY AND PROGRAMS, OFFICE 
    OF ELEMENTARY AND SECONDARY EDUCATION, DEPARTMENT OF EDUCATION
LENITA JACOBS-SIMMONS, DEPUTY ASSISTANT SECRETARY, EMPLOYMENT AND 
    TRAINING ADMINISTRATION, DEPARTMENT OF LABOR
CARRIE COCHRAN-McCLAIN, CHIEF POLICY OFFICER, NATIONAL RURAL HEALTH 
    ASSOCIATION
BRITTANY HOTT, PH.D., ASSOCIATE PROFESSOR, UNIVERSITY OF OKLAHOMA
LAURA K. SCHEIBE, DIRECTOR OF CAREER AND TECHNICAL EDUCATION, SOUTH 
    DAKOTA DEPARTMENT OF EDUCATION
TEARSANEE C. DAVIS, D.N.P., DIRECTOR OF CLINICAL PROGRAMS AND STRATEGY, 
    UNIVERSITY OF MISSISSIPPI MEDICAL CENTER
    Mr. Aderholt. Good morning. Good to have everybody here 
today.
    And this is a hearing that so many of us have been looking 
forward to, and I am glad to welcome everybody to the Labor, 
Health and Human Services Subcommittee of Appropriations. And 
glad to be here with my colleagues and thank all the witnesses 
for being here. Thanks for taking time out of your schedule to 
carve time to be here and testify and talk about some rural 
issues that are facing America.
    I am proud to represent the Fourth Congressional District 
of Alabama. It is composed of about 14 counties in the 
northcentral part of the State of Alabama. It is actually the 
only congressional district in Alabama that actually borders 
three States. I border Mississippi, Tennessee, and also 
Georgia.
    And my district has only 3 cities with a population over 
20,000. I do encompass some areas that are a little bit more 
populated than that, but wholly contained within the district, 
there is only 3 over 20,000. I will also give you some 
perspective. I represent also part of Tuscaloosa, where the 
University of Alabama is, and that stadium holds well over 
100,000 people.
    So the Fourth District is a beautiful district, a diverse 
area, so much to offer. Great people, as I always say. But like 
many rural parts of our country, we face unique challenges, and 
I have found that many of our policy debates here in Washington 
sometimes overlook and sometimes disregard many of the 
challenges that rural Americans face.
    Many of our colleagues also represent rural areas. Our 
districts have been changed by the limited access to 
healthcare, workforce opportunities that are insufficient, and 
an education system that often is not able to meet the needs of 
students and especially those with disability. It is my 
intention this morning for the hearing that we will shed some 
light on some of these challenges that are faced by rural 
constituents and also present solutions to address them.
    I would also like to start with some basic information. 
Just under 50 million Americans live in rural areas, making it 
just under 14 percent of the U.S. population. A typical rural 
district contains less than 10 percent of the typical urban 
county, with just over an average population of 20,000.
    Access to healthcare, lack of specialty care and nursing 
shortages, high rates of opioid addiction, lack of facilities, 
and a disproportionate burden of chronic disease relative to 
the rest of the country are challenges that we face in rural 
communities. Due to the geographic isolation, we also face lack 
of access to many educational services, such as specialized 
services for children with disabilities and opportunities for 
higher education near home.
    Unemployment in rural areas reached levels not seen since 
the Great Depression back in the 1930s, and even now, rural 
unemployment continues to be higher than the national average. 
We face challenges in developing and maintaining a high-skill 
workforce, with some areas' local economies reliant on a single 
industry or a single sector.
    And while it is not the jurisdiction of this particular 
subcommittee, I would be remiss if I didn't take just a minute 
to mention the impact of limited access to broadband in rural 
America. And I know this is something that I share with my 
colleague from Wisconsin, Mr. Pocan, because we sat on the 
Agricultural Subcommittee of Appropriations, which that was an 
issue that we dealt with. And, oh, I remember even years ago 
that that was an issue there, and I am sure you still deal with 
it in rural Wisconsin as well.
    But these areas represent a smaller customer base and more 
difficult terrain, and in addition, it is a lower adaption 
rate. And this results in higher prices and sometimes fewer 
options. As more services move online, especially in the 
education and healthcare sector, the gap between the urban and 
the rural areas for Internet service will only magnify the gap 
in access between urban and rural populations.
    The departments covered by this subcommittee have several 
programs targeting rural populations. We have asked witnesses 
from each agency to come before us today to speak about the 
work that these programs are doing to address the challenges of 
our communities.
    We also plan to hear from a second panel this morning of 
experts in the area of health, education, and workforce 
development, who can tell us more about the day-to-day 
challenges they face in delivering these important services to 
rural America.
    Rural Americans are the backbone of this country. The small 
businesses, healthcare workers, and the educators of my great 
State of Alabama and many rural States continue to strive to 
better their communities despite the disparities that they do 
face. It is past time that we draw attention to these issues 
and certainly to take action.
    I look forward to hearing from our speakers this morning 
about the programs that they are working on for rural America 
and see what they can do to help the committee serve all 
Americans.
    I would like to now turn to the committee's ranking member, 
Ms. DeLauro, for any remarks that she would like to make. Ms. 
DeLauro.
    Ms. DeLauro. Thank you very, very much, Mr. Chairman.
    And I will keep the larger seat. Thank you very much. It is 
very comfortable.
    Mr. Aderholt. Oh, good. Good. Yes.
    Ms. DeLauro. So, thanks. Let us just get the important 
business out of the way.
    But thank you so much for holding this hearing, and it is a 
critical and important hearing. I want to say a thank you to 
the agency officials and the outside experts that will join us 
today. Deputy Assistant Secretary Jacobs-Simmons, Associate 
Administrator Mr. Morris, Deputy Assistant Secretary Ruth 
Ryder, thank you so much for being with us.
    And our second panel is Dr. Carrie Cochran-McClain, Dr. 
Tearsanee Davis, Ms. Laura Scheibe, and Dr. Brittany Hott. 
Thank you all very, very much for really helping us to lay out 
the issues that are critical and important in terms of rural 
America.
    I look forward to taking a closer look at the programs in 
the Department of Labor, Health and Human Services, and 
Education that serve rural America. Our rural communities are 
integral to our national economy, to our history, to our 
identity. And about one-fifth of all Americans live in rural 
parts of our country. And unfortunately, the challenges these 
communities face are too often overlooked and poorly 
understood.
    Addressing these enduring issues and advancing equity and 
opportunity for people in rural areas is something that I care 
deeply about. Connecticut has larger cities, but we do have 
very rural communities in our State as well.
    Rural Americans are more likely to die of chronic illnesses 
than their urban counterparts. Rural communities have higher 
childhood and adult poverty rates, less access to healthcare, 
less likely to have health insurance.
    In reviewing your testimony, I noted from two of our 
witnesses--Dr. Cochran-McClain and Associate Administrator 
Morris--that since 2010, 147 rural hospitals have closed. In 
the United States, the wealthiest nation in the world, millions 
of people cannot get the healthcare that they need. This is 
unacceptable.
    Beyond healthcare, accessing childcare is more difficult in 
rural areas, as is accessing higher education and finding a 
job.
    And to Dr. Hott, as you mention in your testimony, almost 
17 percent of your rural students live below the poverty line, 
and nearly 15 percent qualify for special education services. 
Teachers lack the resources and the support that they need to 
do their job. On top of that, nearly 40 percent of rural 
students have inadequate Internet access at home.
    And on top of all of this, rural families also struggle 
with the same challenges that all working class and underserved 
families face. They are living paycheck to paycheck, with jobs 
that do not pay them enough and costs that are too high. And 
they have not seen their wages increase in years. They 
personally feel the impacts of our most urgent health crises, 
including the epidemics of opioid and substance use disorders, 
unconscionable rates of maternal mortality, chronic diseases, 
and mental health crises.
    Because these obstacles impact the health and the financial 
well-being of our rural communities so intensely, this 
committee has made great strides to increase funding for the 
targeted programs that support the health, safety, and 
prosperity of rural areas. As you know, we increased funding 
for rural health programs that specifically address rural 
communities most pressing health crises. This includes the 
Rural Communities Opioid Response Program that fights substance 
use and provides often lifesaving support to people who are in 
desperate need.
    We also created the Rural Emergency Hospitals Technical 
Assistance Program to better support rural hospitals and the 
people they serve. And to safeguard the health of women and 
mothers at a time when more than half of our rural counties 
lack hospital obstetric services and maternity mortality rates 
are simultaneously rising, we strengthened the Rural Maternity 
Obstetrics Management Program, RMOMS, to meet this critical, 
but unmet need in rural areas.
    To increase the quality of and access to good educational 
opportunities for rural schools, we strengthened the Rural 
Education Achievement Program to increase the capacity of 
school districts to serve students. At the same time, we funded 
large formula grants that serve students everywhere, including 
rural students.
    These include increases for the Title I grants that provide 
Department of Education funding to support low-income students 
in our Nation's public schools and the IDEA grants that support 
students with disabilities across the country, recognizing the 
great needs that rural communities in our country face with 
these areas.
    To help workers and working families, we improved job 
training program grants that help workers in rural areas gain 
the skills they need to succeed in their jobs. The programs we 
fund in this bill have the capacity to drastically improve 
people's lives at every stage of their life, and we must do 
more.
    We must find high-quality schools and childcare to grow 
opportunity for children and their families. We must support 
high-quality job training programs, apprenticeships to help 
workers reenter the workforce or find a better-paying job.
    We must find the health programs that improve access to 
lifesaving healthcare and prevent or treat chronic illnesses. 
And as Dr. Tearsanee Davis makes clear, to make sure that 
healthcare is more accessible for families, we must increase 
our support for telehealth programs and other critical tools 
that keep people connected to and accessing the healthcare that 
they need.
    As you mention in your testimony, Mr. Morris, Medicare fee-
for-service telehealth visits went from less than 1 million in 
2019 to more than 50 million in 2020. Investing in telehealth 
has never been more important. This is a key way we can 
continue to fight unacceptable and dangerous health 
disparities.
    I am concerned that--I am concerned, take a moment, that 
rural communities will suffer the brunt of the impact if some 
of my--some, and I say some of my Republican colleagues move 
forward with their plan to roll back spending to the 2022 
level. As you might know, I received letters from agency heads, 
including the Department of Labor, Health and Human Services, 
and the Department of Education, outlining the impact that 
these cuts would have. Just let me run through some of the ones 
that would most impact rural children and families.
    Cuts to the Department of Education would remove more than 
100,000 teachers and service providers from classrooms serving 
low-income students and students with disabilities funded 
through Title I and IDEA grants.
    Cuts to the Department of Labor would cut workforce 
training and development for 750,000 job seekers.
    Cuts to HHS, Health and Human Services, would result in 
fewer opioid use disorder and medication-assisted treatment 
programs that millions of people in rural areas depend on.
    These deeply impact rural families. Some people have 
questioned the approach to analyzing these cuts on the premise 
that the Republican majority will cut spending, but that these 
cuts might not be shared equally. The members of this 
subcommittee know well that if certain other programs are 
exempt from cuts, health and education programs that working 
families rely on would be cut by even more than the Office of 
Management and Budget's current estimates.
    This subcommittee can and must do more to lift up our 
Nation's most vulnerable so that every person, no matter their 
background or zip code, has the opportunity to contribute, to 
succeed, and yes, to prosper. This means strengthening the 
programs we just spoke about, not gutting them.
    Again, welcome, and I thank all of our witnesses this 
morning for testifying and obviously letting us know what more 
can be done.
    Mr. Chairman, with that, I yield back.
    Mr. Aderholt. Thank you.
    At this time, I would like to introduce the panel that we 
will have.
    We have Mr. Tom Morris. Tom Morris serves as the Associate 
Administrator for Rural Health Policy in the Health Resources 
and Services Administration of the U.S. Department of Health 
and Human Services. So, welcome.
    We also have Ruth Ryder who is Deputy Assistant Secretary 
for the Office of Policy and Programs, Formula Grants, in the 
Office of Elementary and Secondary Education at the U.S. 
Department of Education.
    And also we have Lenita Jacobs-Simmons, who has over 20 
years experience in working at the Employment and Training 
Administration, serving in numerous positions. Currently, she 
is ETA's Deputy Assistant Secretary responsible for the Office 
of Unemployment Insurance, Trade Adjustment Assistance, Policy, 
Development, and Research, as well as oversight of regional 
operations.
    So, at this time, you each have 5 minutes to deliver your 
remarks. But of course, your entire testimony will be included 
in full.
    So, Mr. Morris, we will begin with you. Welcome. And I look 
forward to your testimony.

                        HRSA Opening Statements

    Mr. Morris. Chairman Aderholt, Ranking Member DeLauro, 
members of the subcommittee, thank you for the opportunity to 
testify before you today on behalf of the Health Resources and 
Services Administration and the Federal Office of Rural Health 
Policy.
    I am pleased to be able to discuss with you our investments 
in rural health, our initiatives to support rural hospitals, 
expand access to healthcare services in rural communities, our 
response to the opioid epidemic, and our efforts to grow the 
rural health workforce.
    I also want to thank you for the recently passed 
Consolidated Appropriations Act of 2023 and its support of 
rural health efforts.
    HRSA is dedicated to providing equitable care to the 
Nation's highest-need communities. My office acts as the focal 
point for rural health activities within the U.S. Department of 
Health and Human Services, and we are charged in Section 711 of 
the Social Security Act with advising the Secretary on rural 
health issues. In addition, we also administer a range of grant 
programs that support rural communities.
    I am pleased to be joined today by my colleagues from the 
Department of Labor and the Department of Education, and we are 
all working together as part of the administration's Rural 
Partners Network initiative to link rural communities to our 
respective grant funding and technical assistance resources.
    You brought up the issue of rural hospitals. They play a 
critical role in the rural healthcare infrastructure, providing 
essential care to small, isolated rural communities. They are 
an essential part of the healthcare delivery system in rural 
communities, along with community health centers and rural 
health clinics.
    Our research shows that rural hospitals face considerable 
challenges, including low patient volume, high fixed cost, a 
payer mix that is heavily dependent on Medicare and Medicaid. 
And unfortunately, as the ranking member noted, 147 rural 
hospitals have closed since 2010, and many more of these face a 
high degree of financial risk.
    In light of these challenges, the administration's 2024 
budget proposal includes $30,000,000 in additional support for 
these facilities. This includes $10,000,000 to help those rural 
hospitals that are at imminent risk of closure. Also features a 
broader $20,000,000 effort to expand services by providing 
start-up funding to help rural hospitals expand into new 
service areas such as pulmonary rehab, cardiac rehab, cancer 
services, and primary care.
    The 2023 enacted budget continues the funding that allows 
us to provide TA to rural hospitals that are seeking conversion 
to a rural emergency hospital, the new provider type that 
Congress created in 2022 to address gaps in care. We are going 
to continue to support rural communities through the Rural 
Health Outreach Program, and we are also ramping up our efforts 
about the need to enhance obstetric and maternal care through 
the RMOMS program, as mentioned earlier.
    Rural communities, as you know, continue to face challenges 
related to the opioid epidemic. Data from the Centers for 
Disease Control and Prevention show that rural residents age 25 
to 44 are at a higher overdose death rate than their urban 
counterparts. The impact of the crisis is obviously felt 
nationwide, but I think in rural communities it is felt 
particularly acutely because of geographic isolation and the 
lack of treatment facilities.
    The fiscal year 2023 appropriation includes $145,000,000 
for the Rural Communities Opioid Response Program, RCORP. This 
HRSA initiative targets funds directly to rural communities to 
help them implement their best ideas for how to focus on 
prevention, treatment, and recovery. The fiscal year 2024 
President's budget would request $165,000,000 for this program 
to expand it even more.
    The administration and Congress have both made expanding 
behavioral healthcare services a priority, and rural areas will 
benefit greatly from this push. The fiscal year 2024 
President's budget includes a new proposal for $10,000,000 to 
expand behavioral health services in the Nation's rural health 
clinics with start-up funding to get those services started.
    Maintaining and growing the workforce is also essential for 
ensuring access to care. Rural areas face a lot of challenges 
in terms of recruitment and retention. HRSA is the lead HHS 
agency to train the next generation of healthcare clinicians to 
work in rural and underserved areas, and we appreciate your 
support for those HRSA programs in the budget.
    Research shows that if we can expose students to rural 
training during their practice, they are more likely to 
practice there. That is certainly true for family medicine. We 
have put that into practice with the Rural Residency Planning 
and Development Grants Program. This helps rural hospitals and 
communities create rural residencies, and so far we have been 
able to create new rural residencies in 32 States.
    I want to thank you again for the opportunity to discuss 
all of these issues with you today, for your support of HRSA, 
HHS, and the Federal Office of Rural Health Policy. And I look 
forward to answering any questions you might have.
    [The information follows:]
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Ms. Ryder.
    Ms. Ryder. Chairman Aderholt, Ranking Member DeLauro, and 
distinguished members of the committee, thank you for the 
opportunity to share the Department of Education's critical 
work to meet the needs of the 9.7 million students enrolled in 
rural schools.
    I am Ruth Ryder, and I serve as the Deputy Assistant 
Secretary for Policy and Programs in the Office of Elementary 
and Secondary Education, OESE, at the U.S. Department of 
Education.
    OESE implements programs to support disadvantaged students 
under the Elementary and Secondary Education Act, ESEA. In this 
role, I oversee a broad range of management, policy, and 
program functions related to formula and discretionary grant 
programs under the ESEA.
    I have served at the Department for over 35 years in a 
number of roles and have been a classroom teacher, special 
education teacher, and district administrator. I am honored to 
be here with my esteemed colleagues from the Department of 
Labor and the Department of Health and Human Services and 
appreciate our cross-agency collaboration through the Rural 
Partners Network.
    It is important to note that the largest source of funding 
to rural schools comes through our formula grants under the 
ESEA Title I and Part B of the Individuals with Disabilities 
Education Act, known as IDEA. These funds serve millions of 
students in rural communities by providing critical academic 
support, preschool services, school improvement, educator 
professional development, and before and afterschool 
programming. We also compete discretionary grants that may 
include a rural priority.
    For the purposes of this statement, I will focus on 
programs that are directed to specifically serve rural 
students.
    First, I am pleased to share some programmatic updates from 
OESE's Division of Rural, Insular, and Native Achievement 
Programs, RINAP, and they administer the Rural Education 
Achievement Program, REAP. REAP is designed to help rural 
school districts that may lack the personnel and resources to 
effectively compete for Federal grants and that often receive 
grant allocations that are too small to be effective to meet 
their intended purposes.
    The two grants within REAP are the Small, Rural School 
Achievement Program, SRSA, which awards formula grants directly 
to eligible school districts to carry out activities authorized 
under other specified Federal programs, and the Rural and Low-
Income Schools Program, RLIS, which is designed to address the 
needs of students that attend rural and low-income schools.
    In 2022, the Department awarded $195,000,000 in REAP funds 
to support approximately 6,200 rural school districts across 
the United States. These rural school districts, which met 
small and/or low-income eligibility criteria, are using their 
REAP funds this school year for a variety of activities, 
including supporting supplemental teaching and learning 
activities, digital resources, high-quality professional 
development, school-based mental health services, and 
partnerships with outside healthcare entities.
    This summer, we estimate that we will award another 4,200 
SRSA grants and provide RLIS program funding to another 2,000 
rural school districts through our State subgrants.
    OESE administers a number of grants that support specific 
needs across the country, including in rural communities. 
Recently, OESE released grant awards for two new grant programs 
under the Bipartisan Safer Communities Act to increase the 
number of mental health providers in schools, including the 
Mental Health Service Professional Demonstration Grant Program, 
which provides grants to support and demonstrate innovative 
partnerships between schools and institutions of higher 
education to train school-based mental health providers for 
employment in schools and school districts, which we know is a 
particular need for students in rural communities.
    The partnerships with institutions of higher education must 
include one or more high-need school district or State 
educational agency on behalf of one or more high-need school 
districts. Eligibility for SRSA or RLIS are two ways that 
school districts can show that they are high-needs LEAs.
    In closing, the Department has a multifaceted approach to 
address the needs of students in rural communities. Recently, 
the Department hired a Director of Rural Engagement, who will 
lead our rural work, including the rural strategy and action 
team, which brings together nine different offices in the 
Department. Our goal is to ensure that support and funding is 
reaching communities in need and that technical assistance is 
available to meet the unique needs of rural students.
    I welcome the opportunity to answer your questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. And Ms. Jacobs-Simmons, you have 
the floor.
    Ms. Jacobs-Simmons. Good morning. Chairman Aderholt, 
Ranking Member DeLauro, and distinguished members of the 
subcommittee, I am pleased to be here today to discuss the 
Department of Labor's job training programs and the role they 
play in rural economies throughout the United States.
    America's rural communities are strong, dynamic, and 
economically diverse. Rural businesses are creating high-
skilled, good-paying jobs in new and expanding industries from 
real estate and education to health, finance, and 
manufacturing.
    In 2021, employment and manufacturing of transportation 
equipment, including electric vehicles, increased by 5 percent 
in rural counties. These are exciting trends. But rural workers 
and businesses face barriers that continue to hold them back.
    Rural communities have persistently high rates of long-term 
unemployment, and they often lack access to the education and 
training opportunities that give workers the skills needed for 
the growing number of good rural jobs.
    Rural communities, without reliable, affordable, high-speed 
Internet, struggle to connect their businesses with the larger 
economy and to provide the services and training needed to grow 
a skilled workforce.
    The Department recognizes that to continue the strong 
economic growth, rural workers need access to employment 
services, such as skills assessment and career counseling, and 
they need it in their own communities with reliable broadband. 
They need high-quality workforce education and training 
programs that have a proven track record for getting workers 
good jobs. And they need effective work-based learning 
strategies like registered apprenticeship and on-the-job 
training that are created in partnership with businesses who 
understand the local economy.
    Last year, through a network of almost 2,300 American Job 
Centers nationwide, almost 10 million people sought information 
and services from the publicly funded workforce system. People 
find this system through a variety of front doors, including 
libraries, mobile service centers, and virtually from their 
homes.
    For 2021, over 1.2 million participants had a barrier to 
employment. This included long-term unemployment, receipt of 
food stamps assistance, and/or homelessness, just to name a 
few.
    The primary source of funding for these services is the 
Workforce Innovation and Opportunity Act, or WIOA. DOL's WIOA 
formula programs are allocated to States through a formula. The 
Department distributes these funds to States, who then allocate 
funds to local areas where business-driven workforce 
development boards establish policies and determine how to 
spend the funds based on local labor market data and employer 
demand.
    WIOA is working to place individuals with some of the 
highest barriers to employment in quality jobs. WIOA creates 
opportunities for effective work-based learning in the critical 
rural sectors my co-panelists have discussed here today. This 
includes education, nursing, and I would like to acknowledge 
our teacher apprenticeship effort.
    These industry-led apprenticeships and training programs 
offer high-quality pathways, on-the-job learning, and industry-
recognized credentials. In addition, the Department makes 
targeted rural investments with discretionary funding. This is 
to respond to the shifting economy and the economic landscape 
of today and the known demands of tomorrow.
    The Workforce Opportunity for Rural Communities, or WORC, 
initiative is also ensuring Americans in rural communities 
impacted by economic transitions, including the energy sector, 
have access to job training and support services to place them 
in good jobs in high-demand occupations. The Department has 
awarded over $118,000,000 to support these grants.
    We also support these efforts through our H-1B Skills 
Training Grant for Rural Healthcare and nursing expansion grant 
programs that address workforce shortages, expand diversity in 
the pipeline of quality healthcare professionals. In the coming 
months, we expect to announce up to $80,000,000 to support this 
work.
    A thriving rural workforce requires thoughtful strategies 
for recruiting, for training, and for retaining workers and job 
seekers in rural communities. Together, we can provide more 
rural Americans with the tools that they and their communities 
need to access good jobs and to contribute to America's future.
    Thank you again for inviting me today, and I am pleased to 
answer any questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Thanks for each of your testimony, 
and we will begin our questioning.

                         TELEHEALTH CHALLENGES

    Mr. Morris, let me start out with you. Access to 
specialists, particularly difficult in rural communities. 
Advances in technology have opened the field of telehealth that 
enable rural hospitals to have access to consultations, 
training, and other medical support from specialists who 
actually may be hundreds of miles away.
    What are some of the challenges to expanding telehealth in 
this respect in rural areas?
    Mr. Morris. Mr. Aderholt, thank you for that question.
    And also thanks to the Congress for extending the public 
health flexibilities for telehealth reimbursement under 
Medicare in the recently enacted omnibus bill. That was a big 
step in ensuring that we build on what we saw during the 
pandemic, when we saw a dramatic expansion in the use of 
telehealth as people turned to this technology.
    Of course, as you know, rural areas have been relying on 
telehealth for some time now, and it is urban areas that sort 
of leveraged it during the pandemic in sort of a new way. So, 
anyway, I think we have been investing at HRSA in telehealth 
since the early 1990s. We are home to the Office for the 
Advancement of Telehealth.
    But to your specific question, I think there are several 
programs that we have that are seeing dramatic use of 
telehealth. Obviously, there are the grant programs within that 
Office for the Advancement of Telehealth. We have seen great 
adoption by our community health centers in telehealth. 
Congress has also funded the maternal and child health--the 
Pediatric Mental Health Access Program that does more for 
provider-to-provider telehealth where they connect primary care 
docs with pediatric specialists via telehealth.
    And so there are several challenges I think that are 
largely structural in their nature. One is cross-State 
licensure and the burden for clinicians to have to be licensed 
in multiple States. That is a pretty arduous process, and to 
have to do it the same way every time for multiple States can 
be a bit of a burden on a busy practitioner.
    Second, you have already referenced this. The broadband 
access issue is a real challenge. You can have the greatest 
equipment, but if there is no broadband, it is not going to 
work.
    A third area would be workforce. We know the technology 
works, but we have to have clinicians on either end of the line 
to really make it work.
    So we have a number of efforts underway. On the licensure 
side, we stood up what is called the ``provider bridge,'' where 
we can have clinicians that can take the common elements of 
licensure and post them securely so that they can then be used 
to make it a little bit easier to apply for licenses in 
multiple States.
    We also continue our work to work with physicians and with 
social workers on a compact so that States can join together 
and have a common way for providers to seek licensure.
    On the broadband issue, I am encouraged by the fact that 
the infrastructure bill has funding that the Commerce 
Department is putting out as we speak to really address the 
remaining broadband gaps that are there. That process is 
underway, and hopefully, that will alleviate some of the 
challenges that are out there.
    A third area on workforce I think we have underway, thanks 
to the Congress' generous support of our health workforce 
programs, particularly the expansion of behavioral health. If 
you look at the utilization of telehealth, probably the number-
one application of it is around ensuring access to mental 
health services. And so those are the three ways that we are 
trying to address it.
    Mr. Aderholt. Thank you.

                        RURAL PHYSICIAN TRAINING

    Let me turn just to discuss rural physician training. 
Practicing as the only physician in a remote area I know can be 
a challenge. Clinicians can feel isolated. They can feel 
overwhelmed and unequipped to handle the unique aspects of 
rural medicine.
    How are we encouraging medical schools to include a rural 
rotation or establish a rural residency track?
    Mr. Morris. Very good question. On the medical school 
track, HRSA has a number of programs that can support this. The 
Primary Care Training and Enhancement Program allows for 
medical schools to apply for funding, and they have the option 
to develop targeted admissions or rural training tracks within 
that medical school curriculum.
    We also have a Medical Student Education Program that can 
be used for this as well. The Area Health Education Centers can 
also play a key role in sort of exposing people to rural 
practice during their clinical rotations.
    On the residency side, I do have to credit this committee 
because in 2018, the committee created the Rural Residency 
Planning and Development Grants. And it builds on an idea that 
had been around for a while that we could have residencies in 
rural communities, but the challenge was that it takes a lot of 
resources and time to get through the accreditation and the 
process and setting up all the various rotations for a 
physician residency.
    And that was a big hurdle to overcome. So when the 
committee provided the funding for the Rural Residency Planning 
and Development Grants, we were able to then provide the 
support that helped people get through that accreditation 
process, and they were able to take advantage of flexibility 
under Medicare right now for rural hospitals to be able to 
create new residency programs, meaning that the committee can 
invest in the creation of the residency and then hand it off to 
either Medicare, Medicaid, or State revenue for that to be 
covered in perpetuity.
    And so what we are seeing now is a growth in the number of 
rural residency programs around the country. Our research shows 
from the University of Washington that exposure, like having 
half of your time in a rural residency under family medicine, 
is connected to a fivefold increase in the likelihood that 
those physicians will choose to practice in rural communities.
    So it is a model that works, and we just appreciate the 
support you provided over the years.
    Mr. Aderholt. Are we doing enough for these rural residency 
policy grants, or could we do more? Or what is your opinion on 
that?
    Mr. Morris. We are getting more high-scoring applications 
than we can fund under the current appropriation.
    Mr. Aderholt. All right. Ms. DeLauro.
    Ms. DeLauro. Thank you very, very much, Mr. Chairman.
    First of all, let me just say--and I hope this doesn't 
detract from my time. I want to just say thank you for your 
testimony. Oftentimes, agency officials are denigrated in a 
number of ways, what they do, how they do it, et cetera. What 
just eloquent testimony. But the work that you are doing in 
addressing the needs of whether it is education, whether it is 
health, or whether it is job training is really outstanding and 
meeting a need.
    And the second thing I would just say is this committee--
and I am just proud to be on this committee--that, in fact, it 
would appear that while we could do more, and we could always 
do more, Mr. Chairman, in terms of the funding opportunities, 
that what is critically important is to know that the omnibus 
bill in December really has played, I think, a role in allowing 
you to carry out your mission.
    And for that, I say thank you to you and working to make 
it--working to make your vision and our resources work for 
rural America.
    I do have a question--I have a question for each of you. 
Ms. Ryder, let me just say this, and this is on education. And 
we have tried to create this education pipeline in the 2023 HHS 
bill.
    I know you are aware of the nationwide teacher shortage. 
Can you share what the Department is doing to support more 
teachers entering the teaching profession, including rural 
areas?
    Ms. Ryder. Thank you for the question. I think it is such a 
critical issue for our work to address teacher shortages.
    The Department is advancing a major initiative, elevating 
the teaching profession, encouraging more young people to come 
into the teaching profession. Coming out of the pandemic, we 
had a 130,000 teacher shortage relative to pre-pandemic. But we 
know there were shortages before the pandemic, and our schools 
still have a long way to go before they are fully staffed.
    You heard Ms. Jacobs-Simmons talk about the federally 
registered teacher apprenticeships, which we are supporting 
along with DOL by getting information out and really working 
with communities. We have 16 States that have taken up at least 
1 federally registered teacher apprenticeship program, with 
Tennessee being the first State.
    We also, through our discretionary grant programs, are 
supporting residency models and grow your own, which we think 
are really good models for rural communities where people want 
to stay in their rural community. If they want to be part of 
the school system, they can go through their training while 
they are actually earning a salary working within the school 
system.
    We are----
    Ms. DeLauro. I will run out of time.
    Ms. Ryder. I understand.
    Ms. DeLauro. And I have got the three questions, but it 
goes on. And I will just say to you that that is why I am 
concerned as I acknowledged the proposed Republican cuts to the 
Department's budget. Secretary Cardona shared the 22 percent 
cut to Title I and IDEA grant funding would amount to an 
equivalent of removing 100,000 teachers and service providers 
from classrooms serving low-income students and students with 
disabilities.
    Ms. Jacobs-Simmons, and you talked about WIOA, yes. What is 
the Department doing to get teens and young adults into the 
workforce?
    Ms. Jacobs-Simmons. We are committed to serving young 
people. The Department is part of a shared youth vision Federal 
partnership, and I think we have demonstrated here today how we 
are partnering, and the whole-of-government approach works. 
This commitment is to ensure that the neediest youth in America 
acquire the talent, skills, and knowledge they need to 
transition into successful adult roles.
    We are meeting youth where they are in the communities to 
carry out the vision. We go to midnight basketball. Our 
programs support youth. Our Job Corps program is serving youth.
    These centers provide education and career services to help 
youth complete their education. We are also trying to do youth 
on-the-job training, giving them those work experiences and 
looking at sectors where they can have a future. We are 
training, for example, in the electric vehicle community. Some 
of our workforce boards are targeting high school youth so that 
we can create a pathway to employment.
    Ms. DeLauro. Great. And I will just make note to you that 
according to--this is the Department's analysis. A 22 percent 
reduction to DOL-funded workforce training and development 
would prevent 750,000 job seekers from accessing services. That 
would have an enormous impact on rural America.

                          EXPAND RMOMS PROGRAM

    Mr. Morris--and I beg the indulgence of the chair, to ask 
this one last question here. Maternal mortality rate in the 
U.S., unacceptable, appalling. And you talked about the RMOMS 
program. What would it take to expand the RMOMS program to all 
rural areas so all pregnant women can have access to high-
quality obstetric services and maternal healthcare?
    I am looking for--I would love to get dollars and cents 
because if it looks for places where we need to plus-up, as the 
chairman was talking, like can we do more with grants in some 
areas, we need your advice in this area.
    Mr. Morris. Ms. DeLauro, I would like to get back to you on 
that because we would have to sort of do some calculations to 
figure out what that would be. I will say that what we are 
trying to do with the RMOMS program is to regionalize maternal 
healthcare to get everybody to work together a little bit more.
    That has proven to be a bit of a challenge sometimes to get 
all the hospitals, the clinics, everybody sort of pulling in 
the same direction. So we haven't had a robust number of 
applications to that program, but we have seen some early 
successes on it. But I will be happy to come back to you with 
more information on that.
    Ms. DeLauro. Thank you. I yield back, Mr. Chairman. Thank 
you very much for the time.
    Mr. Aderholt. Ms. Letlow.
    Ms. Letlow. Thank you, Mr. Chairman.

              TECHNICAL ASSISTANCE TO RURAL ORGANIZATIONS

    And thank you to the witness for being here. The Census 
Bureau estimates that 60 million people live in rural areas, 
and I am one of them. I represent 24 parishes in Louisiana who 
are mostly rural, and so my heart is definitely with our rural 
communities.
    I have to tell you I have only been here for 2 years, but 
over the past 2 years, I have visited every single parish and 
sat down and listened to their needs. What I hear from them 
overwhelmingly is that they know that the federal funds are 
there. They know they are not always aware of the grant 
opportunities, but they don't have financial resources to hire 
grant writers to go after the funding that they desperately, 
desperately need. I know that those monies are set aside for 
them.
    So my question really is to all three of you. What are you 
actively doing to help rural communities, know that these grant 
programs exist and then help them with the grant writing 
process so that they can apply for these funds? How do rural 
set-asides in grant programs help level that playing field 
specifically?
    Ms. Jacobs-Simmons. I will start.
    Ms. Letlow. Thank you.
    Ms. Jacobs-Simmons. For the Department of Labor----
    [Pause.]
    Ms. Jacobs-Simmons. Okay. For the Department of Labor, we 
have, one, changed our Funding Opportunity Announcements so 
that they are more designed so that community-based 
organizations can easily apply. We are also conducting various 
webinars and trainings. I recently attended one in Memphis, 
Tennessee, where we are talking to people about how to apply 
for our funding opportunities, and that was recently in the 
Southeast region.
    We are also working with National League of Cities and the 
other--and the Conference of Mayors to get the word out to our 
communities that these funds are available. Unfortunately, our 
funding cannot be used to support grant writers, but we are 
providing the technical assistance.
    There is also some foundations that we have connected with 
that are willing to work with those. So we are doing outreach 
to rural communities and other community-based organizations.
    Ms. Letlow. Okay.
    Ms. Jacobs-Simmons. Thank you.
    Ms. Ryder. So we have been doing a major initiative around 
growing our grantee pool, and we really want to diversify the 
grantees who are applying. We have been greatly increasing our 
outreach. We have been working with the Organizations Concerned 
with Rural Education, OCRE, and the NREA, National Rural 
Education Association, to get information out to rural 
grantees.
    You mentioned the rural set-asides for some programs. We do 
have several programs that include a rural set-aside. The 
Promise Neighborhoods, Full-Service Community Schools, and our 
Education Innovation Research programs have set-asides, and we 
have consistently exceeded those set-asides, being able to fund 
high-scoring applications. So we feel like our outreach to 
rural communities in those programs has been successful.
    Ms. Letlow. Okay.
    Mr. Morris. And Congresswoman, thank you for the question. 
It really is an important issue.
    And we have a number of efforts underway. We work very 
closely with each of the 50 State Offices of Rural Health and 
the State Rural Health Associations. There is a State Rural 
Health Association in Louisiana, and they can be a key 
resource, I think, for rural communities in sort of accessing 
that TA.
    We also are working with Dr. Cochran's organization, the 
National Rural Health Association, to have a targeted sort of 
promotion of our grants over the next couple of years. We also 
have an effort underway to look at underrepresented groups that 
either haven't applied or are applying and not scoring well and 
see if we can do targeted technical assistance to all of those 
as well.
    And then I think the point about philanthropy is an 
important one. We have for the last 10 years worked with the 
Rural Health Philanthropy Partnership to educate them about our 
programs. But we also invite our Federal colleagues to those 
meetings as well because sometimes the grants can--like in 
Missouri for an example, they hire grant writers on behalf of 
community organizations that lack capacity. So that is a model 
I think worth replicating.
    Ms. Letlow. It is encouraging to hear that these efforts 
are underway, and I would just--I encourage you to keep doing 
it. So many of my constituents don't have access to rural 
broadband, when you talk about webinars, when you talk about 
outreach over the Internet, even that is still a struggle I 
want to do everything I can in my capacity to make sure that 
there is an awareness. I am especially interested in the RMOMS 
program. I think that that is wonderful for our rural 
communities, especially our women, as you know. I don't have to 
belabor statistics to you. You have seen them.
    I just want to know how we can best partner with you to 
increase awareness and help my rural communities apply for 
these grants.
    Thank you. I yield back.
    Mr. Aderholt. Mr. Hoyer.
    Mr. Hoyer. Thank you very much, Mr. Chairman.
    And thank all of you for being here and for the service you 
perform for our people.
    Mr. Morris, you indicated--or I am sorry, Ms. Ryder, you 
indicated 35 years experience. Mr. Morris, how much experience 
do you have?
    Mr. Morris. Twenty-five years.
    Mr. Hoyer. Twenty-five years. And Ms. Simmons.
    Ms. Jacobs-Simmons. I just celebrated my 24th anniversary 
with the Department of Labor.
    Mr. Hoyer. So that is about 80-plus years experience. We 
have heard--the chairman mentioned in his opening remarks 
something that I thought was very relevant, and that is 
broadband. One of the problems that so many people living in 
rural areas have is not access to broadband.
    We passed a very significant piece of legislation, the 
infrastructure bill, which includes $65,000,000,000 for rural 
broadband. All of us I think are very concerned about the rural 
areas because a significant number of our people live there. To 
the extent they do better, we all do better. Unfortunately, 
that did not have very broad-based support on the other side of 
the aisle, but it is being implemented now.
    In addition to that, we passed a very substantial piece of 
legislation, which dealt with substantially increasing by 
$55,000,000,000 water projects. Many in rural areas of our 
country rely on septic tanks and perhaps wells.
    I want to ask the three of you--and the reason I asked for 
your experience, this very substantial experience--over the 
last 2 years, 3 years, frankly, we passed very significant 
pieces of legislation, starting with the Rescue Plan, the 
infrastructure plan, the CHIPS bill, the Inflation Reduction 
Act, and the Safe Communities Act, which one of you mentioned.
    I would like the three of you--and this is the only 
question I am going to ask this time because of time, and I 
want to give you the time--to give me your view as to how 
impactful those pieces of legislation were, including the 
omnibus to which the chair responded, have had on rural areas 
from your experience, relatively speaking.
    Mr. Morris, we will start with you.
    Mr. Morris. Well, I think any time we have an investment in 
rural communities, it is a net plus. And all of the pieces of 
legislation that had healthcare aspects to it I think have been 
tremendously beneficial.
    The broadband in particular, in addition, it is not just 
the infrastructure bill, but the ongoing work of the FCC and 
the USDA to support broadband. It has sort of become 
fundamental to healthcare. So I think that is critically 
important.
    The other one I would point to is just the dramatic 
expansion of health profession training dollars. Given the 
challenges that I think we all recognize with the healthcare 
workforce and the stress they have been under over the last 
couple of years, that money, while not rural specific, will 
definitely benefit rural communities.
    Mr. Hoyer. And which bill specifically are you referring 
to?
    Mr. Morris. That has been mostly through the appropriations 
process.
    Mr. Hoyer. The omnibus and other legislation?
    Mr. Morris. Yes.
    Mr. Hoyer. Ms. Ryder.
    Ms. Ryder. I would like to speak to the Bipartisan Safer 
Communities Act. The Department received $2,000,000,000; 
$1,000,000,000 in formula grants, which we distributed to 
States in September of last year. These funds will be used to 
meet the really critical school safety and mental health needs 
that we are seeing in schools.
    The funds will be distributed to high-needs LEAs, and 
States are working on getting those funds out right now. We 
will be providing support to them in identifying best practices 
for them to implement.
    The other $1,000,000,000 went towards increasing the number 
of mental health providers in schools, school counselors, 
school psychologists, school social workers through the School-
Based Mental Health Program funding, which goes to school 
districts primarily to hire, respecialize, retrain mental 
health professionals within the school system. And then the 
Mental Health Services Professional Demonstration Grant, which 
I mentioned earlier, which is increasing the pipeline of people 
going into school mental health professions.
    Mr. Hoyer. And that bill to which you referred also made a 
substantial contribution to local police departments, funding 
local police departments so they could maintain safety, which 
we have seen so dramatically, unfortunately and tragically, 
over the last few days.
    Ms. Simmons.
    Ms. Jacobs-Simmons. Yes, sir. As you are aware, those 
bills--in those bills, there was no direct funding to the 
Department of Labor. However, in the infrastructure bill--and 
we are critical partners. Each of those bills requires 
coordination with workforce development. So we are leveraging 
our WIOA dollars in communities to work with entities that are 
receiving the grants under the infrastructure bill and the 
CHIPS bill.
    That is how we are working. And as I said, we are 
leveraging the WIOA funds that we currently have to try to 
support those initiatives.
    Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
    Mr. Aderholt. Mr. Moolenaar.
    Mr. Moolenaar. Thank you, Mr. Chairman. And thank you for 
having this hearing today and focusing on the rural--needs of 
rural America.
    And I appreciate all of you being here and your testimony 
today.
    I have a very--20 counties, rural Michigan. Family farms 
are really the cornerstone of the rural communities in my 
district and really across the country. The adverse effect wage 
rate is having a severe impact on family farms in my district. 
And Ms. Jacobs-Simmons, are you familiar with that? Is that 
part of your area?
    Ms. Jacobs-Simmons. It is not, sir.
    Mr. Moolenaar. Okay. Well, this would be something where I 
would welcome your help on this because recently we spoke with 
a fifth-generation grower and recent college graduate who 
decided not to take responsibilities for her family farm. And 
the primary reason was the financial instability and 
unpredictability of the long-term, the labor issues.
    And one of the issues she raised is that Michigan farmers 
using the H-2A programs were required to pay $17.34 per hour, a 
12.8 percent increase from the 2022 rate of $15.37. And what 
strikes me is this is a Government mandate to pay certain wages 
that they want to be competitive, they want to pay their 
workers fair wages, but these kind of Federal Government 
requirements are making Michigan the fourth-highest wage state 
for agriculture, and it is actually discouraging people from 
continuing as family farms.
    And that is a concern. I don't know if you have heard that 
concern before, but I would ask you to consider the implication 
on that.
    Ms. Jacobs-Simmons. Yes, sir. We have our Office of 
Congressional Affairs here, and we will look into it.
    Mr. Moolenaar. Okay. Thank you.
    The second area I would like to talk about, we all 
mentioned the rural broadband and the importance of that. I 
recently had a discussion with the electric cooperatives in our 
State, very excited about different grant opportunities to 
build out rural broadband.
    One of the things they struck me was when they said that 
they are applying for like a $50,000,000 grant to do a project, 
and it was going to cost $10,000,000 additional for them to use 
that grant because of Davis-Bacon prevailing wage requirements. 
That concerns me because we have so many areas of need for 
rural broadband, and when you think of $50,000,000, you think 
it would be going to build out this needed infrastructure. And 
instead, it is a Government mandated wage issue where they are 
not going to be able to do as much in that area.
    Is that something you have heard anything about, or are you 
concerned about that?
    Ms. Jacobs-Simmons. Again, that is not in my area of 
responsibility. That is our Wage Hour Department, and I don't--
am not involved with that, sir.
    Mr. Moolenaar. Okay. All right. Well, again, if you could 
just--these increasing costs are really hurting rural America 
because it is based on a formula that may have nothing to do 
with the cost of living in some of these rural areas.

                         HEALTH/CARE CLINICIANS

    Well, and finally, I appreciate the work you are doing to 
help the healthcare clinicians. How do you--what is the 
description of the healthcare clinician? What categories would 
that be?
    Mr. Morris. Thank you, Mr. Moolenaar. It is a catch-all 
term, but I use it to refer to everything from the physicians, 
nurse practitioners, physician assistants, all the allied 
health professions, lab techs, everybody that basically has a 
clinical roll.
    Mr. Moolenaar. Very broad range?
    Mr. Morris. Yes, sir.
    Mr. Moolenaar. Okay.
    Mr. Morris. It is easier than listing all of them.
    Mr. Moolenaar. One of the things in talking with some of 
the health centers in my district in some of the rural areas, 
they are really trying to do some innovative things. For 
example, family healthcare in Baldwin, Michigan--Second 
District--it has trained four dental assistants, one registered 
dental assistant, two medical assistants, and they are planning 
to use a program through the Michigan Health Center Careers 
Training Program to train additional medical and dental 
assistants and pharmacy technicians.
    And I guess my main thing is how do we support those 
initiatives in local areas, and then not get in the way of kind 
of a ``one size fits all'' when these programs seem to know 
their communities and what is most needed and what is most 
effective?
    Mr. Morris. Well, Mr. Moolenaar, I think that is exactly 
the right approach in terms of being community specific. And I 
think sometimes we do tend to focus a lot on the physician and 
sort of the advanced practice nurse professions, but all of 
those are important. And that is where the partnership with the 
Department of Labor has been really valuable.
    In HRSA, we fund universities and colleges and also some 
associate degree programs. But the Labor Department, their 
programs is very much laser-focused on a lot of the professions 
you mentioned. And so like last year, we worked together on a 
nursing initiative. And I think when we both do what we can do 
well within our authorities, and then do it collaboratively, I 
think it pays off for the community just in terms of 
flexibility.
    Mr. Moolenaar. Thank you. I know I have exceeded my time. 
Thank you, Mr. Chairman.
    Mr. Aderholt. Mr. Pocan.
    Mr. Pocan. Thank you, Mr. Chairman. And I just want to say 
thank you for having this hearing. This would be great if this 
was across all the subcommittees because as we talk about these 
issues, I am thinking of things that aren't related to this 
subcommittee as well I would like to talk about related to 
rural areas. But really appreciate you having this today.
    I live in a rural town of 830 people. I got broadband about 
half way through living out there. So I know what it is like 
not to have broadband. It kind of sucks. [Laughter.]
    Mr. Pocan. Have propane heat, everything else. So, and my 
district also has some of the most rural parts of Wisconsin. 
There are 72 counties in Wisconsin. Two in the State don't have 
a stop and go light, and one is in my district, Lafayette 
County.
    So the issues, though, that I see the most as I go to these 
rural communities is, unfortunately, decades ago they lost that 
last manufacturer that employed a lot of the people, and they 
just haven't really bounced back from that.
    So you have an agrarian or an agricultural economy. You 
have a home-based business or self-employed economy. But I hear 
if you don't have broadband, which we have talked about many 
times, and you don't have a post office, they are not in 
business. So a lot of those issues aren't directly related to 
some of your budgets, but that is what I hear the most when I 
go around.
    I guess the concern that I have and I share with the 
ranking member is that we are hearing there could be some 
substantial cuts proposed to the budget. There is some in 
leadership on the Republican side of the aisle that have 
proposed going back a couple years spending. And if you take 
that number and look at the discretionary nondefense spending--
because I have been told that our chair of the full committee 
has said we are not going to be cutting defense--that is like a 
22 percent cut.

                         IMPACT OF FUNDING CUTS

    And I guess my question is specifically in your three 
areas, if you could just address if there was something you 
wanted to highlight that is important for rural America that if 
they are looking at a 22 percent cut across the board, what is 
something you really want to say please be very careful because 
this is a program that benefits rural constituents in all of 
our districts? And just love you to highlight what the concern 
you have is.
    And Mr. Morris, we could start with you.
    Mr. Morris. Thank you, Mr. Pocan, for that question.
    It is very hard to pinpoint like one program and elevate it 
over the others. I think that any cuts result in fewer grants, 
fewer communities served. So within the Federal Office of Rural 
Health Policy, the budget lines I think would all be affected 
by any sort of reductions, but we would make do the best we can 
with what Congress provides to us.
    Mr. Pocan. So would that result in perhaps less healthcare 
outreach in rural communities?
    Mr. Morris. Yes. For example, like with our Rural 
Communities Opioid Response Program, if this was to happen, we 
would not make any new grants in the coming year, and we would 
not be able to make all of our continuation grants for the 
grants that we have already funded.
    Mr. Pocan. Thank you. Ms. Ryder.
    Ms. Ryder. So I would mention, and I did in my opening 
statement, the REAP program, the Rural Education Achievement 
Program. I think that is critical funding for small rural 
school districts, and the funds are allowed to be used in a 
flexible way, which I think is an advantage for these school 
districts.
    But I do also want to go back to the fact that the large 
formula funding, the Title I at $18,000,000,000, the IDEA at 
$14,000,000,000 is really critical funding that also goes out 
to all rural school districts. And many of you mentioned 
students with disabilities, and the IDEA funds to all school 
districts to support the diverse needs of children with 
disabilities.
    Mr. Pocan. Thank you. Ms. Jacobs-Simmons.
    Ms. Jacobs-Simmons. Like my colleagues, it is hard to focus 
on one. But we have the Workforce Innovation and Opportunity 
Act, which is the principal funding for our programs. And that 
is what enables us to leverage our funds with our colleagues 
here, and it is across our program and the Department of Labor 
and the tens of millions of folks we serve.
    Mr. Pocan. Thank you. Well, I just--yes, I hope that what 
we have been hearing doesn't happen because for all the reasons 
that you said. But I really do appreciate having a hearing like 
this, and I do think, Mr. Chairman, if more committees did it, 
because all of these other questions I would have. But the 
number-one thing does seem to be jobs in those communities, and 
you go there, and unfortunately, it has been decades long.
    And at least the CHIPS bill is going to help restore in 
some communities some ability to have jobs. We need to make 
more things here again. Steny has been saying that for decades. 
But that really is, I think, at the crux of much of this.
    So thank you so much. Thank you, and I yield back.
    Mr. Aderholt. Dr. Harris.
    Mr. Harris. Thank you very much.
    And thanks, all of you, for your help with rural 
communities.

                            BALANCED BUDGET

    You know, mention was made of the omnibus bill in December, 
but I will tell you that that omnibus bill, the increased 
spending, led to increased inflation, which Americans are tired 
of. And they made unrealistic--they built unrealistic 
expectations. I mean, we cannot sustain a $1,000,000,000,000 a 
year deficit in this country.
    And while I understand there are numerous programs, 
everybody wants to spend more money on good programs. The money 
just isn't there. We can pretend it is. President Biden 
pretends it is there. He is 1 month late presenting a budget 
that never, ever balances.
    I don't know about your families. My family budget has to 
balance. Your employer's budget doesn't have to balance. It is 
pretty amazing. I know a lot of private employers in my 
district. They wish they could have budgets that don't balance. 
It is completely unrealistic.
    So let me ask you, because there are other solutions. And 
the lazy man's effort is to say, well, assume it is a 22 
percent across-the-board cut. Nobody is talking about a 22 
percent across-the-board cut, but let us set up a strawman and 
let us talk about it. And that is what we have been doing for 
the last few days here.
    That is fine. If that is the way you want to play, that is 
fine. But let me ask you specifically, Mr. Morris, how many of 
your grants have a required State co-funding or copay?
    Mr. Morris. The only one that we have is the State Offices 
of Rural Health. They have to match every dollar three to one.
    Mr. Harris. So that is it? For all the other grants, you 
don't require a State match?
    Mr. Morris. No, sir.
    Mr. Harris. Well, that is pretty interesting because the 
traditional Medicaid program, which people hold up as a perfect 
example of State and Federal cooperation, has an average 44 
percent State match. So, within your programs, if we just 
instituted a, oh, half of that match, 22 percent, we just heard 
that number somewhere. Maybe we should just ask--what do you 
think? Should we just ask States to maybe help us out? Because, 
remember, they have balanced budget requirements. We don't.
    There sitting in my State billions of dollars that have 
been sent to them for COVID, billions of dollars unspent. Do 
you think it might be realistic for us, do you think it would 
be helpful if we asked them instead of cutting back the 
programs, ask them to cost share in some of them, some of those 
grants?
    Mr. Morris. Dr. Harris, I----
    Mr. Harris. It is semi-rhetorical question. I mean----
    Mr. Morris. Yes, and I understand that.
    Mr. Harris [continuing]. Of course, in order to preserve 
some of this, maybe we should just ask States to actually pay 
``their fair share.'' That is the bottom line, their fair 
share. And remember, traditional Medicaid, 44 percent fair 
share.
    So, Ms. Jacobs-Simmons, on the WIOA grants, what is the 
State-required co-pay, co-share?
    Ms. Jacobs-Simmons. There is no match.
    Mr. Harris. None, wow. So here is another program where the 
State benefits--and look, I served in the State legislature for 
12 years before I came here. The best thing we ever had was a 
Federal program with no State match because, man, you wanted to 
pull up--you wanted to back up to that and have the Federal 
truck unload the dollars into your State. No incentive for 
performance. All you wanted was more money coming into your 
State.
    I would suggest that what this Congress should look at is 
making States pay their fair share.
    Now, Ms. Jacobs-Simmons, in your testimony, I have heard 
that only about a third of WIOA participants, the people who 
actually--the workers get skills training. Is that correct? I 
heard it is 36 percent, somewhere around there?
    Ms. Jacobs-Simmons. I don't have that number. I will be 
happy to get it.
    Mr. Harris. Would you get that number to me? Because let me 
tell you, if it is about one-third getting skills training, 
what is going on? My understanding is that is the purpose of 
the program is to train people for modern jobs, to give them 
the skill set they need.
    Shame on us if we have a program that $3,600,000,000 
funding, and only one-third of the people are actually getting 
skills training. That doesn't work. Maybe what we should do is 
ask the States to pay their fair share, and maybe the States 
would keep an eye on whether or not those programs were 
actually training people with the skills they need.
    So I would suggest that a return to pre-COVID spending 
levels, the Federal share, is a perfectly reasonable thing. 
People understand COVID is over. The time for 
$1,000,000,000,000 deficits has to draw to a close. The 
President's budget, remember, has $1,000,000,000,000 deficits 
forever, for all intents and purposes forever. Never balances. 
It is completely unrealistic to believe we can continue on that 
spending pathway without asking States to pay their fair share.
    I yield back.
    Mr. Aderholt. Mr. Harder
    Mr. Harder. Thank you so much, Mr. Chair, for holding this 
very important hearing. I am excited to be here, and I think I 
echo my colleague's point, Mr. Pocan, that we should be doing 
this in all of our subcommittees. I think it is tremendously 
important.
    And thank you so much to all of our panelists for being 
here.

                RURAL AND INDERSERVED COMMUNITY CRITERIA

    I represent San Joaquin County in California, and we 
consider ourselves pretty rural and pretty underserved. We are 
the nut and fruit basket of the entire world. We have a 
fraction of the physicians that we need. We have 26 percent 
fewer primary care physicians, 34 percent fewer dentists than 
the State average.
    We have a whole bunch of healthcare outcomes that reflect 
that deep disparity. The average life expectancy in my district 
is 6 years less than it is just an hour and a half away in 
Silicon Valley or San Francisco.
    However, most of the really tremendous programs that HRSA 
supports in the rural and underserved areas we don't qualify 
for. That doesn't make a whole lot of sense to me. I think a 
lot of these criteria are based on States that have lower cost 
of living than California, that have smaller counties than 
California does. We have about 800,000 people in our county.
    And so if you look at us across the county, you may see us 
as an urban or semi-urban area, even though there are some deep 
rural pockets. And so I am thinking about some of the programs 
that we desperately need in my district, like the work for 
Teaching Health Center Graduate Medical Education, the effort 
to support more residency programs in rural areas. And yet we 
often do not benefit from that.
    Mr. Morris, can you talk a little bit about the criteria 
that HRSA uses for allocating those grants? Specifically, what 
does it take to be both a rural and an underserved community?
    Mr. Morris. Mr. Harder, happy to answer those questions.
    So, with our programs, we do have to define what is rural 
and what is not. And I take your point about the size of 
California's counties. Some of them are bigger than States as 
you move east.
    What we have done over the years in trying to do that is 
realizing that there is no perfect definition that fits the 
entirety of this country, so we use the county definition used 
by the Office of Management and Budget for non-metro counties. 
But we realized we needed to do more than that.
    We then identified through the USDA's rural-urban commuting 
areas those rural Census tracks within metro counties, and we 
made a special adjustment for California because some of your 
Census tracks are also bigger than anywhere else in the 
country. So we are constantly trying to figure out ways that we 
are not disadvantaging any community.
    The most recent change we made to our definition of rural 
is we identified metro counties that had no urban population. 
They were just sort of pulled into metro because of commuting 
data, and we have adjusted that and made those areas eligible. 
But we are happy to work with your office to identify the 
places that you feel are really disadvantaged on that and see 
what we might be able to do.
    On your reference to some of the programs, so that affects 
the programs you apply for in the Federal Office of Rural 
Health Policy, but more broadly in HRSA, those programs are not 
real specific. So you mentioned Teaching Health Centers. 
Anybody can apply for that, rural or urban. What does come into 
play is are you medically underserved? Do you have a health 
professional shortage or any of those sort of things?
    Mr. Harder. Thank you. I think one of the challenges that 
we have, if you drive around my district, it feels pretty 
rural. And it is full of almond trees and wine grapes. A lot of 
folks live in those rural areas spread out, but we do have some 
urban centers. I mean, Stockton has 300,000 people. That is 
where most of the hospitals are that are applying for these 
programs, even if they serve rural populations that are spread 
out.
    How do you take that into account? Because when I talk to 
our hospitals, they don't qualify for any of this, even though 
they serve a very rural population.
    Mr. Morris. One of the changes Congress made around 2020-
2021 was with our Rural Health Outreach Grants. They redefined 
the eligibility so urban entities could apply on behalf of 
their rural eligible areas.
    So, for instance, your hospital in Stockton sees a lot of 
those rural patients in the outlying areas. As long as they are 
serving patients from the rural eligible Census track, they can 
apply for our funding and tap into that.
    Mr. Harder. Got it. Got it. Well, thank you. That is very 
helpful to know.
    I would love to work with you on that because I think we 
are a poster child for a rural and underserved community that 
desperately needs more physicians that wants them to be 
homegrown, that wants to make sure that we are bringing along 
all sorts of healthcare opportunities. And yet, as I go line by 
line through the HRSA rural office support system, we are not 
eligible for a lot of that, and I feel like we should be able 
to.
    So I would love to hear more about what those criteria are 
and specifically if there are programs that might apply to our 
district. And thank you for all the work you do. We just want 
to make sure that we get what we believe are eligible for.
    Thank you so much. I yield back.
    Mr. Aderholt. Thank you. Mr. Ellzey.
    Mr. Ellzey. Thank you, Mr. Chairman. Thank you for holding 
this hearing.
    Before I begin my questions, I would like to address my 
friend and colleague from California and the comment that you 
made that many of us in Texas have long suspected that is you 
do represent the land of fruits and nuts. Did I hear you say 
that? [Laughter.]
    Mr. Harder. Absolutely. Absolutely.
    Mr. Ellzey. Okay. Very good. I just wanted to clarify that.
    To our panel today, thank you for being here. It is clear 
from the work that you do that you serve our country and you 
have servant's hearts, and I appreciate the work that you do. 
It is not an easy task. And I am grateful for you being here.
    I am a supporter of programs dealing with job training and 
retraining. Rural healthcare, I represent Texas 6, which is 
south of Dallas, which means I am in nine rural counties while 
the urban stuff is up north of me. So we have a lot of veterans 
in rural areas and veterans in general, and so I am glad we are 
having this hearing today.
    The first question is for Ms. Jacobs-Simmons. What do you 
see as the biggest barriers to rural America using DOL-provided 
funds for successful job training programs?
    Ms. Jacobs-Simmons. As we have discussed here today, too 
much of rural America doesn't have access to broadband. The 
lack of reliable high-speed broadband severely hinders the 
nature and quality of the education and training programs. It 
impacts their ability to get to the programs, transportation, 
the whole 9 yards.
    I would see that as the biggest barrier.
    Mr. Ellzey. Thank you very much. That is a good answer.
    And I would like to note that just a year ago--I don't know 
how long it is going to take--but we spent $65,000,000,000 
ensuring that everybody in America has broadband, regardless of 
where they are.
    So I don't know what the measure of effectiveness for how 
long that is going to take is. My guess is it takes them some 
time. But hopefully, we will get there fairly soon.

                         RURAL TARGETED FUNDING

    Mr. Morris, it can be hard for my small rural communities 
to get Federal support that larger communities can access for 
help with things like treating people with substance abuse 
disorder, especially during COVID and after COVID, even when, 
as you know, the needs are greater and greater in some rural 
communities. So how do HRSA's programs address this challenge, 
and what can this subcommittee do to make sure that HRSA meets 
those needs?
    Mr. Morris. Mr. Ellzey, thank you for the question.
    I think you have hit on an important point, which is rural 
targeted funding, and one of the things that we are 
particularly thankful for, for the committee, is the ongoing 
support of the Rural Communities Opioid Response Program. 
Because I think it gets at the point you are making, which is 
that a lot of times with sort of public health funding, we tend 
to distribute the funds through the States, and that is a very 
effective and efficient mechanism, and it gives the States a 
role in sort of deciding where those funds go.
    But sometimes the rural communities have unique needs that 
don't necessarily fit in with that. And so by providing support 
for the RCORP program, we are specifically allowing rural 
communities that are facing opioid use disorder, substance use 
disorder, to come up with their own solutions because everybody 
sort of sees it differently. And so we want to provide them 
with the flexibility to do that, and you can do that through a 
rural targeted program that emphasizes community control.
    And the other part we do is we don't provide a grant to 
just one entity. We make them come in as a network so that more 
people in the community and the region are invested in that 
project's success.
    Mr. Ellzey. Thank you very much, sir.
    Finally, Ms. Ryder, in the time that I have left, how do 
rural school districts use Federal funding to help address 
educational challenges in rural America?
    Ms. Ryder. So I think rural school districts are using 
their funds in roughly the same way as all. They are using it 
for teacher salaries. They are using it to support personnel, 
materials, supplies, and so on.
    I do think one of the things we see in rural communities is 
more instruction that is done over virtual mechanisms, and that 
speaks to the broadband issues that we have been hearing here. 
But I know we see rural communities using funds to access 
advanced placement courses through virtual learning and, also 
other high-needs areas such as math and science.
    And also we are increasingly seeing telehealth-related 
services being provided to students with disabilities, and I 
think rural communities take advantage of that with their 
funding as well.
    Mr. Ellzey. Thank you very much. Thank you all for you 
time.
    And I would like to thank the attendees in the audience 
today. Seeing a lot of folks in the seats really does make a 
difference as we have these hearings so we can know how 
important it is to people in the United States.
    Mr. Chairman, I yield back. Thank you.
    Mr. Aderholt. Thank you. Mr. LaTurner.
    Mr. LaTurner. Thank you, Mr. Chairman.
    Good morning to the panel today. Thank you all for being 
here.

                        EXPANSION OF TELEHEALTH

    Mr. Morris, you discussed in your testimony the role of 
telehealth in serving rural communities where access to care 
may be limited. One of the few silver linings of the pandemic 
was that we were able to expand access to telehealth across the 
country, and Congress did provide some additional support on 
this front through its recent extension of the Medicare 
telehealth flexibilities.
    Given HRSA's role on this issue through the Office for 
Advancement of Telehealth, what do you believe are the primary 
lessons learned from the expansion of these services in the 
past several years?
    Mr. Morris. Mr. LaTurner, thank you for the question, and 
your point is well taken on the silver lining of the pandemic 
in the sense that while rural communities have long leveraged 
telehealth, I think we saw that the whole country benefited 
from it. And as a result of that, the need to reimburse those 
services is really important. So the passing of the 
flexibilities in the recent appropriations bill was critically 
important.
    I think some of the key lessons learned are that there are 
still challenges with cross-State licensure, where a clinician 
has to get licensed in multiple States in order to provide 
telehealth services. And we have got some efforts underway at 
HRSA to try to reduce that burden and get States to work 
together on that.
    We have talked about the broadband and how important that 
is going to be. You can't provide telehealth without the 
capacity to actually deliver the service.
    And then the third area is just making sure that we have 
the workforce there to do it, and the Congress has supported 
these programs to expand the number of clinicians that work in 
rural and underserved areas. In particular, the expansion of 
the behavioral health workforce training because mental health 
is probably the highest utilization service within telehealth.

                  RURAL EMERGENCY HOSPITAL DESIGNATION

    Mr. LaTurner. I appreciate that. As you mentioned, Congress 
recently created the rural emergency hospital, or REH, 
designation for hospitals to provide rural communities with 
another option to maintain access to emergency care and other 
essential outpatient services in their hospitals is at risk of 
closure. However, the law restricts REH eligibility to only 
those facilities who are designated as either a critical access 
hospital or inpatient hospital with no more than 50 beds as of 
December 27, 2020.
    Would you support expanding eligibility for REH designation 
to facilities that previously had the CAH or appropriate 
inpatient designation and is still serving the same community, 
but whose provider designation changed before the enactment of 
the CAA?
    Mr. Morris. The rural emergency hospital designation, I 
thank the Congress for creating it because I think it does give 
communities another option. Before, you could either be a 
hospital or you weren't, and now this is a viable option for 
them.
    Anytime you write a piece of legislation, you have to set 
eligibility criteria, and in this case, they picked a firm date 
by the Congress about when you could be applying and how long 
you could be essentially closed. So I think what we can commit 
to is working with Congress to see where the pain areas are 
that folks are identifying where they think they might benefit 
from REH status but are currently precluded by the existing 
statute. And get a better sense of those, and then work with 
you to figure out how best to proceed on that.
    But it is a concern I have heard from rural stakeholders.
    Mr. LaTurner. Do you support extending the eligibility?
    Mr. Morris. I think we support working with you to figure 
out how to do that best. I can't speak for legislation and 
those things.
    Mr. LaTurner. Okay. I look forward to working with you on 
that.
    I yield back, Mr. Chairman. Thank you.
    Mr. Aderholt. Thank you, Mr. LaTurner.
    At this time, we will take about a 5-minute recess. We have 
got our second panel that will be coming on. So we have to make 
some adjustments to the mike over here that Ms. Jacobs-Simmons 
has been having to deal with. So we will take about a 5-minute 
break, and we will send along our second panel.
    Thank you.
    Ms. DeLauro. Mr. Chairman, just let me just apologize to 
the panel, if I can. There are five hearings that I am trying 
to get to today. So I appreciate all your work.
    Thank you very, very much.
    [Recess.]
    Mr. Aderholt. Okay. Again, good morning. As we begin panel 
two, I will try to keep my remarks brief.
    Our second panel consists of recognized experts in 
addressing rural issues.
    First, we have Dr. Carrie Cochran-McClain. She serves as 
the Chief Policy Officer at the National Rural Health 
Association, responsible for driving the policy agenda for 
rural health for a 21,000 member organization. Carrie has more 
than 20 years of experience working in Federal healthcare 
policy development, including leadership roles at the Health 
Management Associates, U.S. Department of Health and Human 
Services, and the Federal Office of Rural Health Policy.
    Second is Dr. Brittany Hott. Dr. Hott is an Associate 
Professor of Special Education and Associate Director of the 
Institute for Community and Society Transformation at the 
University of Oklahoma. Over the last 23 years, Dr. Hott has 
served as a special education teacher, instructional leader, 
teacher, educator, and researcher. Her focus--her work focus is 
on instructional methods for rural students with learning and 
behavioral disabilities, assessment and evaluation in rural 
education, and the translation of special education research to 
rural practice.
    And next we have Ms. Laura Scheibe. Laura serves as South 
Dakota's Director for Career and Technical Education and the 
Director of the Division of College, Career, and Student 
Success at South Dakota Department of Education.
    She oversees secondary CTE programs and coordinates closely 
with the Board of Technical Education to oversee the State's 
four public technical colleges. She also guides Jobs for 
America's Graduates South Dakota, which offers school 
counseling, dual credit, student wellness and supports, and 
other initiatives that work together to ensure students are 
prepared for success through and to after graduation.
    And fourth witness is Dr. Tearsanee?
    Dr. Davis. Tearsanee.
    Mr. Aderholt. Tearsanee, okay. I will just say it quickly. 
Tearsanee Davis. She serves as the Director of Clinical and 
Advanced Practice Operations at the University of Mississippi 
Medical Center's Center for Telehealth. She has earned her 
bachelor's degree in nursing from the University of Southern 
Mississippi, her master's of science from Alcorn State 
University, and her Doctor of Nursing practice from none other 
than University of Alabama Birmingham. Dr. Davis has conducted 
extensive research into telehealth medicine and worked on five 
studies into the effectiveness of telehealth.
    I want to thank all of our witnesses for coming today, and 
now I would like to turn to my ranking member to offer any 
remarks that she would like to make.
    Ms. DeLauro. Mr. Chairman, I just want to welcome our 
guests. Anxious to hear their testimony. I had referenced them 
in my opening remarks and so forth, and really grateful for the 
work that you do in addressing these really serious challenges 
that people are facing and really making opportunity real for 
folks.
    So thank you very much. And with that, I will yield back.
    Mr. Aderholt. Very good. Well, welcome again. It is good to 
have all of you here. And you will--what we will do is each of 
you will have 5 minutes to provide your testimony, but your 
full written testimony will be included in the record.
    So, Dr. Cochran-McClain, we will begin with you.
    Ms. Cochran-McClain. All right. Well, thank you, Chairman 
Aderholt and Ranking Member DeLauro, for this hearing to 
discuss the many challenges facing rural America.
    I have the honor of representing the National Rural Health 
Association and grateful to advocate for the nearly 60 million 
individuals who call rural America home.
    In the coming year, we look forward to working with you to 
strengthen rural healthcare safety net and to ensure 
individuals and families across rural America have access to 
critical healthcare services they need.
    I would like to thank the subcommittee for their vision and 
leadership in the creation of a number of critical programs 
mentioned here today, including the Rural Residency Planning 
and Development Program, and for making the rural healthcare 
workforce a continued priority.
    Unfortunately, the pandemic exacerbated healthcare 
workforce shortages that have plagued rural communities for 
decades. Nearly three-fourths of rural counties are health 
professional shortage areas, and 1 in 10 counties don't even 
have a physician. With far fewer clinicians per capita, the 
maldistribution of healthcare providers between rural and urban 
areas results in increasingly unequal access to care, which 
negatively impacts rural health outcomes.
    Research shows that rural exposure during healthcare 
clinical training results in higher rates of rural practice. 
However, less than 2 percent of physician residency training is 
in rural settings. We seek your support for initiatives that 
expand the capacity of rural areas to train future clinicians 
through community-based rural residency training.
    Further, we urge you to maintain funding for core rural 
workforce development and distribution programs, such as the 
Area Health Education Centers and the National Health Service 
Corps. Now, more than ever before, it is crucial for the 
subcommittee to fund programs that seek to address healthcare 
crises in rural America.
    As you mentioned, the rural hospital closure crisis 
continues to intensify with 147 rural hospitals shutting their 
doors. Of those remaining, as many as one in three are 
vulnerable to closure.
    When a rural hospital closes, not only does the entire 
community lose access to care, but a major employer and 
community linchpin disappears, impacting the larger region. 
Investing in strong rural health infrastructure is critical to 
the future of rural areas, and NRHA calls on the subcommittee 
to consider proposals, including the President's budget 
request, for the financial and community sustainability for at-
risk rural hospitals program, as well as the Rural Hospital 
Stabilization Pilot Program.
    As you all know, COVID-19 devastated the financial 
viability of rural practices. It disrupted rural economies, and 
it has eroded availability of care. Medical deserts are 
appearing across rural America, leaving many without timely 
access to healthcare services.
    In one of the more distressing examples, rural communities 
across the Nation are struggling to maintain obstetric 
services, with two-thirds of our Nation's maternity care 
deserts located in rural counties. Rural maternal mortality 
rates are nearly 60 percent higher in rural areas than large 
metropolitan communities. And that is why we need targeted--
that is why we need your continued leadership for targeted 
solutions that help rural hospitals and clinicians keep 
delivering maternal health services to rural families.
    Compared to their urban counterpart, individuals living in 
rural areas are more likely to die of the five leading causes 
of death. Further, untreated behavioral health needs, including 
treatment for substance use disorders, continue to plague our 
rural communities at alarming rates.
    Opioid use disorders are the fastest-growing subtype of SUD 
nationwide, with overdoses related to synthetic opioids 
significantly higher in rural areas. That is why continued 
funding for programs like the Rural Communities Opioid Response 
Program located in the Federal Office for Rural Health Policy 
are so essential.
    It is also why we count on your support for the newly 
established Centers for Disease Control and Prevention Office 
of Rural Health, an essential new voice for rural public health 
within the administration.
    NRHA recognizes that strong, productive rural communities 
depend on access to timely and high-quality care to fulfill the 
significant role they play in our Nation's economy and the 
overall well-being of the entire country. As we often like to 
say, rural areas provide the fuel, food, fiber, and fun our 
urban and suburban neighbors rely on.
    I would like to once again thank the subcommittee for their 
leadership and opportunity to join you today. The investments 
we seek for rural health programs at the U.S. Department of 
Health and Human Services are a small portion of overall 
healthcare spending but are critical to the families and 
communities in rural America and our Nation as a whole.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you so much.
    Next we will hear from--let us go ahead with Dr. Hott.
    Ms. Hott. Good afternoon, Chairman Aderholt, Ranking Member 
DeLauro, and subcommittee members. Thank you for the 
opportunity to provide testimony and participate in the hearing 
today.
    Thank you to the National Center for Learning Disabilities 
for connecting us.
    I am a proud graduate of rural schools. I am a recipient of 
State and Federal personnel preparation support that provided 
the training necessary to serve our rural students and their 
teachers. My research is situated in rural communities, where 
almost 17 percent of our rural students live below the poverty 
line, and 14 percent qualify for special education and related 
services.
    Often, our rural schools are portrayed negatively through a 
deficit-oriented lens. This is not reality. Our rural districts 
have so many strengths, including a strong sense of community, 
teacher autonomy, effective and longstanding partnerships, and 
the ability to implement individualized interventions. When 
district personnel and our communities leverage these 
strengths, we have the potential to enhance instruction and, 
ultimately, outcomes for students.
    For example, preliminary results from current projects at 
the University of Oklahoma that serve rural students that are 
funded through the Office of Special Education and 
Rehabilitative Services and the Office of Elementary and 
Secondary Education have been quite positive. Our school 
partners report increased student academic achievement, 
decreased suspensions, and improved capacity to deliver special 
education services.
    I am going to talk to you about challenges facing our rural 
educators, but I don't want us to forget the strengths and the 
opportunities that we have. Unfortunately, our rural educators 
continue to face significant challenges, including longstanding 
and pervasive personnel shortages, lack of access to 
professional development, and lack of resources.
    Although there is a troubling lack of research reporting 
the educational outcomes of students receiving special 
education services from our rural localities, current data 
indicates that rural students with disabilities perform 
significantly below their peers with disabilities from suburban 
localities in mathematics and reading and are more likely to 
receive suspensions and expulsion.
    Rural students with disabilities face many of the barriers 
that we have heard about today, including lack of broadband 
access, low expectations, geographic isolation, poverty, and 
teaching quality. These disparities directly impact 
postsecondary options, particularly in STEM fields where rural 
students are uniquely situated to contribute to our workforce.
    IDEA funds flow through to districts and schools that 
provide these services. Yet we have yet to fully fund IDEA. 
Increases in funding are needed to support our rural students 
and ensure access to high-quality programming.
    These concerns are not only limited to our students. 
Similar disparities pointing to inequitable treatment, 
resources, and results can be seen in our rural special 
education teaching force. These shortages limit access. These 
shortages lead to an inability to provide early intervention 
services for children and an overemphasis on compliance. They 
are more pronounced in our rural districts, where schools are 
twice as likely to experience difficulties with teacher 
retention than our suburban counterparts.
    Many rural localities face high levels of teacher turnover, 
which is even more pronounced in rural localities serving our 
high-poverty schools. Teacher attrition creates significant 
financial burdens for our districts and our schools, and it 
reduces student achievement. Although alternative routes to 
certification and provisional educator preparation pathways 
offer some reprieve from these shortages, individuals who 
pursue alternative certification are two to three times more 
likely to exit our field.
    With respect to equity, students of color and students from 
low socioeconomic backgrounds are upwards of four times more 
likely to be taught by a teacher licensed through alternative 
programs. Addressing the achievement gaps between rural high-
need schools and their suburban and urban counterparts requires 
thoughtful and deliberate action. Comprehensive training 
increases teacher retention.
    To alleviate these issues, we have found success in using 
networked communities of practice and grow our own programs. 
This investment hedges poor outcomes that have resulted from 
emergency and alternative certification programs that do not 
provide training through mentored student teaching experiences 
and comprehensive curriculum. It also builds a community of 
educators that can maximize the strengths to meet student 
needs.
    In summation, I am here asking for your support to ensure 
our children are workforce ready, highly productive, and strong 
citizens. We cannot do that without funding for IDEA, personnel 
preparation, and research.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. Ms. Scheibe.
    Ms. Scheibe. Good morning, Chairman Aderholt, Ranking 
Member DeLauro, and members of the subcommittee. Thank you for 
the opportunity to appear before you today to share a bit of 
the national landscape on career and technical education, or 
CTE, and the success South Dakota's technical colleges have had 
in meeting rural workforce needs.
    My name is Laura Scheibe, and I have the honor of serving 
as the State CTE Director in South Dakota, and I am currently 
serving as the elected president of Advance CTE, a 103-year-old 
organization that represents me and my peers in all 50 States, 
the District of Columbia, and U.S. territories.
    CTE marries students' interests and abilities with business 
and industry demand. It is no longer an either/or proposition 
between technical training and a 4-year university degree, but 
rather, a yes/and. A pathway along a continuum that can meet 
learners where they are, both literally and figuratively, with 
stackable credentials that have workplace and personal value.
    So what does this look like on the ground in the States? 
South Dakota is where rural gets real. With fewer than a 
million residents and one area code that covers the entire 
State, our expanses are vast, but our economy and our people 
are thriving. With 2 percent unemployment and labor force 
participation at 70 percent, we do not have room to not get 
workforce right. The State's technical college plays a vital 
role in this equation.
    In the years that COVID-19 hit college enrollment hard, our 
system barely skipped a beat. We actually gained students over 
a 5-year period, increasing enrollment by 9 percent. While 
nationally, 2-year public college enrollment declined by more 
than 19 percent. Across the system, 67 percent of students 
graduate, 98 percent are placed, and 89 percent choose to stay 
in State.
    So what is our secret? The technical college label is 
deliberate. Most programs are eligible for funding from the 
Carl D. Perkins Career and Technical Education Act, or Perkins, 
the primary Federal investment in CTE.
    Out of our four technical colleges, this year three were 
named to the top 15 percent of all 2-year colleges in the 
country, and the fourth won the award in 2017. It is not just 
me saying our technical colleges are great.
    The skills learners master help our rural communities 
thrive and our economy grow. Whether it is independent 
contractors looking to meet skyrocketing demand or long-term 
care facilities trying to stay open, CTE is often the answer.
    Our colleges are intentional in meeting the needs of adults 
for whom traditional schedules might not work. Campuses are 
building satellite locations to meet rural needs, as well as 
online, high-flex, and even competency-based education options 
to meet learners literally where they are, complete with labs 
on campus on the weekend or with business partners in the 
learner's community.
    Scheduling and options accommodate working adults to keep 
them engaged and move them--and keep them moving forward to a 
credential, and industry gains the workforce needed to keep 
doors open. While these delivery options can get a student to 
enrollment, our supports keep them there. Learners move through 
their programs as a cohort, a built-in support and 
accountability network of their peers to help them persevere.
    Additionally, Perkins-funded student success coordinators 
meet not just counseling needs, but transportation, affordable 
housing, and navigating postsecondary as a first-generation 
student. For learners facing barriers, this can make all the 
difference to move from poverty into a family-sustaining 
career.
    To achieve these results takes resources. A CTE classroom 
looks like a well-equipped workplace. Although the investment 
in our future workforce pays off, doing CTE well is costly. 
That is where our colleges are good stewards of the taxpayer 
funding they do receive and leverage those dollars to attract 
industry investment.
    Perkins plays a significant role in helping us deliver 
affordable, high-quality education. My State's fiscal year 2023 
allocation is $6,000,000, with $2,300,000 in formula grants to 
postsecondary and a separate reserve fund that specifically 
benefits rural communities. This Federal investment means our 
students can experience, not just learn, their skills and come 
out workforce ready.
    As a State, South Dakota invests its own funding into the 
system, including through one of our most successful programs, 
the Build Dakota Scholarship. It was conceived as State and 
donor-funded scholarships for learners in high-wage, high-
demand areas. Yet last year, 81 percent of awardees benefited 
from $3,100,000 in industry commitments.
    Industry's partnership has stretched the State's funding, 
grown the number of awards per year, and has guaranteed 
workforce for those employers. A sure thing in an economy when 
little is certain.
    Across the system, you will find industry professionals 
helping shape programs, bringing their own workforce needs to 
colleges or providing millions of dollars of state-of-the-art 
equipment. In short, you will find industry at the technical 
college table.
    In sum, I hope you take away that these keys to success are 
not secret and can and do work throughout the country. CTE is 
achieving real results for learners, and the Federal investment 
is vital to that success. We are proud of how we in South 
Dakota are working together to meet the needs of learners in 
industry to create an economic future that values both urban 
and rural alike.
    Thank you very much, and I would be happy to stand by for 
questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you. And last, but certainly not least, 
Dr. Davis.
    Dr. Davis. Chairman Aderholt, Ranking Member DeLauro, and 
members of the committee, it is an honor to appear before you 
to share from my perspective a portion of the challenges rural 
communities encounter while in pursuit of reasonable access to 
health services.
    I thank the committee for the opportunity to testify before 
you today and anticipate a thoughtful and productive 
discussion.
    My name is Tearsanee Davis, and I currently serve as the 
Director of Clinical Programs and Strategy at the University of 
Mississippi Medical Center's Center for Telehealth in Jackson, 
Mississippi. Additionally, I am a dually certified nurse 
practitioner trained in family practice and psychiatric mental 
health. I am a native of Durant, Mississippi, Holmes County, 
the poorest county in the poorest State as of 2019.
    My testimony today is drawn from my personal and 
professional experiences while living and working in rural 
Mississippi, as well as my knowledge of efforts aimed to 
alleviate rural residents' lack of access to quality care.
    Many factors contribute to disparities in health, such as 
unavailability of needed resources, socioeconomic issues, and 
lack of knowledge. Funding made possible by committees such as 
this enable us to implement programs, test models of care, and 
integrate innovation into practice in Mississippi that have a 
national impact.
    The University of Mississippi Medical Center's Center for 
Telehealth is a Telehealth Center of Excellence, as designated 
by the Health Resources and Services Administration, and its 
partners have worked diligently to understand and address 
issues that continue to plague our State. There is more work to 
do.
    It is no secret that rural areas have their own set of 
challenges that undoubtedly affect the health of the residents. 
Special populations like expectant mothers and those with 
substance use disorder have unique needs that are often unmet 
within their communities.
    Mississippi's maternal mortality rate is among the highest 
in the Nation. Federal programs like the Rural Maternity 
Obstetrics Management Strategies, RMOMS, program are available 
to help many States connect obstetric services to create 
networks that better address the needs of rural mothers. 
However, in States like Mississippi, where there is a shortage 
of physicians who specialize in high-risk maternity care and 
more rural hospitals are discontinuing obstetrical services, 
more mothers and babies are at risk.
    In Mississippi alone, fatal drug overdoses in people under 
the age of 35 nearly doubled from 2019 to 2020. This increase 
in death has mostly affected the African-American population 
and people under the age of 35. Timely access to substance use 
disorder treatment in rural areas is but one way to reduce the 
impact of this epidemic.
    Recently, the Department of Psychiatry at UMMC was awarded 
a grant by SAMHSA to provide emergency consultation, 
medication-assisted treatment, Web-based linkage to resources, 
and education to consumers, families, and providers for 
substance use disorder.
    These are just a couple of examples of how funding you 
authorize helps us build new models, but sustaining them 
remains a challenge. Over the past 20 years or so, Mississippi 
has made great strides in creating partnerships between larger 
healthcare systems and community providers to bring the care to 
the patients using telehealth. Funding from HRSA, USDA, and the 
FCC have made the expansion of these services faster.
    Our community health centers are invaluable to the health 
of our people. For many, they are the hope of consistent, high-
quality, equitable healthcare for all. The role of innovation 
and digital solutions to transform the healthcare delivery 
system has steadily increased in Mississippi, but it was 
birthed out of necessity, and now it must be sustained out of 
necessity.
    Through those early programs, we learned that the need was 
much greater than acute care. It was about specialty services, 
convenient care, and school-based services. Very few providers 
are choosing to live and work in these rural areas, and those 
that do are at capacity or do not stay.
    As the only academic medical center and Level I trauma 
center, it is our responsibility to address the needs of the 
entire State and to aid rural health providers in caring for 
their patients. Where you live should not determine your 
health.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you so much.
    And I will kick off the question. As you mentioned, we may 
have a few questions here with Ms. DeLauro. As you--as already 
been said, we have multiple hearings that are going on this 
morning, and so members have been coming in and out. But I want 
to focus a little bit about rural hospital closures, and so, 
Ms. Cochran-McClain, let me address this to you.
    You mentioned in your testimony the problem of rural 
hospital closures, and I know it far too well. And you did talk 
a little bit about some of the factors, but could you elaborate 
on some of the factors that are leading to a lot of these 
closures and mention any additional efforts that you think need 
to be done that we can do to support obviously a vital part of 
each community.
    Ms. Cochran-McClain. Yes, thank you for your question, Mr. 
Chairman.
    And I know you know about rural hospital closures because 
you have had a number of them in the State of Alabama. And I 
think I desperately wish there was one thing that I could 
identify and one thing that we could fix to stem the hospital 
closure crisis, but it varies on a community and the individual 
hospital about what the challenges that they are facing.
    I can speak generally. Factors that lead to rural hospital 
closures include kind of declining financial performance. Part 
of that is around the payer mix and who is reimbursing them. 
Rural hospitals have many more public payers--Medicare, 
Medicaid--and are more reliant on those folks. But they also 
tend to pay a little bit less than some of the commercial 
payers.
    Volume and low patient volume and the patient mix has a big 
impact. So you are seeing lower number of patients that you 
have to spread your fixed costs across. And then, as we have 
heard today, a lot of the patients seen in rural areas have 
additional healthcare challenges when compared to other 
populations.
    And I would be remiss if I didn't mention obviously 
workforce staffing shortages. We saw during the pandemic was an 
example of when we were having shortages of nurses and others, 
folks having to close service lines because they couldn't 
continue at a high enough quality rate.
    And then last, but not least, there are definitely 
regulatory and administrative burdens put on by payers, 
Medicare in particular, that make it more challenging for rural 
facilities to keep their doors open. And part of that is 
because a lot of our Federal policy is developed for larger 
healthcare systems and not for the situation we are facing in 
our rural facilities.
    Mr. Aderholt. Thank you.
    Dr. Hott, let me address some rural school challenges to 
you. What are, in your opinion, unique challenges faced by 
rural schools that you don't always see in urban school 
districts?
    Ms. Hott. Well, in our rural schools, we wear multiple 
hats. It is not uncommon to see the principal also teaching 
algebra and driving the school bus. And those hats, we can see 
that as a deficit, or we can see that as a strength.
    And if we had increased funding and support to train our 
leaders and our teachers and ensure that we have quality 
teachers and quality leaders, we have better outcomes for kids. 
We retain those teachers and leverage those partnerships and 
strengths that we have in our rural community.
    Mr. Aderholt. Could you talk a little bit about some of the 
barriers that you see when rural schools go to apply for a 
Federal grant?
    Ms. Hott. Yes. It is tough. There is multiple hats. I 
didn't mention grant writing, and I didn't mention school-
university partnerships as a possibility.
    I think we can talk about those barriers, and we can talk 
about how rural schools may not have all that we need, but we 
can also talk about what we do have. And we have those strong 
university and school partnerships, particularly in Oklahoma.
    The lack of trained personnel, we have solutions for that. 
We know that increased funding for IDEA Part D would allow us 
to train more leaders, would allow us to train additional 
teachers. So those barriers of lack of teachers, lack of 
retention of teachers can be addressed.
    Mr. Aderholt. Thank you. Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    And thank you all for your powerful testimony.
    Let me just ask, I have got two or three questions, but Ms. 
Cochran-McClain, Dr. Davis, and anyone who would care to, we 
talked about the closure of hospitals. And just yesterday, 
there was an article that said, ``We Are Going Away: A State's 
Choice to Forgo Medicaid Funds Is Killing Hospitals.'' And it 
is focused on Mississippi, I will just tell you, Dr. Davis.
    But I just want you to, if you might, just expand a little 
bit on. I know you said that there are multiple reasons why 
hospitals are closing, and but it is also care for people as 
well. The hospital is closing, but it is about neonatal 
intensive care unit closes in July.
    The issue, what happened in what is the name of the town? 
Rolling----
    Dr. Davis. Rolling Fork.
    Ms. DeLauro. Rolling Fork, that victims of the tornado that 
struck the Delta last week had to be ferried 50 miles away for 
medical treatment because the local hospital had no power. I 
mean, this is more Medicaid dollars would have equipped it with 
an emergency generator.
    In any case, talk to me a little bit about the lack of 
Medicaid and that on the closure of hospitals are a detriment 
to healthcare in rural communities. And I would like to have 
both of you comment on that.
    You want to speak on that, Dr. Davis?
    Dr. Davis. So I will just--I will just start. I will just 
start.
    Without the appropriate funding, the hospitals don't have 
what they need. The cost of providing care is increasing. And 
as Ms. McClain said, there are more--the payer mix. So if you 
think about Mississippi, we are mostly rural, you know, and 
underserved, if you think about it. There are only three areas 
in Mississippi that are even remotely considered urban. The 
rest of the State is rural.
    And you know I mentioned that it is the poorest State or 
one of the poorest States and always has been. So that equates 
to more of our people are on Medicaid. And so that is more 
people on Medicaid, and they are the people that need the most 
care. Yet there are limitations.
    So what are the hospitals to do? And they try to stay open. 
They seek out opportunities. I have one good example is many 
years ago--well, not many years ago, but several years ago, the 
hospital that was 10 miles from my home was threatening 
closure, but the TelEmergency Program was able to help them 
stay open.
    So I think that it is a cycle. It is a circle, you know, 
less the few people that have coverage. But they are the people 
that need the care, and the hospitals have to have funds to 
operate. And that is what we have seen is just it is the 
burden.
    Ms. DeLauro. Yes. This article is very enlightening and I 
just--I read it, and it says in Mississippi, one of the 
Nation's poorest States, the missing Federal healthcare dollars 
have helped drive what is now a full-blown hospital crisis. So, 
and there are----
    Ms. Cochran-McClain. Yes, and I would just add we know--and 
I mentioned payer mix as being one of the issues that hospitals 
face. And we have seen in States that have not expanded 
Medicaid----
    Ms. DeLauro. There is about 10.
    Ms. Cochran-McClain [continuing]. The higher rates of 
hospital vulnerability, rural hospital vulnerability and 
closure. So there is a correlation there between Medicaid 
expansion and rural hospitals being able to keep their doors 
open. I mean, it is a new payer for a lot of uninsured folks.
    And I would just note before hospitals close their doors, 
they frequently are shutting down service lines. So because if 
they can't afford to keep kind of the full range of services 
open, they are going to look to see where they can trim. And 
obstetric services is one of those prime areas. Chemotherapy is 
another area where people tend to get their infusion local is 
another area. And that is why we were so excited about the 
President's proposal.
    Ms. DeLauro. So people can--so people die.
    Ms. Cochran-McClain. Mm-hmm.
    Ms. DeLauro. People die. I mean, let us take it to where it 
goes. So without----
    Ms. Cochran-McClain. Without access to care, especially 
emergency care or ongoing treatment for some of the chronic 
conditions that they face, there are definitely poorer health 
outcomes, and we see higher morbidity and mortality rates in 
rural areas compared to their urban and suburban counterparts.
    Ms. DeLauro. Staggering to me that if there is one thing 
that Federal resources can do is to alleviate that issue, and 
the refusal of those dollars is--it is hard to fathom in many 
respects. But there isn't any more noble cause that we are 
engaged in than saving people's lives, and the Federal 
Government has the ability to do that, and it is up to the 
States to take advantage of that as well.
    But thank you. Let me just go on, if we can.
    Dr. Davis, because of countless conversations with parents 
in my own State of Connecticut, educators, I created the 
School-Based Mental Health Services Grant Program. That 
occurred in the 2020 Labor-HHS bill. It is about helping school 
districts increase the number of quality mental health trained 
professionals working in schools.
    When they passed the bipartisan bill, Safer Communities 
Act, there was an additional $500,000,000 to this program on 
top of the resources included in our bill. The grants expand 
the program's reach. They move us closer to ensuring that every 
child goes to a school that has a qualified mental health 
professional on staff. And I see, Dr. Hott, you say that 
because I think my own view is that we ought to have a 
qualified medical professional, mental health professional in 
every school in the United States.
    But my question to you, Dr. Davis, in your testimony, you 
highlight the partnership between the Center for Telehealth and 
the Mississippi Department of Education, and you say to improve 
urgent care and behavioral health service, along with lifestyle 
coaching and education to all students in K-12 and charter 
schools in the State.
    Can you expand on the partnership, what services you 
provide? How do you connect students to mental health or 
behavioral health counseling?
    Dr. Davis. Absolutely. So we are go grateful that in 2022 
we were awarded the opportunity, given the opportunity to 
provide services to these K through 12 and charter schools in 
the State. It was made possible by ESSER funds. So we are 
grateful for that. It runs through September 2024, September 
2024.
    We are providing urgent care services, behavioral health 
services. The behavioral health team consists of licensed 
professional counselors, and we have psychiatric nurse 
practitioners if that child needs medication management.
    And then there is also lifestyle coaching, just in regard 
to healthy lifestyle, a more preventive approach. And we also 
provide education to staff, faculty staff around the education 
of healthcare needs of their students and also support their 
school nurses.
    We do have lots of challenges, though. One of the biggest 
challenges is all of the schools do not have the same 
resources. So we may have--I don't know the exact number, but 
we do have many schools in our State that do not have school 
nurses, and we feel like the school nurses are the glue. They 
are the glue between the healthcare team and the community. 
They know the parents. They know the students. They know what 
is needed.
    And then in some districts, they have a school nurse in 
every building, and in some districts, they have one school 
nurse for nine schools that are scattered across a very large 
geographic area. So there is a challenge there.
    The other thing is you mentioned the funding that you all 
have provided for mental health professionals in the schools. 
If they don't exist, they can't be there. And that is a 
problem, too. You know, the maldistribution of the mental 
health professionals is there just aren't enough, and 
especially in our most remote rural areas.
    So this is where we feel like we come in is it is offered, 
it has been offered to every public school and charter school 
in the State. However, they do not have to opt in to the 
program. We have had--I think we have had 70 that have signed 
contracts to enter into this program with us, and 64 are 
actually live right now.
    We are servicing currently 166,600 students that have 
access to this. The school nurse at each of these schools is 
the conduit. So they are the connector. We set up a system to 
where they can self-schedule for the visit. The parents, 
guardians can join the visits remotely. So that is also an 
advantage of having a telehealth program.
    We see ourselves as bridging the gap. We are not replacing 
anything. So if it is a district that has mental health 
professionals, we ask that they continue to do what they do so 
that we are better able to serve those districts that have 
absolutely nothing.
    Ms. DeLauro. Well, thank you. Just it really is--and I will 
ask you if you could get back to us on that.
    Dr. Davis. The number of school nurses?
    Ms. DeLauro. No, on what you need on what kind of 
additional investments as a committee should we be making to 
deal with the issue of telehealth to ensure that every 
individual sees a doctor, a nurse, or a counselor? If you could 
just get back to us on that, that would be helpful in terms of 
the committee's deliberations as we go forward.
    Mr. Chairman, can I ask one more question?
    Mr. Aderholt. Go ahead.
    Ms. DeLauro. Thank you.
    And this has to do with the education side of the coin 
here. Dr. Hott, you highlight students with disabilities in 
rural areas and the barriers and quality instruction, 
intervention, increases--and calling for increased Federal 
funding for the instructional programming. What is your 
personal experience with the challenges in how IDEA and Title I 
funding can support positive outcomes for kids with 
disabilities in rural areas?
    And I would just say to you, Ms. Scheibe, we increased 
Perkins by $75,000,000 in 2023, strong promoter of CTE, which I 
think we need to increase. I think it really has taken off in a 
very--in a very important way, and so anyway, let me just ask 
Dr. Hott if you have anything to contribute to this.
    Dr. Hott, go ahead on IDEA and Title I funding and kids 
with disabilities.
    Ms. Hott. Thank you for the question. That is such an 
important issue, and right now, we have IDEA funds and Title I 
funds, and some people believe that students can only be served 
through Title I or only be served through IDEA, particularly 
students with disabilities. And that is not the case.
    In our rural schools where we may have a Title I reading 
specialist, that person is specially trained to teach reading. 
We may have a child who also has a disability and is in a co-
taught classroom where there is a general educator and a 
special educator serving a student.
    That student could see the reading specialist in the 
morning. They could also be in the co-taught classroom where 
all students are benefiting, and we are capitalizing on the 
strength of the personnel we do have. We don't have enough 
personnel. That is the bottom line.
    We don't have enough mental health providers. We don't have 
enough teachers. We don't have enough special educators. I have 
districts that do not have a special education teacher, no 
counselor, no school psychologist, and no social worker.
    There are waiting lists of children to be evaluated for 
special education of over 100 students. A special ed director 
told me yesterday that she had a student in crisis, and there 
is one special ed teacher that is serving both the middle and 
high school, and she couldn't handle both situations at the 
same time.
    Ms. DeLauro. I would just make one point about this, and 
that is what we were talking about before, is Medicaid. When 
people make reference to Medicaid, they think of--which it is 
true, but seniors, nursing homes, et cetera. All of which is 
very positive, all of which we need to look at.
    What they don't realize, there are two other areas, is that 
children with disabilities, that is the--Medicaid is the 
primary way that families get healthcare for their disabled 
kids. I had one mother say to me, ``My child would not have 
survived without Medicaid.'' And so these things are really 
connected in profound ways in trying to deal with the issues of 
healthcare and what it does.
    And the other piece of Medicaid is substance use disorders. 
That is where so much of the care comes, and it gets paid for 
through Medicaid. And if we want to address that problem, that 
we need to look at where we need to expand Medicaid and make 
sure that it has the resources that it needs.
    I have gone so far beyond any time that I have had here on 
the indulgence of the chair, but I just wanted to say again we 
have focused on the CTE in a very substantial way. Also with 
apprenticeships and registered apprenticeships, et cetera, and 
the school-to-work connection is really critical, and the 
engagement with community schools, et cetera, in creating the 
opportunity for youngsters to be able to get the career or 
technical education that they need, but also to be able to have 
a job at the end of the pipeline.
    I can't thank you enough for the work that you are doing 
because you are on the ground. And please understand that you 
heard me speak before--and Mr. Chairman, bear with me on this. 
I look at this as not as a--we need to take a very, very hard 
look at the investments that we have made and the benefits of 
those investments. And if we don't build on those investments, 
but if we move backwards on that, we then will have not been 
able to--we will slip back in very profound ways to 
communities.
    And particularly I think in rural communities where they 
are already suffering with a lack of investment in some areas. 
And you know the needs better, you know, than most. And so we 
have to take a look at it.
    Thank you. Thank you very, very much for being here. Thank 
you for your testimony and for your great work. Much 
appreciated.
    Mr. Aderholt. Well, thanks again for being here. But I 
would, before we conclude--and I know we are going over about 
2\1/2\ hours here for this entire hearing. But we will 
conclude, but before we do, I would like to just pose one 
question to each of you, and you--I don't know whether you will 
have one or two or three or whatever, but just in your opinion, 
what are the biggest challenges facing--that you see facing our 
rural communities today, and if there is anything that this 
subcommittee could do to address them?
    And Dr. Davis, we will start with you.
    Dr. Davis. So I think we have--thank you--have spoken 
extensively about the problems, and I have brought up some of 
the solutions or some of the things that we have done to 
address those things.
    One of our biggest problems now, and I will speak about 
telehealth in particular, is sustainability of these programs, 
is we do rely on funding to begin these programs and to test 
out models of care and to get the outcomes data, and we have 
that outcomes data. But there is still an issue of how do I 
continue this program after the fact?
    So when we are talking about the school-based program, that 
is one of our biggest concerns right now is if we are not 
getting the funding elsewhere, how do we generate the funding? 
We know it is not a program where we are going to get rich. 
That is not our desire. Our desire is to serve the children of 
the State.
    If we are left to rely solely on reimbursement, then we 
still have an equity issue. Because having an insurance policy 
does not mean that you have coverage, and it does not mean you 
have access to that coverage if you don't have the funding to 
meet the co-pays and pay the deductibles, which is why we 
structured our school-base program as it is right now the way 
that it is to where we don't have to think about does that 
child have insurance? Can that parent pay a co-pay?
    And that is something we would love to continue. Just being 
realistic about it, most of our kids are still not going to 
have access if we rely on reimbursement. So I think that is one 
of our biggest problems.
    And then also the other programs that we--through the 
substance use disorder programs, the maternity programs, and 
all that, it all relies on reimbursement. And that is a big 
problem for us with telehealth with the geographic 
restrictions, the administrative specifications that you have 
to meet. They have to be in a certain place. The provider has 
to be in a certain place. They have to have an in-person visit 
after so many months. What if there is nowhere to have an in-
person visit?
    I feel like also a challenge coming behind the pandemic 
that we have is that prior to the pandemic, we had a large 
population of people who sadly had just accepted that they 
would not have access to certain services. The pandemic has 
allowed us to provide those services to them without regard for 
where they are and all of that.
    And now there is concern that if we back up, these are 
people who have seen the mental health professionals. They are 
on track. They are back in the workforce. They are doing well, 
but there is going to be a slip back. So we are concerned about 
those.
    Those are our biggest challenges, I would say, in 
telehealth.
    Thank you.
    Mr. Aderholt. Thank you. Dr. Hott.
    Ms. Hott. That is a great question. I think the biggest 
shortage in the rural communities that I am serving are 
teachers. Without comprehensively trained teachers, our 
children aren't able to go on to postsecondary education. They 
don't have access to workforce development, and ultimately, it 
becomes very costly.
    When we train a teacher, they enter a school, and we are 
not able to retain them with ongoing professional development, 
then we lose them, and it is expensive, really expensive. Some 
of our school districts are reporting 18 to 24 months with 
unfilled job postings for special education, and that means 
children go without services. And when the children go without 
services, they can't make that time up. It is gone.
    We also have individuals who lack comprehensive training 
teaching our children. We need the individuals who are teaching 
our children because it is reality--it is not right, it is not 
fair, it is reality--they need resources. We need professional 
development.
    And quite frankly, if we don't do something, the outcomes 
are going to be very, very poor. We are going to have more 
students needing Medicare and needing State support, than if we 
had allowed them to have the mathematics and reading and social 
supports that they needed while they were in K-12.
    On the flip side, we know that there are many STEM job 
opportunities right now, and our rural kids are uniquely 
situated for those positions, but we have to educate them. They 
have to have quality mathematics instruction. They have to have 
quality reading instruction.
    And for kids with disabilities, we need intervention. And 
without continued funding through IDEA Part B for kids and Part 
D for teachers, this isn't going to happen. And it is going to 
disproportionately continue to impact our rural schools.
    Mr. Aderholt. Thank you. Ms. Scheibe.
    Ms. Scheibe. Thank you, Mr. Chairman, for that question.
    I would echo what my colleague indicated, that certainly 
the teacher and faculty workforce shortage is something that we 
definitely face in rural communities. But I would take my 
answer perhaps a bit higher level and say that I think one of 
our biggest challenges for our rural communities is how do we 
continue to grow our economies, and how do we find the 
workforce in order to meet those needs?
    And I would indicate not just for today, but looking at 10 
years from now. Where are our economies going to be? What is 
our workforce of the future? How do we begin meeting those 
needs today? I think that is really a challenge that all of us 
in a policymaking role can look at.
    We have an incredible opportunity to innovate and to 
imagine what that future does look like down the road. We 
appreciate the Federal resources that help us get there.
    Mr. Aderholt. Dr. Cochran-McClain.
    Ms. Cochran-McClain. And I think I have two that I will 
mention quickly. I think one really is stemming the tide of 
closures of rural hospitals because they are such a hub of care 
in our communities and play such an important role in terms of 
an employer and the economic impact.
    Support for programs like the Rural Hospital Flex Program, 
the Small Hospital Improvement Program, continued support for 
those, as well as consideration of the President's proposals to 
really help rural hospitals stabilize the financial crisis they 
are in, are two areas I would really love for the committee to 
look at.
    And then the other area, like the other panel members have 
said here, is really just workforce. We really need to continue 
to build the capacity to grow and train individuals in 
workforce. We talked a lot about physicians today. They are an 
important part of it through the Rural Residency Planning and 
Development Program and the Teaching Health Center GME Program. 
But thinking creatively about how we can use those same kind of 
models for nursing and other allied health professionals to 
really be able to--or, again, recruit, train, and retain those 
individuals in their rural home.
    Mr. Aderholt. Thank you so much.
    Ms. Cochran-McClain. Thank you.
    Mr. Aderholt. Well, thanks so much again for your testimony 
here this morning and answering our questions, and we look 
forward to working with you to work on rural America.
    And this is dismissed--is adjourned.

                                           Tuesday, April 18, 2023.

                 UNITED STATES DEPARTMENT OF EDUCATION

                               WITNESSES

HON. MIGUEL CARDONA, SECRETARY, UNITED STATES DEPARTMENT OF EDUCATION
LARRY KEAN, BUDGET DIRECTOR, UNITED STATES DEPARTMENT OF EDUCATION
    Mr. Aderholt. Well, the subcommittee will come to order, 
and I wanted to say good morning to everyone and thanks to 
everybody for being here.
    Mr. Secretary, good to have you here and good to have the 
Budget Director from the Department here as well. Thank you 
both for taking time out of your schedule to join us, and we 
appreciate your presence here. I look forward to your 
testimony.
    I do want to start by expressing some real concern with the 
new rule that has recently come out of the Department of 
Education and, of course, which would violate the Title IX when 
they categorically ban biological male students from 
participating in women's sports teams. Forcing schools to allow 
biological teen males into girls' locker rooms is one of the 
greatest overreaches of the Federal Government that so many of 
us have seen and feel like we have seen out of the Federal 
Government in quite some time.
    Not only does it undermine the decades of work in giving 
girls the same opportunities to compete in women's sports, 
which was the original intent of Title IX, it creates potential 
unsafe situations. The proposal robs girls of the chance at 
fair competition.
    Gender identity cannot be changed, even though there are 
some that would argue to the contrary. But let us be clear. 
Basic biology cannot be changed. Chromosomes can't be changed. 
The simple fact is that biological males and females are 
different. Biological males will have the natural advantage in 
size, in speed, in strength, even when they take suppressive 
hormones.
    As biological men continue to dominate women's 
competitions, someone must stand up and say enough is enough. 
And the fact that the Department of Education is proposing a 
rule that says those who do so are in violation of the very 
rule that gave women's sports an equal footing in the first 
place leaves me and millions of Americans extremely concerned.
    Let me turn now to the budget proposal. I also have 
concerns that the proposed 13 percent increase for the 
Department of Education will leave the next generation 
unprepared academically for competing in the 21st century and 
saddled with the highest national debt our Nation has ever 
seen. I believe a more responsible approach for your budget is 
called for, especially as painfully high inflation continues to 
strain American families' budgets.
    The latest test scores put out by your department show 
significant declines in math and reading scores. And minority 
students, by the way, have fallen behind more than anyone else.
    Closing most public schools for nearly 2 years during the 
pandemic period was perhaps one of the greatest public policy 
blunders of our lifetime, and the effects of this mistake will 
be suffered by our Nation I would say for actually generations 
to come. Closing public schools at the behest of some unions 
have contributed to widespread learning loss, unprecedented 
youth mental health crisis, and increased marginalization of 
students with disabilities.
    There is also concern about a broader trend that we are 
seeing in the K through 12 education space, and that is a 
shifting focus away from teaching our kids to read, to write, 
to add and subtract, but toward indoctrinating children with 
the ideology that divides and that achieving equality in areas 
outside of academic achievement. Kids should learn how to 
think, not what to think, in our public schools. It is not the 
Federal Government's role to take over the role of parents and 
insert an administration's political agenda.
    Sadly, the data shows that increased topline funding for 
the Department of Education continues to yield worse results 
for our kids in public schools. Something is not right, and we 
cannot continue as the status quo.
    I would also like to touch on another area of extreme 
executive overreach, and that is the President's decision to 
conduct blanket Federal student loan forgiveness, as well as 
repeatedly extend the pause on student loan repayment and 
interest accrual. Not only is this inflationary, but it also 
makes hundreds of--or also people making hundreds of thousands 
of dollars a year are not asked to be paying their student loan 
debts back. I think this is blatantly unfair to the millions of 
Americans who never went to college and also those that don't 
have a student loan debt.
    It is unfair to those who choose a less expensive school or 
work during their school in order to achieve their goal and 
avoid student loans, or who sacrificed during their time in 
school in order to pay off their debts.
    Mr. Secretary, you and I share an interest in seeing 
students who go to college complete their studies and earn a 
degree. There may be agreement that the loan repayment system 
needs to be fixed. However, adding another repayment program in 
the way the Department has proposed is troubling. Even the 
liberal Brookings Institute has stated that this proposal would 
largely turn Federal loans into grants.
    We do have the grant programs that are included in this 
committee's funding. But the purpose of loans is not to provide 
grants just by another name, especially in ways that are 
untargeted. For instance, it is higher-income borrowers who 
will reap the windfall of loan forgiveness benefits as part of 
this income-driven repayment plan.
    I am a longtime supporter of Pell Grants and the TRIO 
program. Pell Grants and participation in TRIO help first-
generation college students chart a course to a better future 
in the middle class. We need to continue to help these students 
not only enroll, but also graduate and find good-paying jobs.
    Unfortunately, high inflation is eating away at the 
salaries of these recent graduates and making it more difficult 
for them to establish themselves in their careers. I know we 
will be addressing these topics today and many others as we 
move forward. But again, I want to thank you for being here.
    Like I said, I did want to mention those concerns that I 
think are the concerns of millions of Americans across the 
country, but I do look forward to hearing from you this morning 
and from your insight and your perspective.
    And at this time, I would like to turn to my colleague Ms. 
DeLauro for her opening statement.
    Ms. DeLauro. Thank you very much, Mr. Chairman, for holding 
the hearing.
    And I want to welcome Secretary Cardona and our Budget 
Director here for the Department. Mr. Kean, thank you so much 
for being here and for your work, both, over the past 2 years 
and throughout your entire career. Mr. Secretary, we in 
Connecticut had already witnesses your career of passion, of 
dedication for America's students and teachers, a commitment 
that has now been on full display nationally.
    When you first joined the Department over 2 years ago, 
students and families were facing unprecedented change and 
disruption to their education. But as you and I both know, 
schools and learning provide consistency to kids who need it 
most. As educator Horace Mann said, and I quote, ``Education, 
beyond all other devices of human origin, is a great 
equalizer.'' And I would add provides great consistency when it 
is greatly needed.
    With your leadership and investments this committee made 
over the past 2 years--the American Rescue Plan, the Bipartisan 
Safer Communities Act--schools now have the resources to 
strengthen this great equalizer. They can better support 
student academic recovery, address mental health needs, and 
tackle nationwide teacher shortages.
    Most recently, in the 2023 Government funding bill we 
passed and enacted in December, the committee secured a 
historic $3,200,000,000 increase for programs administered by 
the Department. We expanded programs that meet the needs of 
students who most need our help. We made record investments in 
Title I, the cornerstone of our Federal support for public 
education, to support students from low-income background. And 
we invested in IDEA grants that support kids and students with 
disabilities at every stage of their learning.
    To build on our work to prioritize, and I quote, ``whole 
child approaches to education,'' we doubled funding for full-
service community schools, a program we have grown by nearly 10 
times since I first became the chair of the subcommittee. My 
focus on these models would take a holistic approach to 
education, dates back to my time as a teacher at the Conte 
Community School in New Haven, Connecticut.
    To make education accessible to even more students, we 
proudly fought to increase the maximum Pell Grant by $500, the 
most in more than a decade, for the second year in a row. We 
have made college more affordable so that students from diverse 
and underserved backgrounds have a fair shot at a high-quality 
postsecondary education.
    And to narrow our Nation's racial disparities in 
educational attainment and economic opportunity, a top priority 
for me, we increased our support for HBCUs and MSIs to over 
$1,000,000,000, an increase of 30 percent since you took 
office.
    As we begin the 2024 Government process and to ensure that 
we continue to build on these critical investments, I am 
pleased to note that the Biden administration proposed a 
$90,000,000,000 budget, a 13 percent increase, for the 
Department that would strengthen and expand these programs to 
serve even more students and families.
    The budget proposes important investments to ensure 
students from low-income backgrounds can succeed. It includes 
increases for programs that serve students with disabilities 
throughout the Nation and equips special educators with the 
tools they need, including IDEA personnel preparation funding.
    The budget also addresses pressing issues with funding to 
combat teacher shortages, expands school-based mental health 
professionals, increase civics education, and grow community 
schools. And to help underserved students access higher 
education, the budget makes strong increases for the maximum 
Pell Grant and college access programs like TRIO and GEAR UP.
    Students, teachers, and those who support them depend on 
the Department's programs, which is why I must mention how 
deeply concerned that I am over some of my House Republican 
colleagues' calls for massive spending cuts to so many of these 
programs. Yesterday, on Wall Street, Speaker McCarthy verified 
Republicans' intent to cut funding back to the 2022 level and 
impose dangerous caps going forward.
    I am not sure that my Republican colleagues realize the 
impact that the proposed cuts would have. Let me read some of 
the scariest numbers that you shared in a letter to me.
    Cuts to Title I and IDEA grant funding would take 100,000 
teachers and service providers out of classrooms serving low-
income students and students with disabilities.
    They would strip away the opportunity for 80,000 people to 
attend college and impact all 6.6 million students who rely on 
Pell Grants by decreasing the maximum award by $1,000. They 
would cut work study benefits, eliminate financial support for 
85,000 students working while earning a degree. Administering 
student financial aid would become more difficult, and 40 
million borrowers would experience decreased service.
    I would like to note that I know some of my Republican 
colleagues claim these cuts would not be implemented evenly 
across the board, but that is even more dangerous. Because if 
other programs are exempt from cuts, we both know that 
education programs that students and families rely on will be 
impacted even more than your agency estimates.
    And that kind of extreme thinking is not just some 
hypothetical scenario, as some claim or that I have imagined. 
It appears to be a real goal that a majority of my House 
colleagues have.
    Last month, Representative Massie introduced an amendment 
to H.R. 5 that read, and I directly quote, ``Any office or 
program related to elementary or secondary education should be 
terminated by December 2023.'' Fully terminated. One hundred 
sixty-one, nearly 75 percent of House Republicans voted in 
favor of this amendment.
    Let me reiterate, nearly 75 percent of my Republican 
colleagues voted to eliminate all K through 12 education 
funding last month. My God. My fears of these cuts and 
eliminations are not hypothetical because there are those who 
have already voted for them. And I am so grateful for the 60, 
60 of my Republican colleagues who had the courage to stand up 
and to say no.
    The amendment did not pass, and I know that those who did 
not vote for it know well that we should not go in this 
direction, and I will work with these like-minded colleagues 
across the aisle to make sure that this never happens. Because 
investing in kids, not defunding their education, is how we 
make our economy stronger and our future brighter.
    We should be doing everything we can to increase access to 
these programs, not cutting off very basic education services 
for children who need them. And it is my plan to dive deeper 
into the disastrous implications of these cuts during my round 
of questions.
    In the meantime, to my colleagues across the aisle, I say 
this. We garnered bipartisan support for this bill as recently 
as December. Republicans and Democrats came together and 
approved the investments that were made. But cuts of this 
magnitude would take back our progress at a time when we should 
be fighting for more investment in our students and teachers, 
not less.
    As I have made very clear, I will never stop fighting these 
drastic proposals. I thank you, Secretary Cardona, for doing 
the same, and I look forward to your testimony.
    With that, Mr. Chairman, I yield back.
    Mr. Aderholt. Thank you.
    Mr. Secretary, you have the floor. We look forward to 
hearing from you.
    Secretary Cardona. Thank you, and good morning, Chairman 
Aderholt, Ranking Member DeLauro, and distinguished members of 
the committee.
    I am pleased to join you today to testify on behalf of 
President Biden's fiscal year 2024 budget request for the 
Department of Education.
    My time in front of you today is about choices. The choice 
to invest in America's children or the choice to protect the 
status quo of underachievement. The choice to come together on 
behalf of the students, parents, and educators who are looking 
to us to serve and raise the bar for education in this country 
versus the choice to break down in partisanship or divisive 
culture wars.
    It is best to think of this budget proposal by thinking of 
a child's journey through education. In this scenario, a child 
starting her educational journey builds a strong foundation for 
learning right away because this budget made it possible to 
expand high-quality preschool for more 4-year-olds across the 
country.
    Imagine when she gets to elementary school. If she is a 
student with disabilities, she benefits from the additional 
$2,700,000,000 in this budget to help include and support her. 
If she goes to a Title I school, she learns the fundamentals of 
reading, math, and other rigorous subjects she will need to 
succeed in life because that school is able to tailor 
instruction and use data to provide one-on-one support thanks 
to the $2,200,000,000 in additional funding for Title I schools 
in this budget.
    Wherever she goes to school, she can count on having a 
highly qualified teacher who has gained years of experience in 
helping students learn and grow because we invested early to 
fully prepare, develop, and empower our educators. And as she 
walks around her school, she feels welcome and included, 
gaining the benefits of a strong, intentional focus on a safe, 
supportive school climate that helps her learn.
    She sees teachers who look like her because we invested in 
programs that build a talented and diverse pipeline of 
educators, from the Hawkins grants to the Teacher Quality 
Partnerships.
    Now imagine that this student faces some challenges with 
her mental health, as we know so many students do. She can go 
to a mental health professional right at her school who is 
available to help students directly because that school 
benefitted from our investment of another $500,000,000 to 
advance our goal of doubling the number of school counselors, 
social workers, and mental health providers available to our 
kids.
    She and her family can also get wrap-around supports from 
her community because we have more than doubled funding for 
full-service community schools that are designed to do exactly 
that.
    As the student comes closer to adulthood, she has pathways 
to careers and skills to succeed in the world. We set her up to 
compete and succeed in a stronger economy than ever with well-
paying jobs at the ready because this budget delivered more 
funding for career and technical education, more funding for 
career-connected high schools, and more investment in helping 
every student become multilingual.
    She also has a jump-start on her path toward earning a 
college degree or credential because we worked together to make 
postsecondary education inclusive and affordable. We increased 
the Pell Grant. We invested in proven strategies to help 
students like her better afford college and succeed in earning 
her degree. We supported HBCUs, TCUs, and MSIs, and we made 
free community college a reality nationwide.
    This vision of our future isn't reality yet, but these are 
just a few of the incredible ways that, together, we can raise 
the bar for education when Congress acts to advance these 
educational priorities in President Biden's 2024 budget.
    We have a choice to give our students more, not less with 
this budget. We have a choice to go back to a broken status quo 
or to raise the bar together. If we can work together to do 
what we agree needs to get done, I know we can raise the bar, 
and we will.
    I thank you, and I look forward to answering your 
questions.
    Thank you.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you Mr. Secretary.
    And we will begin our Q&A session at this time for members 
to pose questions. We will stick by the 5-minute rule and as 
close as possible. So keep that in mind as we move forward with 
the questioning.
    As I mentioned in my opening statement, as a father, I am 
very concerned about the proposed Title IX regulations that I 
believe will do grave harm to the safety and success of young 
women athletes and girls across the country. Under these 
proposed rules, a mediocre male athlete can simply identify as 
a female and go on to dominate women's sports.
    Simply put, I would just have to ask you, do you think this 
is fair to biological girls?
    Secretary Cardona. Thank you, Chairman Aderholt.
    Our focus at the Department of Education is to provide 
equal access, free from discrimination, to students. We know 
Title IX has helped over the last 50 years provide 
opportunities for girls, and we are proud of the work that we 
are doing to make sure that, for example, the training 
facilities for girls has the same attention and funding as it 
does for boys.
    So we are proud of the Title IX proposal, and the current 
proposal that you are speaking about is just that. It is a 
proposal, and we have a window open for comments that we are 
going to take very seriously. The last comment period in Title 
IX we received over 240,000 comments, and we want to make sure 
that we are listening to the American people in this process as 
well.
    Mr. Aderholt. I understand that a complaint against the 
University of Pennsylvania regarding discrimination against a 
female athlete has been pending at the Department of 
Education's Office for Civil Rights for over a year now. Can 
you give us any idea of when the Department will respond to the 
civil rights complaint?
    Secretary Cardona. Yes, thank you.
    We take each of the complaints that are submitted to us 
very seriously. The Office for Civil Rights has received--last 
year, I think it was 19,000 complaints compared to about 10,000 
in 2019. They are working really hard, and I am proud of their 
work. However, I can't speak specifically to that one.
    What I can do is ask the Office for Civil Rights to reach 
out to your team to see what information we can provide and 
make sure that whatever we can provide we make it available to 
you.
    Mr. Aderholt. Yes, I think that would be helpful. If you 
could ask them to get back with the subcommittee about their 
timeline on that, I think that would be very helpful.
    And how is your department gathering feedback from all the 
parties that are concerned when there is a rulemaking process?
    Secretary Cardona. We take very seriously that process of 
getting feedback. As I said before, 240,000 comments when we 
first released the Title IX proposed rule. We have open portals 
for information to be shared with us. And as you can tell by 
that number, many people have shared information.
    We welcome different perspectives. I think that is what 
helps us get to where we need to go. And I want to assure you, 
Chairman, that we welcome feedback that differs in opinion. It 
is not just the opinion that we share. We welcome feedback from 
all.
    Mr. Aderholt. Well, I ask that because I understand the 
Department has held roundtables with transgender students who 
make up perhaps only less than 1 percent of the population, and 
I just want to make sure that that is also being done with 
other groups as well.
    Secretary Cardona. Thank you, Chairman Aderholt.
    I will make sure that message is clear. And I know in my 
experience traveling the country, I have had conversations with 
families and parents and students from all different walks who 
shared their perspective. We remain committed to listening to 
different perspectives and engaging folks from whatever 
perspective they have.
    Mr. Aderholt. Also in my opening comments, I mentioned 
about the Department pursuing mass loan cancellation. Your 
proposals all but turn loans into grants by having borrowers 
pay so little.
    In this budget, we also see a massive $120,500,000,000 for 
a free community college proposal. These proposals will do 
nothing but drive up inflation and punish students who have 
made difficult choices, and that may have included not going to 
college or making lifestyle sacrifices to pay off loans 
responsibly.
    What would you say and what do you say when you encounter 
middle class Americans who just ask very straightforwardly how 
is that fair?
    Secretary Cardona. Thank you, Mr. Aderholt.
    And I appreciate your support of Pell, recognizing the 
importance of college affordability and accessibility. And I 
also appreciate, Chairman, your mention of the disparities in 
achievement and the achievement gaps that have widened during 
the pandemic.
    Part of the challenge in this country is that higher 
education is out of reach for too many people. I have spoken to 
hundreds as Secretary, but I think even more jarring to me were 
the conversations that I had when I was a school principal 
talking to fourth graders who said they are not going to 
college because they don't want to put their parents in debt.
    We have a problem in this country, and we are committed to 
fixing it. Part of it is making sure that loan payments don't 
prevent students from considering college or from buying a 
home. What we are proposing is an income-driven repayment plan 
that allows more folks to go to college and not have $600, $700 
college debt bills a month, which prevents them from family 
planning.
    So we want to make sure that while we are looking at fixing 
a broken system like the Public Service Loan Forgiveness 
Program, we are also looking to drive down college costs to 
make sure that there is a good return on investment.
    And with regard to community college, sir, we have an 
opportunity of a lifetime to prepare our students for the 
tsunami of careers that are coming with the Bipartisan 
Infrastructure Plan, with the CHIPS and Science Act, and with 
the climate provisions of the Inflation Reduction Act. There 
are going to be so many jobs that, to me, providing universal 
access to 2-year schools will prepare our workforce, adds to 
the economy, making sure folks get into these jobs, making 
$60,000, $70,000 to start, without $150,000 in college debt.
    I think we can work together to make that a possibility for 
this country. And not only will these students grow, their 
families grow, but our economy and our country will grow.
    Mr. Aderholt. And I understand there is a lot of merit in 
what you say. The problem is we do have a real debt crisis in 
this country, and we can't overlook it.
    But anyway, my time has elapsed, and I will turn to my 
ranking member, Ms. DeLauro.
    Ms. DeLauro. Thank you very much, Mr. Chairman.
    Thank you for your testimony, Mr. Secretary.
    Mr. Secretary, when really confronted with the devastating 
impacts of the proposed cuts, some of my Republican colleagues 
are dismissive. They claim that major cuts would not be 
implemented evenly across the board. As I mentioned and we both 
know, if other programs are exempt from cuts, education 
programs that students and parents rely on will be cut even 
more by the Department's estimate in your letter to me.
    In fact, already in this Congress, nearly 75 percent of my 
Republican colleagues voted to eliminate all K through 12 
education funding by the end of the year. My question--and I 
again want to say thank you to the 60 who voted no.
    If nearly 75 percent of House Republicans had voted for 
Representative Massie's amendment to H.R. 5, if they succeed in 
their goal that authority of the Department of Education, 
Secretary of Education, operator, administrator, any office or 
program related to elementary or secondary education should be 
terminated on or before December 31st of 2023, what impact 
would that have on the students and schools around the country?
    Secretary Cardona. Thank you, Ranking Member DeLauro.
    Let me just share I think we are all in agreement that we 
need to raise the bar in this country academically. The 
percentage of students reading at proficiency in the last 
Nation's Report Card was 33 percent. That is appalling. That is 
unacceptable for the United States. Thirty-three percent of our 
students are reading on grade level.
    We are asking for Title I support. This Massie amendment 
would cut that. When I was a fourth grade teacher, when I was 
school principal, the Title I dollars were used for reading 
teachers to help children who were reading below grade level.
    This would further exacerbate gaps not only within our 
country, but gaps between our country and other countries. You 
know, we are 31st in math compared to other countries, 9th in 
reading. That is unacceptable for this country.
    So, Title I. Another area that it would eliminate--Impact 
Aid, which supports our military-connected students. So, for 
me, these cuts would be devastating for our students and 
families.
    Ms. DeLauro. Thank you. Let me move to another area, Mr. 
Secretary.
    This is a report recently came out about 2U, a for-profit 
online program manager showing again how the company partners 
with colleges to aggressively recruit students into high-cost, 
low-value degree programs that fail to provide promised jobs.
    This is editorializing. This is my belief is that for-
profit OPMs are the new predators in higher education. They 
split Federal student loan revenue with colleges in exchange 
for aggressive recruitment services and outsource educational 
programming. The arrangements are predatory and unlawful under 
the statutory incentive compensation ban, something that I 
voted for in 1992.
    Mr. Secretary, as you evaluate the Department's policy 
dealings with the 2U efforts here, can you assure me and the 
public that you will be prioritizing the concerns of students 
and taxpayers over revenue concerns of schools and the for-
profit companies? And what can we expect to see from the 
Department on for-profit OPM recruiters, and when do we expect 
to see new policy?
    Secretary Cardona. Thank you.
    We are committed to a thoughtful review of these online 
program managers. We know that they have been increasing 
substantially. We do know also that students are demanding 
flexibility and online options. We know that innovation is 
needed for our students to have access.
    But we want to make sure that it is done in a way that 
protects our students, and we are going to work toward rules 
that help colleges create better and--better options for 
students, but also protecting students. It is one of those 
things that we want to make sure that we are getting it right. 
Balancing it, but also protecting students.
    The last thing I want to do is end up where we were when I 
came in as Secretary with tremendous borrower defense claims 
because students were taken advantage of.
    So while I do appreciate the innovation and the need for 
evolution and the demand that is asking for online options, I 
want to make sure we are doing it carefully.
    Ms. DeLauro. And just when can we look forward to new 
policy?
    Secretary Cardona. We are anticipating this year, 2023, by 
the close of 2023.
    Ms. DeLauro. Thank you. And I yield.
    Secretary Cardona. Thank you.
    Ms. DeLauro. Thank you.
    Mr. Aderholt. Mr. Fleischmann.
    Mr. Fleischmann. Thank you, Mr. Chairman.
    Good morning, Mr. Secretary. Good to see you today.
    Secretary Cardona. Good morning. Thank you. Same here.
    Mr. Fleischmann. Mr. Secretary, I have worked with 
colleagues across the aisle to increase STEM education 
opportunities to rural and low-income communities. The most 
recent data shows that 3.5 million STEM-related jobs will need 
to be filled by 2025 in order to maintain a stable workforce. 
It is imperative, in my view, that we continue to support 
public-private partnerships to close the skills gap and to 
cultivate a diverse workforce.
    How can Congress, in your view, help in efforts to increase 
STEM and computer science education in these low-income and 
rural communities? And what is the administration doing to 
promote public-private partnerships in this area?
    Secretary Cardona. Yes. Thank you, Congressman Fleischmann. 
I agree with you 100 percent not only that we have to develop 
our STEM capacity in this country, but we need to make sure we 
are focusing on our rural communities as well.
    In my visits to different--I have been to Nebraska and 
Kentucky, I heard from educators, from parents and students 
that they sometimes felt ignored and that their needs are not 
being prioritized the way they felt they should be. And I agree 
that we need to focus on our rural communities.
    I am proud to say that this budget proposal does increase 
education innovation research in rural communities. There is a 
set-aside, $100,000,000, just for rural communities to make 
sure that we are giving them the opportunities to innovate 
around STEM education.
    And with regard to the public-private partnership, sir, I 
couldn't agree with you more. We are working really hard at the 
Department of Education to really remove silos and make sure 
that we are engaging our private partners as well in this 
education process because it leads to more opportunities for 
our students. It leads to better pathway development in our 
schools.
    And then just one last thing I want to say about rural 
communities, sir. When I was in Hazard, Kentucky, one of the 
goals that we had there was to make sure that we are providing 
those high school students with career pathways where they 
don't have to leave Kentucky. We want to make sure that they 
have job opportunities there in Hazard, Kentucky, to grow that 
economy.
    So I agree with you on that, sir.
    Mr. Fleischmann. Thank you, Mr. Secretary.
    Historically, Mr. Secretary, I have been a big supporter of 
the Federal student aid, particularly the Pell Grant Program. 
Over 11,000 students in my district receive a Pell Grant, the 
single most important tool to enable low-income students to 
access and afford college while preserving student choice.
    Can you explain how the proposed increase in the Pell 
Grant, along with the implementation of FAFSA simplification, 
expands eligibility for low-income students, and how many more 
students will be eligible because of these changes?
    Secretary Cardona. Yes, thank you.
    I agree with you that Pell has opened doors for many 
students who thought college was out of reach. We know over the 
years the Pell increases haven't kept up with the increase in 
college costs. In 1979, Pell covered 80 percent of 4-year 
colleges and 100 percent of community colleges. Today, that 
number is 31 percent of 4-year colleges and 54 percent of 
community colleges. So thank you for the support of Pell.
    And to answer your question, that and an improved, better 
FAFSA will increase the number of students that have access to 
higher education. I don't have the number off the top of my 
head. I know we did calculate it, but I would be happy to share 
it with the entire committee. Because in my opinion, this 
better FAFSA will open more doors to higher education, much 
like Pell did.
    Mr. Fleischmann. Thank you, Mr. Secretary.
    Mr. Chairman, I will yield back.
    Secretary Cardona. Thank you.
    Mr. Aderholt. Mr. Hoyer.
    Mr. Hoyer. Mr. Secretary, thank you very much for agreeing 
to lead to this agency. It can sometimes be very tough.
    The former chairman with whom I served first when I served 
on this committee said as long as you take care of the 
education of your children and the health of your people, we 
will continue to live in the strongest and best nation on 
Earth. I believe that.
    And I believe that the notion that somehow the Federal 
Government doesn't play a key role in both primary and 
secondary and higher education is wrong and will lead to the 
deterioration of our country's competitiveness worldwide if 
that is pursued.
    Did you hear me?
    Secretary Cardona. Yes, yes. I can hear.
    Mr. Hoyer. Let me just turn on my mike. He can't hear me.
    I want to ask you in that context, if we withdrew our 
support for primary and secondary education, what would be the 
impact?
    Secretary Cardona. Thank you, Congressman Hoyer.
    I continue to be thankful to serve in this capacity. It is 
such a blessing to me to be able to serve, as a teacher and a 
father, to be serving as Secretary of Education.
    And I agree with you. There is a tribe in Africa that says 
``And how are the children?'' That is their greeting. Because 
if the children are well, the tribe is well.
    The cuts that were proposed would have significant impact 
on schools across the country, the 50 million students in 
elementary, middle, and high school. I mentioned before Title 
I. For students with disabilities that are protected under the 
Individuals with Disabilities Education Act, it would affect 
and cut 48,000 educators in a profession that is struggling to 
get highly qualified teachers into the classroom for the kids 
that have the greatest need.
    I will tell you, Congressman Hoyer, during the pandemic, I 
heard most from parents of children with disabilities whose 
needs were not being met. So those cuts would affect 7.5 
million students, cutting 48,000 educators in an area where we 
are struggling to get teachers. That is one example.
    The Federal Work Study Program would cut support for 85,000 
students connecting, and Pell recipients, 6.6 million Pell 
recipients would have funding cut by over $1,000. So what would 
it mean, it would worsen public education, and it would limit 
access to higher education at a time where we need to double 
down if we are going to compete with other countries who are 
growing as well.
    Mr. Hoyer. I am a big proponent of full-service schools. In 
fact, there are 69 centers in Maryland named after my wife, the 
Judy Hoyer Early Childhood Education Program. A former 
Republican Governor of our State, Ted Agnew, said that ``The 
cost of failure far exceeds the price of progress.''
    Secretary Cardona. Mm-hmm.
    Mr. Hoyer. By that, he meant, obviously, if you invest in 
your children, if you invest in people's health, mental health, 
and education status, that you will have lesser costs, and they 
will be taxpayers, not tax takers.
    Secretary Cardona. Right.
    Mr. Hoyer. Would you comment on the impact that a--you 
mentioned specific programs, but that a retreat from investing 
in our people----
    Secretary Cardona. Yes.
    Mr. Hoyer [continuing]. Which is what Mr. Natcher was 
referring to, if you invest in your children and the people's 
health, you will live in a strong country. Can you comment on 
that?
    Secretary Cardona. Sure. And let me do it from the 
perspective of a lifelong educator.
    You have all heard the ``pay now or pay later.'' Investing 
in children is an investment in our country and in our 
country's strength, in our country's defense, in our country's 
economic prosperity. And I have seen, as an educator, what 
happens if students don't have the support that they need.
    I once presented to a group of educators in Connecticut, 
and there was a graph that I had that I think it costs roughly 
$13,000, $14,000 on average to educate a child in Connecticut. 
It costs over $50,000 to incarcerate someone for a year.
    Education is an investment in skill development. And I talk 
about the tsunami of jobs because that is where we are right 
now. Let me make that very clear. If we do not invest in the 
skill development and in the career pathways that our students 
need, these millions of jobs--high-skill, high-paying jobs that 
are going to be available very soon--will not be filled.
    My greatest fear is that we are not prepared, as a 
Department of Education, to get our students ready to take 
those jobs, to add to the economy. And it is not only our 
children. We have many underemployed adults that need another 
opportunity to re-skill and get back in there, add to their 
family, but also add to the economy and add to their feeling of 
self-worth.
    I have met so many adults throughout this 2-year period who 
said the pandemic opened my eyes, I am ready to go back to 
school. I need to get skills. I want to do it.
    So it really is an investment, Congressman Hoyer, in not 
only our people, the American people, but in our economy and 
our country's growth.
    Mr. Hoyer. Thank you.
    Thank you, Mr. Chairman.
    Mr. Aderholt. Mr. Harris.
    Mr. Harris. Thank you very much.
    Thank you, Mr. Secretary, for being here.
    First of all, let me just address the issue of the Federal 
Department of Education because I was one of the 161 who voted 
to eliminate it. Because you know it has been in existence for 
42 years, and now 43, and I guess no one will argue that 
education prowess in the United States is better vis-a-vis our 
international competitors now than it was 42 years ago, 43 
years ago.
    I don't know. That kind of defines failure. We established 
the Federal Department of Education. And on a national level, 
we are worse off than we were 42 years ago. So one does have to 
ask do we need it? Or was President Reagan right when in 1982, 
2 years after the establishment, he said this is just plain and 
simple a bad idea. It won't work.
    And Mr. Secretary, by objective standards, it is not 
working. That is all I have to say.
    We can create a strawman and say, well, if you eliminate 
it, you eliminate 48,000 teachers. Baloney. We have a 
$2,000,000,000, $3,000,000,000 surplus in Maryland. The States 
pick up the slack, the local communities. That is where 
education decisions should be made, and there is plenty of 
money rattling around State coffers to pay for it. The question 
is with the Federal Government to do it.
    Let me ask you a question. Were we right to close schools 
during COVID?
    Secretary Cardona. During the pandemic?
    Mr. Harris. Yes, that is right. The COVID pandemic, yes. 
This is a simple question. Do you feel we were right to close 
schools?
    Secretary Cardona. During the pandemic, I was serving as 
Commissioner of Education, and the decision to temporarily 
close schools to protect students and families and educators 
was made at the local level, and it was the right decision in 
those communities.
    Mr. Harris. So you believe it was a good decision to close 
public schools, and there is a good scientific reason to 
believe it was a good decision?
    Secretary Cardona. Absolutely. And I also believe that it 
was important to reopen our schools safely, and when I became 
Secretary of Education, 47 percent of the schools in this 
country were open full time. Within 9 months, I had over 98 
percent open.
    Mr. Harris. Well, I hope so. Because the pandemic was over 
by then. I certainly hope so.
    And again, I disagree with you. I would just say that the 
scientific evidence is pretty clear that children were at very 
low risk or increasingly also still at very low risk, and all 
we did was harm our standing in the international community 
with regards to our performance by students.
    But let me address what the chairman brought up in his 
opening remarks. We spend our time on Title IX new policies 
instead of making sure we have enough people in our workforce 
that perform the duties necessary in the 21st century. Now you 
said you taught fourth graders, and your policy, this new Title 
IX proposed policy--let me ask you first thing. What scientists 
were involved in developing it?
    Secretary Cardona. I would be happy to have my team of----
    Mr. Harris. Please get back to me.
    Secretary Cardona [continuing]. Office for Civil Rights 
reach out to you on which scientists were involved.
    Mr. Harris. Very good. Thank you.
    Because you were actually a fourth grade teacher. You are 
well aware, because the policy says that elementary schools 
have to allow people to participate in teams based on their 
preferred gender. Is that right? My reading of the policy, 
elementary schools?
    Secretary Cardona. The proposed--the proposal that we 
have----
    Mr. Harris. Correct.
    Secretary Cardona. Correct.
    Mr. Harris. Now you are aware that even pre-puberty stark 
contrast exists between the performance of boys and girls, and 
I mean biological--for the purposes of this discussion, I am 
going to talk about biologic boys and girls.
    For instance, a study in Australia, 9-year-olds. Nine-year-
old boys run 16 percent faster miles than 9-year-old girls. 
Six-year-olds, 9.7 percent longer long jump in a boy than a 
girl.
    So under your framework, you are going to take and mix 
biological males and females on the same team, call them all 
girls if you want, and I would propose all you are going to 
do--because there are differences physiologically. I am sorry. 
I can't change chromosomes. You can't change chromosomes. Six 
thousand five hundred different genes between men and women. 
Three thousand different ones that affect skeletal muscle.
    If you have a seven-girl team, six biologic girls and one 
biologic boy, and there is a cut off at six, that seventh 
person, most likely to be a girl because that is the way 
biology works, will be discouraged from doing anything further 
in their athletic career. That is just plain wrong.
    And as a father of a daughter who is a six-time All 
American, she has told me point blank to my face, if those 
rules are enforced, I am not an All American anywhere. I would 
suggest, Mr. Secretary, you didn't base it on science. You 
based it on woke politics, which is rampant through your 
department and the reason why we continue to fail on an 
international scale.
    Yes, I am proud to be one of the 161. We need to completely 
rethink the U.S. Department of Education.
    I yield back.
    Mr. Aderholt. Mr. Pocan.
    Mr. Pocan. Thank you, Mr. Chairman.
    Thank you very much, Mr. Secretary.
    So I really want to ask more concerned about the cuts and 
specifically about a program that I know Mr. Fleischmann 
brought up, the Pell Grant. I have been one of the lead 
advocates for doubling Pell Grants in 5 years, being a Pell 
Grant recipient myself. That allowed me to go to college. I 
didn't get a chance to do spring breaks and a lot of other 
things. I worked all through college, but Pell Grants were 
really extremely important.
    And when I paid tuition and when I talk to students now, 
what they are paying for tuition, it is considerably more. So 
my concern is that as you look at what, hopefully, when we see 
a budget proposed by the Republican majority, from what we have 
heard they are talking about, you could see 22 percent cuts in 
discretionary non-defense spending. And I am concerned what 
that means for financial aid, specifically for Pell Grants.
    In my State of Wisconsin, if you had that kind of a cut, 
1,200 children outright or students outright would lose the 
ability to have Pell Grants. The maximum award would go down 
about $1,000 for the remaining 83,000-plus students who are 
receiving that. Further, nearly half of those Pell Grants are 
going to families who earn less than $20,000 annually. So this 
is very helpful.
    I know there have been some other bills introduced by some 
Republicans, particularly Representative Biggs has a bill that 
would eliminate all Federal funding for student financial 
assistance, including Pell Grants. I am extremely concerned 
about that. But could you just talk a little bit about if you 
were to face something like a 22 percent cut and how that would 
affect Pell in particular and the people who are receiving 
Pell?
    Secretary Cardona. Sure. Thank you, Congressman Pocan.
    And it is good to hear stories of folks who benefitted from 
Pell and seeing you advocate for that now.
    Pell, as I said earlier, opens doors for students who 
wouldn't otherwise have that opportunity. We know college 
graduates on average make $1,000,000 more over the course of 
their lifetime than students who graduated from high school. So 
I always remind folks. That is not only good for the student, 
their families, because it has generational impact, but it is 
good for the community, right? Economic development.
    So, as I said before, there are about 6.6 million Pell 
recipients. All of them would have a decrease of about $1,000. 
So that $1,000 for some might be the difference between 
registering and not registering. We know that.
    A thousand dollars is a lot for someone, as you said, 
working through spring break and trying to make ends meet and 
has very difficult decisions to make in terms of do I pay the 
bill, or do I get food, right? So we know that.
    We also know that for approximately 80,000 recipients, they 
will have their total Pell funding cut. Again, what that 
translates into are more students not going to higher education 
and their talent not being tapped for this country.
    I look at higher education as an investment in our country. 
We have an opportunity here, especially with the legislation--
and I want to thank those of you--in a bipartisan fashion, who 
passed some amazing things in the last couple of years that are 
going to provide opportunities for our students. To me, Pell is 
a necessary component to make sure that we are taking our 
students, giving them the opportunity for higher education, 
whether it is 2-year or 4-year, and getting into those high-
skill, high-paying jobs that add to the economy.
    I have talked to Governors, Republican and Democrat. I have 
talked to State legislators, Republican and Democrat, who are 
excited about the job growth opportunities for their State.
    So, Pell--yes, it gives that child an opportunity to see 
themselves as a college student. But what it does for the local 
community, local economy also cannot be overstated. It is a win 
for all.
    Mr. Pocan. In the minute that is left, I know that the 
administration is trying to double them in 5 years, and we have 
been several years into that effort. Can you just talk a little 
bit more about that effort, the positive side of what you are 
trying to work on?
    Secretary Cardona. Sure, sure. So over $900 in the last 
couple of years is historic. Thank you. And we are asking for 
another $820 this year.
    We recognize, you know, we still have a ways to go to catch 
up to the percentage of what it covered when it was started in 
the 1970s. But we want to be realistic, but we want to be bold, 
too. As you said before, many students count on that to make 
ends meet, and there is so much untapped potential in this 
country that the Pell Grant helps tap. That is a good way to 
put it.
    Mr. Pocan. Thank you very much.
    And just as someone, again, who received Pell and worked 
through school, didn't take the spring break, worked through 
the summer, all of those things, I didn't want to take up the 
ladder from others, right? And I would hope that this is a 
program I think that has bipartisan support. I hope we are 
especially focused as we look at these cuts that this is not 
something that falls too blunt of an object.
    So thank you very much, Mr. Chairman. I yield back.
    Mr. Aderholt. Thank you. Mr. Moolenaar.
    Mr. Moolenaar. Thank you, Mr. Chairman.
    Mr. Secretary, thanks for being with us today.
    Secretary Cardona. Good morning.
    Mr. Moolenaar. Just following up on Mr. Pocan's comments on 
Pell, one of the things I hear in my district is the need to 
adapt to some of the workforce development needs.
    Secretary Cardona. Right.
    Mr. Moolenaar. And even giving greater flexibility in Pell 
for shorter-term programs that may grant some industry-approved 
program that would get someone into a job right away. Are you 
supportive of those efforts?
    Secretary Cardona. Thank you, Congressman Moolenaar.
    I have been telling educators throughout the country, 
evolve. You have to change your programming to meet the demand. 
And I think part of that is us also recognizing the benefits of 
short-term Pell and being open to the benefits of programming 
that gives students the skills that they need in a shorter 
period of time.
    And in the same breath, I want to share with you that if we 
are to consider that, we have to also make sure that we are not 
putting our students in a disadvantage where they are using 
Pell dollars, not having it later and not ensuring high-quality 
or accountability for good programming there. So I am a big 
believer in let us look at different options, but let us also 
make sure that we are increasing accountability and making sure 
that they are quality programs.
    Mr. Moolenaar. Okay. Thank you.
    I am hearing reports of delays in funding or errors in the 
formula share for charter school program funding. Are you 
hearing that, and if so, what measures is your department 
taking to ensure charter schools are receiving access to the 
funding they need and deserve? And especially for new and 
expanding charter schools.
    Secretary Cardona. Sure. Thank you for that question.
    I agree that making sure the funding goes quickly is a 
priority for our charter schools, and making sure that they 
have the money for those programs is critical. I am not aware 
of that, but I will look into that, sir, and I will have my 
team reach back out to you, update you.
    Mr. Moolenaar. Okay. Thank you.
    The Chinese Communist Party is in the news a lot these 
days. Are you aware of efforts to influence U.S. education by 
the Chinese Communist Party?
    Secretary Cardona. No, sir. I don't have any information 
around specific efforts to try to influence----
    Mr. Moolenaar. Okay. Are you familiar with the Confucian 
Institutes, Confucius Institutes?
    Secretary Cardona. I don't have information on the 
Confucius Institute now, but I can--I am sure my team may be 
aware of it and can look into that.
    Mr. Moolenaar. Okay. Thank you.
    And then TikTok, a lot of students on TikTok. What are your 
thoughts on TikTok? Is it a learning tool? Is it something that 
we should ban? What is your sense?
    Secretary Cardona. Well, let me go back to the other topic 
first. It is really important for me that we protect education, 
higher education, and make sure that our school is not 
influenced by others. So that is something that I take very 
seriously.
    And with regard to social media in general, I think we have 
to make sure that our students are aware of digital citizenry 
and making sure that they use social media responsibly and in a 
way that is positive. Because as a father of two teenagers, I 
know that social media can have positive impact, but it could 
also have some negative impact.
    Mr. Moolenaar. Mm-hmm, okay. The Washington, D.C., 
Opportunity Scholarships.
    Secretary Cardona. Mm-hmm.
    Mr. Moolenaar. Are you supportive of that effort?
    Secretary Cardona. I certainly want to make sure we support 
the students that are in the program now, but sir, I don't 
believe Federal dollars should be used for voucher programs.
    Mr. Moolenaar. So you are opposed to that?
    Secretary Cardona. I don't want to--I want to make sure the 
students that are in the program now are supported, but I don't 
believe in using Federal dollars to support voucher programs.
    Mr. Moolenaar. So if the students and the families said 
that they felt supported by using their dollars the way they 
most effectively could, you would say that the Department 
should make the decision as to whether or not those students 
and families are supported, rather than the parents or the 
students?
    Secretary Cardona. Right. I believe what has happened and 
what I am concerned with, sir, is at the expense of quality 
local public education school, what we are seeing is those same 
dollars being considered to go somewhere else, which would 
further negatively impact the education that students are 
getting in their local neighborhood school.
    I am in favor of families having options. I chose a 
technical high school. So--I had choice. But I don't believe 
that it should be done at the expense of the local public 
education schools.
    Mr. Moolenaar. But you realize families with resources 
could make that choice.
    Secretary Cardona. Right.
    Mr. Moolenaar. It is families that don't have resources for 
their children that cannot make that choice under your policy.
    Secretary Cardona. Well, sir, I believe that all the more 
reason because there are children that don't have the resources 
to go to a private school, we have to invest in our local 
neighborhood school. And to me, one of the best options a 
family should have is the school right down their street.
    And when I speak to families in my travels, that is what 
the parents are telling me. I want the school down the street 
to be a great option for my child. And that budget reflects 
that, sir.
    Mr. Moolenaar. Okay. Thank you. And I yield back.
    Secretary Cardona. Thank you.
    Mr. Aderholt. Mr. Harder.
    Mr. Harder. Thank you so much, Chair Aderholt and Ranking 
Member DeLauro, for hosting today's hearing.
    And thank you, Secretary, for being with us.
    I just wanted to start by saying thank you. Thank you for 
the work that you and your team have done working with our 
office and others to expand the Public Service Loan Forgiveness 
Program for physicians to California and Texas, which 
inexplicably were excluded from this program for many years. 
This is something that I have been working on since day one in 
my office because it is so important.
    At the height of COVID, the ICU beds in my district and 
across California's Central Valley were more than 100 percent 
full not because we didn't have the bed space, but because we 
didn't have the nurses and doctors to really take care of 
people. And that has been a persistent issue. It doesn't help 
to have a health insurance card if you can't actually get an 
appointment. And all too often across our area, that is the 
case.
    And we have some successful residency programs. We don't 
have a single medical school for 6 million people, but that is 
another issue. But even our residency programs, once those 
physicians graduate, all too often, they move to other States 
or other areas where they can make an income, and this Public 
Service Loan Forgiveness Program is going to help address that, 
keep our doctors where they need to be.
    This is really important. A local TV station in my area, 
Fox 40, just reported that on a report that said 1 in 5 
hospitals in California are at risk of closure due to a dire 
shortage of healthcare workers, physicians chief among them. So 
many folks are already driving hours to get an appointment. 
This is a health equity issue, and it is really imperative to 
make sure that we get this executed.
    The Department of Education has stated that California and 
Texas doctors can begin applying for the Public Service Loan 
Forgiveness Program for the first time ever on July 1st of this 
year. Is that timeline still accurate, to the best of your 
knowledge?
    Secretary Cardona. To the best of my knowledge, it is. And 
Congressman Harder, if I can--I appreciate your advocacy there 
on behalf of folks in California, and obviously, Texas as well 
is benefitting from that. But just to put it in perspective, 
the investment in our FSA and our higher education programming 
has led to major improvements that has helped our public 
servants.
    You are talking about shortages in healthcare. There are 
tremendous shortages in education. So we set out to fix the 
Public Service Loan Forgiveness Program. From 2017 to 2021, 
this bipartisan effort--PSLF was passed in 2007, bipartisan 
support--provided only 7,000 participants with support, 7,000 
in those years.
    From 2021 until today, there have been over 450,000 public 
servants who have received loan forgiveness. And every once in 
a while, I will get a letter, I will get an email from someone, 
an educator--all those people that we called essential 3 years 
ago--saying thank you. Now I can buy a home. Now I can help my 
children go to college.
    So I am glad to see it is working. Yes, the July 1st 
deadline, I will have my staff follow up with you on that if 
there is any changes. But that is an example of what we are 
trying to do to fix a broken system to get our public servants 
the support that they need so they could get into those jobs, 
or else we are going to have a problem if we don't have 
doctors, nurses, or teachers.
    Mr. Harder. That is great. Well, thank you so much for your 
efforts on that.
    And I know this is a program that has gone through a lot of 
iterations, and I appreciate you simplifying it and making sure 
that folks actually receive the support when they need it.
    Given all the talk about budget cuts, what are the risks to 
the PSLF program? Specifically, given the physician shortage, 
do you think that this extension of the PSLF program to 
California and Texas doctors is at risk of being cut, given the 
conversations going on in Washington?
    Secretary Cardona. I am concerned in general about Federal 
student aid funding. If we don't have significant funding, not 
only will PSLF, but borrower defense, the loan repayment 
process, FAFSA, all that would have an impact. We are really--
and I want to commend James Kvaal, Richard Cordray, the entire 
team, who are really working really hard to try to fix a broken 
system and provide opportunities. So, to answer your question, 
yes. There will be impact for Public Service Loan Forgiveness.
    So the public servants that we promised debt relief, loan 
forgiveness after 10 years of public service, that would be 
impacted. Returning to repayment, we will have challenges 
there. We will have challenges following up on some of those 
borrower defense claims.
    Look, I want to stress the importance of the funding in 
particular to FSA and the millions of Americans who are waiting 
for support and service that whose services will be impacted if 
we don't--if we cut funding there.
    Mr. Harder. Thank you. I appreciate that.
    This will extend this program to 10,000 doctors in 
California, and I am so overjoyed that it is going to be online 
on July 1st. Thank you for your efforts.
    And with that, I yield back.
    Mr. Aderholt. Ms. Letlow.
    Ms. Letlow. Thank you, Mr. Chairman.
    And thank you, Secretary, for being here with us today. I 
share your passion for education. As a former educator myself, 
I believe if you educate a child, you give them a future. So I 
was encouraged to hear you say that.
    I was also honored to bring forth H.R. 5, the parents bill 
of rights, last month. I think this legislation received a 
false narrative that we were going to be dictating curriculum 
or telling librarians what they could and could not have in 
their libraries, and I want to debunk that because it was 
really just about creating transparency for parents and that we 
should have a true partnership between our schools and our 
parents.
    And I believe it is important to empower families with 
accurate and understandable, usable data about their students 
and their schools. And that transparency provided by effective 
data systems can help families make good educational decisions 
for their children.
    So I am wondering how could expanding investments in data 
systems through the statewide longitudinal data systems and 
other grant programs support and encourage family engagement?
    Secretary Cardona. Thank you, Congresswoman, for your 
advocacy and for your years of service as an educator.
    Look, I think it is really critical that when we talk about 
reimagining education, we reimagine how we engage with 
families, and we really improve giving them access to student 
performance data. I recently read something that in some 
communities, an A doesn't really mean an A if you look at it 
compared to the standardized standards that they have for 
learning.
    So, to me, using data systems that are strong gives parents 
an opportunity to understand how their children are performing 
and their level of success compared to standards that the State 
should have. We take that very seriously. I want to make sure 
that families have the information.
    I am really proud of some of the stuff that we are doing 
around full-service community schools because it engages 
families in a way that gives them not only the data systems, 
but the partnership to understand what those data mean and how 
they can engage in learning and support learning and drive some 
of the learning that is happening in the schools.
    Ms. Letlow. Yes, I was encouraged to see that this data 
will show whether students are ready for kindergarten. I am 
very concerned after COVID and the pandemic. In Louisiana, 4 in 
10 Louisiana third graders can't read at grade level.
    And so I am just hopeful that you are hopeful yourself that 
this data is going to help us notify parents and share that 
information with them. Because we know if they get to the third 
grade level and they can't read, then it is going to set them 
up for failure later on in life. And there is data out there 
that shows that they will never catch up.
    Secretary Cardona. Right.
    Ms. Letlow. So I am gravely concerned about our kids.
    Secretary Cardona. I share the emphasis that you are 
placing on early childhood education. We know early on, using 
different screeners or different data points, which students 
need support early, right?
    Ms. Letlow. Right.
    Secretary Cardona. And we can intervene early to prevent 
gaps from widening. By third grade, if a child is not reading, 
we see negative impacts not only on academics, but on their 
self, feeling of self-worth or their connectedness with school.
    So I agree with you. Early childhood education is something 
that the data, we should be looking at data to drive what we 
are doing, but also investing in making sure that we have 
robust early childhood education programs that follow the 
research on how we know children learn best at those levels. So 
I agree with you on that.
    Ms. Letlow. I agree with you.
    Secretary Cardona. Thank you.
    Ms. Letlow. I am switching gears here. Mr. Secretary, do 
you believe it is important for Government agencies to have a 
contingency plan on the different outcomes that might come from 
any pending litigation?
    Secretary Cardona. It is important that our team carefully 
weighs the risks of any litigation and potential implications 
of them.
    Ms. Letlow. Okay. That is good to hear. So is the 
Department's Office of Federal Student Aid being proactive in 
contingency planning and working on clear guidance for student 
loan servicers and students, should loan repayment be required 
to begin?
    Secretary Cardona. Yes, we are working diligently to make 
sure that we are improving our systems to be more clear, to 
have what we call a long on-ramp so that borrowers know what is 
needed from them and when it is needed from them.
    Ms. Letlow. Because the COVID-19 public health emergency 
officially ends on May 11th, and student loan payments have 
been on pause long enough, the Department should not continue 
to drag out this repayment pause for many more additional 
months when they could be using this time to prepare 
regulations and expectations for servicing companies and 
students.
    Secretary Cardona. Thank you, Congresswoman. Yes, we agree.
    Ms. Letlow. Okay. I yield back.
    Mr. Aderholt. Ms. Frankel.
    Ms. Frankel. Thank you.
    And thank you for being here.
    Secretary Cardona. Thank you.
    Ms. Frankel. So, like many of my colleagues, Democratic 
colleagues, I am extremely concerned about what looks like 
might be a 25 percent budget cut in the education issues. I am 
especially concerned about what is going to happen to the 
teachers. Because we have a tremendous teacher shortage in 
Florida and also around the country, and I don't know what that 
means. Maybe the Republicans think we are going to replace 
humans with robots. Watch out, folks. The robots are coming.
    All right. That was serious. That is not even a joke.
    In my county, I live in Palm Beach County--famous for other 
things--we have one of the largest school districts in the 
country. We have about 400 teacher vacancies now. There is 
5,000 teacher vacancies in Florida, and I understand hundreds 
of thousands nationwide. So I am very concerned if we cut your 
budget, the education budget, what is that going to mean for 
teacher vacancies, especially in our poorer schools that we 
fund with Title I? So I am going to start with that question 
for you.
    Secretary Cardona. Congresswoman Frankel, we don't have a 
teacher shortage issue, we have a teacher respect issue. And it 
is resulting in less people wanting to go into the profession 
and less people staying in the profession. All the research 
shows the most influential factor in a child's success is the 
teacher in front of the classroom.
    And we have done a disservice to the teaching profession, 
which is why we are working on public service loan forgiveness, 
which is why in our budget there is a total of $3,000,000,000 
to support high-quality teaching. We have a $342,000,000 
increase requested for Teacher Preparation, Development, and 
Leadership. It is not enough to hire teachers. We have to make 
sure we are providing professional development.
    Our children are coming in with what the Surgeon General 
called a youth mental health crisis. So if we are not investing 
in the professional development of our educators to meet our 
students where they are, we are going to have educators that 
are doing their best, but without the skills.
    So we, in our budget, are putting dollars to that. We, for 
the first time ever, are putting dollars toward the Hawkins 
grant, Augustus Hawkins grant, that creates pipeline programs 
to tap high school students on the shoulder and say, hey, I 
think you would make a great teacher. Here is a program that 
connects to a 4-year school, and you will have an option to go 
back to that district that you love to teach.
    We are trying to create programs. I am asking Governors, 
State chiefs to create programs to make sure our high schools 
students are tapped on the shoulder to become teachers.
    So we have an investment there, but I think it goes beyond 
the dollars. We need to respect our educators. We need to look 
at them as partners. Second to parents, our educators are the 
most influential folks to get our students to where they need 
to be.
    Ms. Frankel. Well, I do respect and appreciate your 
enthusiasm for our teachers. I agree with you on that. My 
concern is the proposed budget cuts and what that would mean to 
us having these teachers that we need in the classroom.
    Secretary Cardona. So I remember getting a letter when I 
was Commissioner in Connecticut from a parent in New York, once 
my name was mentioned as potential Secretary of Education. It 
was a letter from a parent in New York who talked to me about--
she wrote about how her child who has autism was not allowed to 
go back to school because of the risks in the community and the 
negative impact that had on her family and the sibling of the 
child.
    So she was so excited about schools reopening. She saw that 
we were pushing to reopen schools in Connecticut and was 
hopeful that by me being Secretary that will happen throughout 
the country.
    So that student with autism who had tremendous need during 
the pandemic is now going back to a school. Budget cuts, like 
what is being proposed, would make it more likely that that 
student who had greater need during the pandemic is now going 
to a school without a certified classroom teacher, without a 
certified special education teacher, and the services that the 
student needs more of would be decreased even further.
    It would be catastrophic for all children, but in 
particular for children with disabilities and children who are 
not reading at grade level.
    Ms. Frankel. I would say for all children, if you don't 
have a teacher, it is going to be very hard to learn.
    And with that, I yield back.
    Secretary Cardona. Thank you.
    Mr. Aderholt. Mr. Ciscomani.
    Mr. Ciscomani. Thank you, Mr. Chairman.
    And thank you, Secretary Cardona, for coming before us 
today to discuss the Department of Education's fiscal year.
    Now, my background real quick. I am a first-generation 
American. I was born in Mexico. So I immigrated with my family 
when I was a young kid, first in my family to attend college. I 
am proud of that background.
    I am also a product of the community college world. I 
received Pell Grants as well. So I definitely have benefitted 
from a lot of what is being discussed here today, and I want 
others to have an equal shot at the same American dream that I 
have had as well.
    So when I went to college, and I started out at Pima 
Community College before going to the University of Arizona, 
where I eventually earned my bachelor's degree. And like many 
other students, I worked my way through school. And in your 
testimony, you spoke about the administration's Federal free 
community college plan, and I think it is important for us to 
acknowledge that community college is already an affordable 
option for a lot of students.
    And according to the College Board, the average in-State 
tuition at a public 2-year college for the '22-'23 school year, 
it is about $3,860. The average Federal Pell Grant is $4,512. 
And that is the average. Depending on the cost of their 
education and other factors, students could qualify for a 
maximum Pell Grant of $6,895 this year.
    This means the Pell Grant can make community college 
tuition free or very close to it. So we need to be careful and 
not think that the massive new spending is the answer. We have 
seen the inflationary effects in the economy from too much 
spending over the past few years. That is why I am concerned by 
this budget proposal and the Department's other policies like 
mass student loan forgiveness. It will not help inflation, and 
quite frankly, it is wildly unfair in a lot of ways.
    So, Mr. Secretary, looking specifically at the 
administration's blanket loan forgiveness, can you explain to 
me and the millions of others who have maybe never went to 
college or to the graduates who live modestly so they could pay 
off their loans or even during their college years to be able 
to live within the Pell Grant--what the Pell Grant allowed, how 
is this option fair to them, and what can responsible borrowers 
learn from this?
    Secretary Cardona. Thank you for the question, and thank 
you for sharing your story and the benefits of community 
college.
    I agree with you. In some cases, Pell can cover the costs. 
In other cases, it cannot. The Pell increases have not kept up 
with the increase in college costs, and I think the number that 
I said earlier was about 80 percent of the cost of 4-year 
colleges were covered in 1979, 100 percent of community 
college. And today, it is 54 percent on average across the 
country, 54 percent of community college costs are covered by 
Pell. So I do support continued focus on Pell to give more 
students an opportunity.
    With regard to the targeted debt relief, 90 percent of the 
dollars for the 43 million Americans that are currently paused 
and will begin loan repayment for many of them, 90 percent of 
the dollars in the targeted debt relief plan go to people 
making under $75,000. So this is really targeted toward middle 
class Americans who need a little bit of support getting back 
on their feet after the pandemic.
    And the work that we have done from day one until now is 
really targeted to those who were either taken advantage of, 
for example, borrower defense. There were a million borrowers 
that received loan discharges, and this borrower defense means 
that in many cases, they were taken advantage of.
    They were told you are going to get a degree, and you are 
going to get a job making this much money when they were sold a 
bill of goods that were never delivered. And sadly, in many 
cases, a lot of these were veterans coming out and looking for 
another opportunity. So we stood up for those borrowers.
    Total and permanent disability. There were 470,000 
borrowers who had--were classified as totally and permanently 
disabled who were still required to make payments, and these 
folks needed help. So we jumped in and helped with that.
    Mr. Ciscomani. Mr. Secretary, let me jump in here because I 
am running out of time. And when you are listing the people 
that you have helped and the process of how people get into 
loans, in spite of my personal journey here of being able to 
cover with the Pell Grants, due to advice or misadvice, you do 
get into loans like I did as well, and that is exactly the 
narrative. ``You are going to be able to make so much money, 
you will pay these off immediately.''
    So I actually jumped in and did the same thing individually 
and probably didn't need to borrow as much as we did. And you 
know what I had to do? I had to pay it back. I had to pay it 
back.
    And my first years of raising a family--I now have six 
kids, three boys and three girls--we had to tighten the belt, 
and we had to do what we had to do to be able to pay these 
loans back. And I just want to make sure that we are not 
creating an environment where this is seen as an additional 
Pell Grant for people that have actually borrowed loans because 
the Pell Grant is already in place, and the loan should be 
that, a loan that needs to be paid back.
    Because if people like me as the first generation that 
didn't know much more, my parents couldn't guide me into how to 
borrow or what not to borrow or anything else. I didn't have 
any guidance, and I went and made those mistakes. And I ended 
up having to pay them back.
    So I think that that--and that created an additional grid 
and everything else that actually has helped us be where we 
are. So I just want to add that perspective. I am from that 
group that you are trying to help, and I get that. But I think 
there is a better way.
    I yield back.
    Mr. Aderholt. Mrs. Watson Coleman.
    Mrs. Watson Coleman. Thank you, Chairman and Ranking 
Member.
    Good morning to you, sir. It is good to see you here.
    Back in 2019 before the pandemic, I headed an emergency 
task force on mental health and suicide particularly among 
black youth, and I see in your proposal that you are including 
an additional $420,000,000 to fund schools with mental health 
services and with professionals. I am concerned, number one, is 
that I have no idea what percentage of need that represents, 
but I am wondering what your proposal would look like if you 
had to operate under a 2022 funding cut to present these 
services to students who really suffered before the pandemic, 
during the pandemic, after the pandemic, and particularly, 
BIPOC students.
    Minority students sometimes have no exposure to health--
mental healthcare, and oftentimes, their behaviors in schools 
are misinterpreted as they are being uncooperative and bad 
children. And they are classified and qualified and isolated. 
And we all know that we have not addressed the kind of traumas 
that some of them experience in just getting to school.
    So I would like to know what your proposal would have 
looked like if you can get the 2024 proposed spending that you 
are asking for, and what happens if your funding is cut to the 
2022 level that some of our colleagues are proposing on the 
other side of the aisle?
    Secretary Cardona. Thank you, Congresswoman Watson Coleman.
    Let me start off by saying we are at a point in our 
country's history that I have been in education about 25 years. 
I don't ever recall the level of need, mental health need--and 
I appreciate you bringing up the fact that symptoms of trauma 
are often addressed with disciplinary measures, if not 
understood and if we don't invest not only in providing our 
students with mental health supports, but investing in 
professional learning opportunities for educators in our 
schools.
    So what we have in our budget for mental health support is 
grounded in what we know from the CDC report that said that 1 
in 3 high school girls over the last 3 years has considered 
suicide. The CDC report told us that 1 in 5 LGBTQ youth in the 
last 3 years has--1 in 5 has attempted suicide. This is 
unprecedented for our schools and for our educators.
    We are proposing a total of $578,000,000 for school-based 
counselors, psychologists, social workers, and other mental 
health professionals. We are also including support for higher 
education. I have spoken to countless college age students who 
told me to focus on mental health supports, changing how 
colleges are set up to make sure that they provide more.
    Now with regard to the cuts, a $50,000,000 cut to mental 
health supports would cut funding for 40 new grants and the 
support, it would cut the support for 300 existing programs, 
which would mean less support at a time when the CDC's report 
came out and when our U.S. Surgeon General is saying we have a 
youth mental health crisis. It is the wrong way to go. Students 
will suffer. Families will suffer.
    Mrs. Watson Coleman. Thank you.
    And I am also concerned that at a time when we are dealing 
with the impacts of gun shootings, mass shootings at schools--
sorry. I am very concerned about as we experience the gun 
shootings, the uncontrolled access to illegal weapons, I do--I 
am very concerned that our children are even more traumatized 
than ever before and that this impacts their forward movement, 
their forward contribution to their communities.
    And so I wholeheartedly support anything that you can do to 
ensure that our schools have greater access. And I am 
particularly concerned what happens with minority students 
because disciplinary actions are very much discretionary, and 
the statistics show that minority students, particularly black 
students, boys and girls, who both experience the devastation 
of the lack of mental health services are often those who are 
also disciplined, which adds to that pipeline that we want to 
cancel out.
    And I am also concerned about HBCUs and what we plan to do. 
What you all are proposing is an increase in some areas, still 
not enough. Very concerned about the impact for capacity and 
infrastructure should the 2022 funding cuts be realized and be 
nothing more than the bad rumor that they are.
    Thank you, Mr. Chairman. I yield back.
    Mr. Aderholt. Thank you. Mr. Simpson.
    Mr. Simpson. Thank you, Mr. Chairman.
    First, let me say I understand every committee I have been 
on we have heard about the death and destruction that is going 
to happen if all of these cuts go into effect and everything. 
The reality is nobody knows yet. We don't know yet what this is 
going to be. And even in this bill, if there was a 20 percent 
cut, doesn't mean it is going to be in education, could be in 
other areas.
    So all of these stories and fear tactics about what is 
going to happen are just that, speculation. Because nobody 
really knows yet. Now I hope we get to it sooner rather than 
later and what we are going to do.
    Secondly, let me mention when you talk about free college 
tuition or paying off student loans, that type of stuff, there 
is another aspect of it that you briefly mentioned in passing. 
And that is if the individual getting the benefit of 
something--and you mentioned the 4-year college graduate is 
going to make $1,000,000 more--they are going to get the 
benefit of this.
    The people providing that benefit, the colleges, have no 
incentive to keep costs down if the person receiving that 
benefit doesn't look at it and say, well, I am going to go to 
this school because it is cheaper, and I think I can get just 
as good education. There is no competition anymore between the 
schools.
    You mentioned that one of your goals is to keep the cost of 
college down. What are you doing to do that?
    Secretary Cardona. Thank you for that, Congressman.
    And look, I do believe if we have pathways from our high 
schools to the 2-year colleges to the workforce, I do believe 
that is going to make sure that our 4-year schools will say I 
need to stay competitive and I need to stay active. But I 
appreciate that question because while we spend a lot of time 
talking about targeted debt relief and discharging of loans, I 
am just as proud of the work that we are doing to hold higher 
education institutions accountable for a good return on 
investment.
    The cost of college has gone up, and the President told me 
to focus on making sure that not only the targeted debt relief 
we are focusing on that, but also making sure we are not in 
this quagmire again in 5 years. So we have done several things. 
We are improving gainful employment rules. We are tightening 
that up to make sure that if you are telling students this is 
what the program costs, and this is about how much you are 
going to make, we are holding them accountable to that.
    We are putting out a watch list of poor programs, both for-
profit and not-for-profit, schools. If you are charging 
$150,000 for a degree where you could get it down the street at 
half the price, we are going to put your name out there. And 
that is going to mean some institutions that are very well 
known being on that list.
    We have increased oversight, and we increased transparency 
with college outsourcing, too, to make sure that we are still 
keeping our students at the center of the conversation and that 
they are not being taken advantage of.
    Borrower defense is now going to seek restitution from 
school CEOs. So if you are engaging in bad practices and taking 
advantage of students, we are going to hold you personally 
accountable to that.
    And then we reinstated our enforcement team that is going 
after those bad actors who are looking at students as profits 
and not providing a good education.
    So I agree with you. We have to make sure that if we are 
providing targeted debt relief, we have the responsibility to 
have equal amounts of accountability to make sure that these 
costs don't go out of control. We should never be in the 
position that we are today that we have to provide targeted 
debt relief because it has gotten out of control.
    Mr. Simpson. Thank you for that.
    Secretary Cardona. Thank you.
    Mr. Simpson. One other question. I serve as the co-chair of 
the Congressional TRIO Caucus and have for a number of years. I 
want to talk to you for just a minute about the TRIO McNair 
program, which, as you know, provides individualized mentoring 
research opportunities and other support to enable first-
generation, low-income, and underrepresented students to 
prepare for and enter graduate school in a variety of 
disciplines.
    In 2022, the grant competition, the Department of Education 
awarded three additional competitive preference priority points 
to institutions applying for a McNair grant if they identified 
as a minority-serving institution. The additional CPP points 
meant that multiple institutions with a history of operating 
successful McNair programs lost funding as they did not qualify 
as a minority-serving institution and were unable to obtain 
these additional points, even though they had successful 
programs.
    It is my understanding that these grants are to be awarded 
to applicants that demonstrate a need for and the ability to 
provide high-quality services to students to enable them to 
pursue postgraduate study. Low-income, first-generation 
students come from a range of backgrounds and ethnicities and 
also attend a wide variety of institutions and still need 
support.
    I want to ensure that all institutions in my district and 
across the country with track records of success can continue 
to serve their McNair scholars. What is the Department doing to 
ensure these grants are awarded based on merit and not just on 
the status of the institution?
    Secretary Cardona. Thank you for that, Congressman.
    I agree with you. TRIO programs are critical for first-gen 
students. My wife is a TRIO grad, first-generation college 
student. And I have seen firsthand in my community how many 
students were given the opportunity.
    And I recognize what you are sharing with me. What I would 
like to do is ask for my team to follow up with you and your 
team directly to see the impact it had and to communicate how 
the changes are and what--hear from you and your folks the 
impact that it has. Because I agree that we need to expand TRIO 
and provide more opportunities, and I want to make sure all 
students have access to programs like this.
    Mr. Simpson. I appreciate that. And it is--again, it is the 
individual we are trying to help.
    Secretary Cardona. Right.
    Mr. Simpson. Not necessarily the institution.
    Secretary Cardona. Right.
    Mr. Simpson. Regardless of the institution they go to, we 
can help the McNair scholars. That is what we are trying to do.
    Secretary Cardona. Thank you.
    Mr. Simpson. So I appreciate that, and I will follow up 
with you.
    Secretary Cardona. Please. Thank you.
    Mr. Aderholt. Mr. LaTurner.
    Mr. LaTurner. Thank you, Mr. Chairman. I appreciate it.
    Mr. Secretary, President Biden has repeatedly talked about 
the fact that increasing funding for the Pell Grant is a top 
priority for this administration. While I understand that your 
budget proposal includes increases to this program, the support 
that has actually been given to Pell pales in comparison to the 
amount lavished on college graduates in the form of debt 
cancellation, the student debt pause, and your proposed IDR 
program.
    CBO estimates that these student loan policies will cost 
nearly $1,000,000,000,000, which is not just triple what we 
will spend on Pell this decade, but more than the Federal 
Government has spent on postsecondary education over its entire 
pre-pandemic history.
    Let me repeat that. The nearly $1,000,000,000,000 is not 
just triple what we will spend on Pell this decade, but more 
than the Federal Government has spent on postsecondary 
education over its entire pre-pandemic history. Given that some 
projections have shown that the student loan portfolio will 
balloon back into the trillions in just over 5 years, what we 
need now is real accountability and reform to ensure that 
institutions of higher education are invested in the success of 
their graduates rather than simply pumping more money into a 
model that has failed to protect the neediest students, 
increase options for families, or provide competencies valued 
by employers.
    If you are someone sitting in Cherokee County, Kansas, 
without a college degree, what is the rational justification 
for spending this money to cancel debt for college graduates?
    Secretary Cardona. Thank you----
    Mr. LaTurner. Why should your tax dollars go to this?
    Secretary Cardona. Thank you very much for your passion 
around the importance of Pell and access to higher education. I 
can tell you that the targeted debt relief, as a result of the 
pandemic, was intended to help middle class Americans making 
less than $75,000 get back on their feet. That was the 
intention of that.
    With regard to the cost, the economic strategy over the 
last 2 years has resulted in a $1,700,000,000,000 deficit 
reduction, and the 2024 budget would reduce the deficit by 
$3,000,000,000,000 over the next 10 years. So it pays for all 
the investments.
    With regard to opportunities, our budget reflects that 
those folks in Kansas, we want to give them opportunities to 
access higher education at an affordable rate. And if you look 
at the budget, part of it is making sure that we have clear 
pathways that connect to the workforce. We are doing a lot of 
work around pathways not only for our 17- and 18-year-olds that 
graduate high school, but also for the underemployed adults 
that need another opportunity to get back into the workforce, 
to take advantage of some of these careers that are going to be 
made available, thanks to the bipartisan support of some of 
these bills that were just passed recently.
    Mr. LaTurner. I don't think you answered my question. The 
man or woman sitting out there in Cherokee County, Kansas, 
without a college education. Explain how it is fair to them.
    Secretary Cardona. The targeted debt relief plan was based 
off the pandemic, and it was aimed at making sure folks are not 
worse off after the pandemic than they were before. Similar to 
the small business loan forgiveness, we are helping regular, 
everyday Americans get back on their feet.
    If it weren't for the pandemic, the targeted debt relief 
plan would not have happened. But we are doing it to help folks 
recover from the pandemic like we did in other things.
    So I think another thing that I would say is when borrowers 
default, it hurts the entire community. So it is worse for the 
local economy when you have folks who are defaulting on their 
loans and not being to get back on their feet. So it's targeted 
debt relief. It is aimed at those who are negatively impacted 
by the pandemic. It is a one-time thing, and it is part of our 
overall process to hold colleges accountable and make sure we 
are fixing a broken system.
    I would welcome your input and thoughts on how we could do 
it better, and I would hope our teams could come together to 
hear your perspective on how we can make sure we communicate it 
better, but also help those who you represent.
    Mr. LaTurner. Mr. Secretary, respectfully, the reason you 
are struggling to answer my question is because it isn't fair. 
That is the real answer. That is the truthful answer.
    Mr. Chairman, I yield back.
    Mr. Simpson [presiding]. Rosa.
    Ms. DeLauro. Thank you very much, Mr. Chair, sitting in for 
Mr. Chair.
    Mr. Simpson. Temporary chair.
    Ms. DeLauro. Thank you.
    Mr. Secretary, I would like to follow up on my colleague--
my colleague Mrs. Watson Coleman on the issue of school-based 
mental health professionals. I have had countless conversations 
with Connecticut parents, educators, district leaders. With 
that in mind, I created the School-Based Mental Health Services 
Grant Program in 2020 on the Labor-HHS bill to help school 
districts really increase the number of qualified, well-trained 
mental health professionals who are working in our schools.
    I was also pleased that in the Bipartisan Safer Communities 
Act, we provided an additional $500,000,000 to this program on 
top of the resources in the Labor-H bill. So the grants expand 
the program's reach. They help us move closer to the goal of 
ensuring that every child goes to a school that has a qualified 
mental health professional on staff.
    Let me just run this series of questions down, Mr. 
Secretary. Should every child in America go to a school that 
has a qualified mental health professional? A yes or no 
question.
    Secretary Cardona. Yes.
    Ms. DeLauro. Does every child currently go to a school that 
has a qualified mental health professional?
    Secretary Cardona. No.
    Ms. DeLauro. What would it take for every child in this 
country to go to a school with a qualified mental health 
professional on staff? What is it that we need to do to address 
this problem?
    Secretary Cardona. Well, Ranking Member, I think we can 
talk about the $578,000,000 that we are asking for to double 
the number, but I think what we need to do prior to that is 
really understand the importance of having mental health 
supports available to students as a foundational prerequisite 
for schooling. It shouldn't be thought of as an afterthought. 
It shouldn't be when children have an outburst or a traumatic 
experience. We should be thinking about Tier 1 interventions.
    I visited schools, Ranking Member, where they had a very 
well-developed program in partnership with local social work 
providers. We know the community health center, for example, in 
Connecticut, where we have our social worker in our school, but 
we also have access to a local provider that is connected with 
our schools.
    I have seen programs go from hospitals connecting with K-12 
districts, but that takes a mentality and an understanding that 
if our students are not well, then they are not going to 
achieve as well. And I think, yes, our budget reflects the 
importance of it, but I think the mindset that we have to have 
should include the importance of mental health and well-being.
    Ms. DeLauro. So with the grants, you have added to the 
capacity of schools to deal with mental health?
    Secretary Cardona. Absolutely.
    Ms. DeLauro. Okay. Over the last 2 years. And now you have 
requested, what, over $300,000,000 to increase, to expand that 
impact?
    Secretary Cardona. Correct.
    Ms. DeLauro. Okay. Thank you. Let me just ask one more 
question here.
    This is about what I view as a predatory, for-profit 
university, and that is the University of Phoenix. They are 
desperate for a buyer, and the school is looking to strike a 
deal with the public University of Arkansas, that system.
    The University of Phoenix has a documented history of 
receiving sanctions, reaching settlements for unscrupulous 
behavior, including False Claims Act violation findings by DOJ, 
unlawful recruitment on military bases found by DOD, deceptive 
advertising findings by the FTC. So, and I am concerned that 
the university's shareholders are looking to offload their 
troubled asset onto our public higher education system.
    What measures, Mr. Secretary, will the Department take to 
protect students and taxpayers from waste and abuse through a 
transition like this? Can the Department ensure that any 
outstanding liabilities against the school could still be met 
after the transaction?
    Secretary Cardona. Thank you, Ranking Member.
    There is no current transaction in front of us at the 
Department of Education. So I can't really comment on the 
specifics about that school.
    But what I will tell you is our regulations from last year 
laid out what we do when looking at transitions like this or 
transactions. We make sure that the owners are financially 
sound. We ensure that there are no inappropriate relationships 
with prior owners, and we put in place protections that we deem 
necessary to make sure that the students are well served.
    We are aware of in some cases where decisions are made, and 
it negatively impacts students. So we are paying to that, and 
if that comes up in front of us, we are going to be very 
attentive to that.
    Ms. DeLauro. Thank you, Mr. Secretary.
    Just to go back for a second on the mental health issue, I 
know there is this view that we are just, if you will, making 
up the fact that there is the going back to the 2022 numbers 
for the 2024 budget. In fact, I just would repeat that the 
Speaker of the House yesterday on Wall Street indicated that 
that was something that was part of the plan to move forward 
with regard to Government funding.
    So if he doesn't believe that that is the case, he 
certainly said it on a nationwide stage, which would mean--and 
I am just going to conclude with this. Which means that the 
mental health efforts that you have been making to deal with 
the aftermath, the before the pandemic, the after the pandemic, 
and moving forward with mental health would be severely 
curtailed if we make a move to go back to the 2022 figures. Is 
that accurate?
    Secretary Cardona. Absolutely.
    Ms. DeLauro. Thank you. Yield back.
    Mr. Simpson. Mr. Clyde?
    Mr. Clyde. Thank you. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary.
    Following the civil rights movement of the 1960s, lawmakers 
established Title IX rules to prohibit discrimination on the 
basis of sex in federally funded education programs, making a 
historic impact on girls' and women's sports. For example, 
before Title IX, female athletes only received 2 percent of 
college athletic budgets, and athletic scholarships for women 
were quite rare. Title IX unquestionably transformed women's 
sports, ensuring female athletes enjoy the same opportunities 
as their male counterparts.
    Earlier this month, on April 13th, your department filed a 
proposed rule amending Title IX regulations to unilaterally 
force schools to allow biological males to participate in 
women's athletics. This proposed rule would withhold Federal 
assistance from schools across the Nation seeking to maintain 
the integrity and safety of women's sports. Since Title IX 
prohibits discrimination between male and female to ensure that 
each gets appropriate funding, I think it is important that the 
country sees that HHS understands the difference.
    So can you please tell me or can you please define for me 
what is a woman?
    Secretary Cardona. Our focus at the Department is to 
provide equal access to students, including students who are 
LGBTQ, access free from discrimination.
    Mr. Clyde. Is that--so what is the definition of woman? You 
haven't given me that. You haven't answered my question.
    Secretary Cardona. Well, I think that is almost secondary 
to the important role that I have as Secretary of Education to 
make sure----
    Mr. Clyde. My question is not secondary. My question is 
very simple. What is the definition--what does HHS say the 
definition of a woman is?
    Secretary Cardona. I lead the Department of Education, and 
my job is to make sure that all students have access to public 
education, which includes co-curricular activities. And I think 
you highlighted pretty well the importance of Title IX in 
giving students equal access, whether it is scholarship and 
facilities, participation as well.
    Mr. Clyde. Okay. So you are not going to answer my 
question. Do you believe that a biological male who self-
identifies as a woman should be allowed to compete in women's 
sports?
    Secretary Cardona. I believe our focus needs to make sure 
that all students have access to public education.
    Mr. Clyde. A yes or no is sufficient.
    Secretary Cardona. I think it is not answered with a yes or 
no. I think all students should have access to co-curricular 
activities.
    Mr. Clyde. I think that is a yes or no question. Do you 
believe that a biological male who self-identifies as a woman 
should be allowed to compete in women's sports?
    Secretary Cardona. I believe all students should have 
access to things that public education provides.
    Mr. Clyde. You are not going to answer my question. Do you 
believe allowing biological males to compete in women's sports 
benefits female athletes?
    Secretary Cardona. I believe it is important that we take 
into account the needs of all students when they are engaging 
in extracurricular----
    Mr. Clyde. So, again, you are not going to answer my 
question. Do you believe allowing biological males to enter 
women's private spaces, such as bathrooms and locker rooms, is 
safe for female students?
    Secretary Cardona. It is critically important that we make 
sure all students feel safe in their school environment, all 
students.
    Mr. Clyde. Okay. So that means----
    Secretary Cardona. And that is the responsibility of the 
schools.
    Mr. Clyde. So what does that mean? Does that mean then that 
biological males should not be allowed in women's personal 
spaces? Is that what you are saying?
    Secretary Cardona. It means--it means that the perspective 
of all students should be taken into account when decisions are 
made around facilities.
    Mr. Clyde. Okay. Is that what your rule is doing?
    Secretary Cardona. Well, it is a proposed rule, as you 
know. And the proposed rule says there is no complete bans. It 
provides flexibility for schools, and we have an open comment 
period, which we welcome comments from different perspectives 
up until May 15th.
    Mr. Clyde. Okay. I want to be clear. Female athletes across 
this country are bravely speaking out against this dangerous 
and misguided policy that you are putting forth, and rightfully 
so.
    Earlier this month, former college swimmer Riley Gaines 
reported being assaulted, physically hit by transgender 
protesters at San Francisco State University after speaking out 
against trans athletes' participation in women's sports. She 
was also forced to barricade for hours in classroom as 
protesters demanded money, ransom, if she wanted to safely 
leave the campus.
    Are you familiar with the story?
    Secretary Cardona. That is unacceptable. Student safety 
should never be compromised on any of our campuses.
    Mr. Clyde. Thank you. I appreciate you clarifying that.
    So, Mr. Secretary, what is your message to athletes like 
Riley Gaines, who have legitimate concerns about how your 
department's proposed Title IX rule change will destroy girls' 
and women's sports?
    Secretary Cardona. As I said, it is a proposal, and we are 
taking open comment. But it is our focus at the Department of 
Education to provide equal access, free from discrimination, in 
things that are available to students in our public schools.
    Mr. Clyde. All right. The reality is, though, that the 
Department of Education--through the Department of Education, 
President Biden, in my opinion, is attempting to weaponize 
Title IX, morphing it from a law that protects women to a law 
that disadvantages or endangers women. Further, the Department 
is doing so with taxpayer dollars, an action that spotlights 
where you and your President's true priorities lie, in my 
opinion.
    How much money has been spent or will be spent crafting and 
implementing this proposed rule?
    Secretary Cardona. I can have my team get back to you on 
cost for the rule.
    Mr. Clyde. I would appreciate that. Thank you very much.
    Secretary Cardona. Thank you.
    Mr. Clyde. And I yield back.
    Mr. Simpson. Mr. Ellzey.
    Mr. Ellzey. Thank you, Mr. Chairman.
    Mr. Secretary, thanks for being here. You have dedicated an 
entire life to educating our youth, and I appreciate what you 
do. You have a very hard job, and especially when you have to 
sit up here and justify monies going to programs for our youth 
in tight economic times.
    And I would prefer that my limited time be used to 
highlight some areas of agreement that you and I might have, 
but I feel like I must use my time to highlight an issue of 
opportunity and fairness, much like my colleague.
    So going back to the 2016 decision of the DOJ and 
Department of Education mandating how a school that receives 
Federal funds deals with a boy who says they are a girl, a girl 
who says they are a boy. And this was the tipping point when 
the Federal Government began to, in my opinion, dismantle Title 
IX.
    The Department's latest attempt to rewrite Title IX 
administrative rules cites the 2016 guidance as a basis for 
rationalizing the rewrite. Title IX plainly states no person 
shall on the basis of sex be excluded from participation in, be 
denied the benefits of, or be subjected to discrimination under 
any educational program or activity receiving Federal financial 
assistance. In other words, Title IX prohibits sex-based 
discrimination in any education program or activity receiving 
Federal financial assistance.
    Since Title IX and the education amendments of 1972 was 
enacted, female participation in sports has increased by over 
1,000 percent at high school and 600 percent at postsecondary 
level. So it has been a fantastic program.
    Title IX, indeed, revolutionized women's sports. But 
unfortunately, that progress is being, in my opinion, 
intentionally dismantled by this administration and this 
Department of Education, which has proposed regulations that 
will force schools to allow biological males, proposed, to 
compete in women's sports. And female athletes are vocal in 
their objection of the proposed rule.
    Although States, including Texas, are passing laws to 
protect women and girls competing in sports, less than half of 
States have laws in place to protect the integrity of women's 
athletic competitions. In fairness and preserving opportunity, 
I believe the recipient of Federal education funding violates 
Title IX's prohibition against sex discrimination if the 
recipient operates, sponsors, or facilitates athletic programs 
or activities and allows a person whose sex is male to 
participate in an athletic program or activity that is 
designated for women.
    In fairness and preserving opportunity, I believe that sex 
in the athletic context must be recognized based on only a 
person's reproductive biology and genetics at birth. In 
fairness and preserving opportunity, Federal law should not 
prohibit schools or institutions from allowing our male and 
female athletic programs to scrimmage against each other.
    I have just described a thoughtful and fair piece of 
legislation that I am proud to cosponsor with my colleague from 
Florida, Greg Steube, H.R. 734. And thankfully, this week this 
bill will be voted on by the House. It should be sent to the 
President, and he should sign it.
    It is a bitter irony that the ongoing intentional 
destruction of women's and girls' sports is occurring when we 
should all be reinforcing the sanctity of these athletic 
programs following the 50-year anniversary of Title IX. But 
this administration and your Department of Education's radical 
regulatory scheme, proposed, needs to be rejected, and the 
Federal law's existing protections for women and girls needs to 
be strengthened through H.R. 734.
    To me, it is unacceptable that the Department of Education 
is taking it upon itself to unilaterally change Title IX. 
Functionally, the Department of Education's recent rule that 
rewrites Title IX is just the latest example of the overreach 
of the bureaucratic state. It is an end run around Congress. If 
the Title IX law needs to be changed, that is our job, not 
yours.
    I will not support what the Department is trying to do, and 
I believe Congress should resoundingly not support what the 
Department is trying to do. It is not up to the Federal 
executive departments to write the law. It is their job to 
execute the laws that Congress writes.
    In the end, the silver lining of the administration's 
actions is that it reinforces to millions of Americans that we 
stand with female athletes who object to men or boys being 
allowed to declare themselves as females and compete in women's 
and girls' athletic competitions.
    And it is normally my practice to ask a question. I don't 
really have one on this round, but I felt that this is 
something that I feel really strongly about, the people in my 
district I know feel very strongly about. As a father of a 14-
year-old girl who participates in sports, I believe very 
strongly that she should be able to participate only with 
girls.
    So thank you very much for your time. I appreciate you 
being here. I know this is hard work.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Aderholt [presiding]. Thank you. And as we are sort of 
transitioning back into round two, I want to go back, Mr. 
Secretary. We talked about student loans a little earlier, and 
I asked you about the fairness of the issue, and you mentioned 
about the fact that it is trying to make college more 
affordable. And I don't think anyone would disagree with that.
    I guess what the bottom line is, I will go to places and 
will, I am sure, in the future be going to places. You probably 
go to places--because I know you talked about being in 
Kentucky.
    Secretary Cardona. Yes.
    Mr. Aderholt. I think Hazard, Kentucky, you said you were 
at. But when you do have people that will come up and just say 
why is it fairness that you have these people that are get off 
free from paying their loans when they have had to make the 
difficult choice to make sacrifices to pay their loans back and 
those that didn't even go. What am I supposed to tell them, say 
what is the thinking of the administration in doing that?
    Secretary Cardona. Thank you, Chairman.
    Look, when Congressman LaTurner mentioned it, it is 
important to remember the targeted debt relief was a result of 
the impact of the pandemic. And I often make it analogous, and 
I have had conversations with folks who asked, ``I paid for my 
debt''--and me, too. I paid for my college. ``Why is it fair 
that that is happening?''
    Well, for many of the people who are getting the targeted 
debt relief, their parents were paying for their kids' college, 
but also it is important to remember the pandemic put people in 
a bad position. And like we provided relief for small 
businesses who were impacted by the pandemic, this program, I 
liken it to that, to say it is targeted debt relief for middle 
class Americans who right now are struggling.
    We anticipated and we anticipate that defaults are going to 
increase, that folks are not going to be paying their bills. So 
this was an intent to prevent that from happening. One-time 
targeted debt relief.
    And to the folks that say, well, I didn't have to do that, 
this is happening during the pandemic. If it weren't during the 
pandemic, this wouldn't be brought up. So I think it is really 
important to connect it to the pandemic. This is the argument 
that we have for the HEROES Act to give us that authority to do 
that, which is consistent with the previous administration 
holding--pausing loans using the same authority that I use for 
this.
    So it is important to remember that this is connected to 
the pandemic, that it is a one-time deal, and that it is not 
unlike what we have done for small businesses. I think that is 
the conversation that I had with folks.
    And we often think about college student getting debt 
forgiveness. In many cases, it is a parent who is trying to 
help their child pay for college who could use this respite to 
get back on their feet.
    Mr. Aderholt. Yes. And I will be honest with you, when the 
President first came out with the proposal a few months ago, I 
was thinking it would be more like Democrats would probably 
support it and Republicans would probably, by and large, be 
against it. I was shocked by how many Democrats that spoke out 
against it at the time.
    But anyway, but it has been more than 3 years since 
borrowers have had to make payments on the Federal loans. And 
as you know, some borrowers have never had to pay. And yet your 
budget says virtually nothing about your plans for returning to 
repayment schedules. Are you planning on returning borrowers to 
repayment to recoup the taxpayer money that the Government has 
loaned, and when do you anticipate that?
    Secretary Cardona. Yes, Chairman. We are working diligently 
at our Student Aid Office, Higher Education Office. As recently 
as yesterday, we met to discuss the path to repayment for 
borrowers, making sure we are clear on communication of how to 
get back on, making sure that we have resources and assets 
available to support borrowers who, as you said, in many cases 
this is the first time they are making payments.
    We understand that that is going to be a huge undertaking. 
Never has this ever been done where, depending on the decision 
of the Supreme Court, up to 43 million borrowers are going to 
start repaying. It is a huge lift for our team, but we are 
committed to making sure we do a process that communicates well 
with borrowers and gives them the information that they need so 
it can be as smooth as possible.
    Mr. Aderholt. There is a GAO report out there. In 2022, the 
Department didn't have email addresses for about 25 percent of 
the borrowers who were in default. First of all, do you know if 
there is any truth to that? And if it is, how do you plan to 
transition these borrowers into repayment if you don't even 
know how to reach them?
    Secretary Cardona. Right. So we work closely with GAO and 
their recommendations to make sure we continue to improve our 
systems. I will tell you that we have a new program, the Fresh 
Start program, that gives folks an opportunity to get back on 
if they were not able to make payments in the past and they 
haven't communicated.
    We have other mechanisms to try to reach out to those 
folks, and it is an all hands on deck. We are working with our 
State folks. We are working with our universities. We are 
trying to make this, as I said before, this is unprecedented. 
We are doing everything that we can to reach the borrowers out 
there to provide them a pathway to repayment.
    And for so many of them who have felt that they can't make 
any payments, trying to get them back on in a way that is 
reasonable for them, but getting them back on the repayment.
    Mr. Aderholt. But that GAO report that we heard, is that 
true, that 25 percent?
    Secretary Cardona. I can have someone follow up with your 
team about the specifics of that report and our response to 
that. I would be happy to give you more accurate information.
    Mr. Aderholt. That is a big percentage. I would like to get 
some more information on that. So, yeah, okay.
    Secretary Cardona. Sure. Absolutely.
      
    Mr. Aderholt. All right. Mr. Hoyer.
    Mr. Hoyer. Thank you, Mr. Chairman. I have got two 
questions, but I have an observation at the beginning.
    I would hope that every member of this committee would read 
Governor Cox of Utah's veto message on the issue, which is a 
very complicated issue, very difficult issue. But he pointed 
out what the numbers were in Utah.
    ''Here are the numbers most impacted my decision--75,000, 
4, 1, 86, and 56. Seventy-five thousand high school kids 
participating in high school sports in Utah. Four transgender 
kids playing high school in Utah. One transgender playing 
girls' sports. Eighty-six percent of trans youth reporting 
suicidality. Fifty-six percent of trans youth having attempted 
suicide.''
    That is the Republican Governor of Utah. This is a 
complicated issue. He also said in that veto message the sector 
that is supposed to deal with ensuring fairness, the NCAA, the 
Utah high school sports authority, et cetera, were, in fact, 
dealing with this.
    I make that observation, Mr. Secretary, simply to say that 
treating this issue, as I believe it is being treated, as a 
divisive issue, as a pejorative issue, is unfortunate. And I 
would urge everybody on this committee to read his veto 
message.
    Now let me say you have mentioned accountability a couple 
of times, a number of us. It is easy to talk about we want more 
numbers or we want less numbers. It is easy. Accountability is 
tough. I think I mentioned this to you, Mr. Secretary. Head 
Start started in 1965. The first Head Start that was canceled 
for nonperformance was in 1995 by Secretary Shalala, which I 
applauded her for.
    We need to make sure that when we spend the taxpayers' 
money--and I am one of those who believes we need to invest, as 
you know--we need to make sure that that tax money is spent 
effectively. And therefore, I think accountability is a very 
big part--it is part of the Judy program in Maryland. I said 
there are 69 centers, thousands of children--to make sure it 
works.
    So I would urge you to pursue that. And it is tough. Again, 
it is easy to, oh, we are going to cut over the next----
    Secretary Cardona. Right.
    Mr. Hoyer. Lastly, let me ask the question, which I think 
is a very important one. Because we talked about and we all 
talked about and parents talk about and counselors talk about 
how much money you can make more if you go to college.
    We have just passed a number of pieces of legislation, 
which I think are going to expand the ability in the United 
States to manufacture goods and to be self-sufficient and not 
be reliant on unreliable sources of supply. We found that very 
dramatically in the pandemic.
    So while I--probably everybody on this panel went to at 
least 4 years of college, maybe more. It is very important I 
think to have the psychology of counselors, of educators, to 
understand there are some kids who want to be maybe computer 
people that after 2 years of a junior school or 2 years of a 
technical school, if you are a welder in America, and you are a 
senior welder in America, you are making a six-figure income.
    And so while I agree that we ought to all press people to 
attain the highest level that they are capable of and desirous 
of doing, we ought not to in any way denigrate those who want 
to go to technical schools. The CTE that we talk about has been 
increased. I think that is critical.
    If we are going to make, as I think we want to make, the 
infrastructure bill, the CHIPS and science bill, the Inflation 
Reduction Act, and the other pieces of legislation we passed to 
infuse an energy in our economy, we are going to have to make 
sure that we have people doing all the skills necessary to do 
that. Some of which are college skills, but many of which are 
not.
    Secretary Cardona. Absolutely.
    Mr. Hoyer. I would like your comment.
    Secretary Cardona. I often joke that my plumber travels 
more than I do. He is a good friend of mine.
    I studied automotive technology in high school, and it was 
a teacher that tapped me on the shoulder and said you should 
consider teaching. I think in this country we have a 4-year or 
bust mentality, and it is hurting us. I am excited about that, 
but the most purple issue that I talk to folks about is the 
pathway.
    We had a supply chain issue 3, 4 years ago that really 
devastated things. And thanks to you, in a bipartisan fashion, 
we got legislation passed that gives me an opportunity to 
really double down on talking about high school, 2-year school, 
and workforce partnership as a pathway. This is an opportunity 
for our country.
    The pandemic was horrible, but it gave us an opportunity to 
reimagine, and this is one of those areas. When we talk about 
career-connected learning, every high school should have 
internships, paid internships. Every K-12 superintendent should 
be talking to the community college president to make sure that 
their curriculum are connected.
    Our 4-year colleges should be listening, too, to make sure 
that there are options there. And our workforce partners need 
to be brought to the table.
    When we talk about public-private partnership, I am all for 
that. I am excited about the opportunity, but what I am 
concerned about is complacency of us going back to the old 
system. So you will see in our budget a bold investment in 
career-connected learning, in pathway learning. I do believe 
2023 could be the year where we really make that shift and go 
away from that mentality of 4 years or bust.
    And we are aggressively partnering with--and it is not red 
States or blue States--it is all States to make sure that all 
students have options when they graduate. That is something 
that this budget reflects as well.
    Thank you.
    Mr. Hoyer. Thank you. Thank you, Mr. Chairman.
    Mr. Aderholt. Dr. Harris.
    Mr. Harris. Thank you very much.
      
    Let me just follow up on a couple of things that you said. 
One is you talked about the President's budget, but just 
correct me if I am wrong. The President's budget never balances 
in the future. Is that right? I mean never, ever, ever, ever, 
ever. Not 20 years, not 30 years, not 40 years. Is that right?
    Secretary Cardona. The budget----
    Mr. Harris. I think it is the first one ever that a 
presidential budget maybe since wartime that never balances.
    Secretary Cardona. So, as I said earlier, the cost--the 
question was about the cost here, and I----
    Mr. Harris. No, my question is very simple. Do you know if 
the President's budget ever balances? Because you bragged about 
the $3,000,000,000,000 in deficit reduction and all, but you 
presented a budget that never balances, ever.
    Secretary Cardona. The economic strategy over the last 2 
years have resulted in----
    Mr. Harris. Okay. I got to move on. I have limited time. If 
you don't know the answer, I suggest you call the Budget Office 
and ask them what the answer is to that.
    The gentleman from Kansas is absolutely right. I have a 
district where I have a lot of people who didn't go to college, 
but maybe they need a pickup truck for their work or something. 
They had a loan payment on that pickup truck. I didn't see the 
administration say we are going to forgive loan payments on a 
pickup truck that maybe they decided not to go to a 4-year 
college. Maybe they decided to do some of that career-connected 
learning, and a pickup truck is what they needed to do their 
job.
    So I am a little disappointed because the administration--I 
get the politics of it. You shouldn't play politics with it 
because you hurt people. You do. People in my district come me 
and say I didn't go to college. Why am I paying for somebody's 
college loan who did? That is just a comment on that because I 
know there is no loan repayment program for pickup trucks.
    With regards to Title IX, I associate myself with the 
comments of the gentleman from Texas. Title IX uses the word 
``sex'' in it. That is it. S-e-x. I mean, look, it is. And when 
it was passed, there was a clear meaning to sex because most 
people believe in the scientific meaning, which the gentleman 
from Texas used, which is the reproductive biology definition.
    And I agree with him. If we need to rewrite it, it 
shouldn't be done at the agency level. It should be done at the 
congressional level.
    I want to close out my time on a topic that is important to 
me, and I am sorry I have to step out into another hearing. But 
my understanding is that you suggested that you really didn't 
think the Department of Education should spend any money on 
vouchers. Is that right, voucher programs?
    Secretary Cardona. I don't believe Federal dollars should 
be spent on vouchers.
    Mr. Harris. Is that right? So Federal dollars can be spent 
on everything else in the Department of Education, but it 
really shouldn't be vouchers. I mean, right, you spend a lot on 
a lot of things.
    So do you think that is because voucher programs don't work 
to improve education? Do you think we shouldn't be looking at 
it? Because I know there are grant programs in the Department 
that look at innovative strategies to improve performance.
    Look, you and I both see the same proficiency levels. D.C. 
performance, 10 percent proficiency. Baltimore performance, 23 
schools have 0 students proficient.
    Fortunately, D.C. has a voucher program. It is not large. 
It has one. Unfortunately, in Maryland, we have a very small 
one, less than--little more than half the size of D.C.'s, which 
our Governor, despite having billions of dollars in surplus, 
decided he wanted to cut.
    So he must agree with you that, basically, public dollars 
shouldn't go to vouchers. They should go to public schools, but 
they can't go to alternative schools, which parents choose.
    So do you just believe that the Federal Department of 
Education and the bureaucrats there, the Federal bureaucrats, 
know more about what is good for that child than the parent 
does? Is that the philosophy that informs your decision about 
not spending Federal dollars on vouchers? Even though some 
studies have shown--I agree, they are divided, the results--
that voucher students perform better in the voucher school than 
they did in the public schools that they left.
    Secretary Cardona. There has been a historic disinvestment 
in public education, which has resulted in the data that we are 
looking at now. And what I am----
    Mr. Harris. Excuse me. You have to----
    Secretary Cardona. What I am----
    Mr. Harris. You have to define ``disinvestment'' to me 
because public education spending, at least in my State, goes 
up every year. Department of Education funding goes up every 
year. So disinvestment to the average person would be a cut in 
investment.
    Now, Mr. Secretary, you are not suggesting that we spend 
less on education now than we ever have?
    Secretary Cardona. What I am suggesting is that because the 
public schools are not getting the support that they need, they 
are not performing at the level that they should be. You 
brought up----
    Mr. Harris. Mr. Secretary, Mr. Secretary----
    Secretary Cardona. I would love to answer your question.
    Mr. Harris. You haven't answered me about disinvestment. 
You are not suggesting that we are spending less now than we 
did ever historically?
      
    Secretary Cardona. This budget proposal is asking for 
dollars to make sure that students in Maryland, the districts 
you represent, can read on grade level. I am advocating for the 
students that you represent.
    Mr. Harris. So you are advocating--and I will go back to 
the point that I made in the first--in my opening questions. 
You are doubling down on failure.
    The education system in Maryland is failing in Baltimore 
City. Thousands of dollars per student, Federal dollars, goes 
into Baltimore City to prop up a failing system, and you are 
unwilling to fund an alternative that has worked in some 
jurisdictions called vouchers. Is that a good summary of your 
feelings on that?
    Secretary Cardona. I welcome the opportunity to work with 
you to support the Maryland schools and avail to you and 
Maryland the resources that our Department has to ensure all 
students can achieve in their local public schools.
    Mr. Harris. And I yield back. All I can tell you is you 
haven't been ensuring anything up until now.
    I yield back, Mr. Chairman.
    Mr. Aderholt. Ms. Frankel.
    Ms. Frankel. Thank you.
    So, hopefully, this is something we can all agree on, which 
is really the importance of sports to the development of young 
children and to adults. And I want to talk about the real issue 
here when it comes to Title IX, and that is girls and women are 
not getting the legally required fair share of athletic 
opportunities in both high schools and colleges.
    I am going to read you something. According to a recent 
report by the Women's Sports Foundation, 86 percent of NCAA 
schools offer athletic opportunities to men at disproportionate 
rates compared to their study body makeup. And male athletes 
receive $252,000,000 more in sports scholarships than females.
    At the high school level, your department has reported 
receiving over 3,000 complaints in 1 year under Title IX based 
on gender inequities in high school sports opportunities. Now I 
do think those who are watching basketball most recently saw 
that the women, the NCAA women's tournament was quite much more 
exciting than the men's. Correct?
    Ms. DeLauro. Amen.
    Ms. Frankel. Amen. All right.
    Ms. DeLauro. Sorry about the Huskies.
    Ms. Frankel. So really is a two-sided question here. First 
is how does your budget improve enforcement of Title IX so that 
girls and women get the opportunities that they legally are 
entitled to? And number two, how do these proposed budget cuts, 
how would that affect that?
    Secretary Cardona. Sure. So, thank you.
    And I agree. When we talk about Title IX, while it has 
gotten a lot of attention here today, in a manner that, in my 
opinion, tries to create a division and a wedge, I am really 
proud that we can all agree that Title IX has given women 
athletes an opportunity to engage much more, free from sex 
discrimination. It has created safe school environments without 
harassment or violence.
    And we are proud of that work, and we are going to continue 
to push to make sure that all students can participate fully, 
free from discrimination. That is what we are fighting for.
    The Office for Civil Rights is asking for an increase of 
approximately 135 enforcement staff, basically to protect the 
civil rights, including claims of students with disabilities. I 
mentioned that we received 19,000 complaints last year. In 
2019, there were 10,000 complaints. Okay? Almost double.
    Disability discrimination has really gone up. There were 
nearly 5,700 complaints in fiscal year 2022 on that. So a cut 
would make it so that these cases are not being heard as 
quickly. It could be that the students graduate before their 
case is even looked at.
    We have to recognize that the volume of cases has gone up 
significantly. Many of the cases are about making sure sex 
discrimination is not happening. And if we don't have the 
adequate staffing for that, we won't be able to protect the 
rights of those students who are bringing up the complaints.
    So that would be the impact of a cut in Title IX.
    Ms. Frankel. So let me ask you this. Other than enforcement 
obviously, which is very important, any other ideas coming out 
of your department in terms of how to get these high schools 
and the colleges to give women and girls their fair share of 
opportunity?
    Secretary Cardona. Yes. We strongly encourage--I have heard 
several folks here mention that they have children who have 
participated in athletics. I, too, have had that, and I have 
seen, as you mentioned--you started with this--the impact of 
being a part of a team. What you learn about yourself. You set 
goals for yourself, and leadership traits are developed for 
students.
    This is why we are so passionate about making sure that 
every student has access to co-curricular activities like 
athletics. We work--we have more technical assistance being 
offered in this area for districts and States. We have held 
several workshops. We have had participation from all over the 
country. We have done it through Zoom. We have done it in 
person. We have traveled to locations to provide support and 
technical assistance.
    We have partners in the field who are working really hard 
to try to provide more opportunity for girls in our schools, 
and we are proud of that. We are proud of that because, as a 
father and as an educator, I know the important role that 
athletics has had in the development of my children. And I want 
to encourage that for all students.
    So while some choose to look at our Title IX proposal as a 
point of division, I look at it as an opportunity for me to 
express as a father and as an educator the passion that I have 
for all children benefitting from those opportunities that our 
schools provide, all students. All means all.
    And we will not tolerate discrimination. We will not stand 
by idly while some groups--groups who have had higher rates of 
suicide attempts. In Maryland alone--and I am sorry he left--43 
percent of LGBTQ youth have considered suicide, 40 percent 
attempted it.
    I will not sit idly. I will take the hits. We are going to 
make sure all students have access to opportunities to engage 
in what my children benefitted from. All students deserve that, 
and we are going to fight to make sure that that is possible.
    Ms. Frankel. Thank you. I yield back.
    Mr. Aderholt. Ms. Letlow.
    Ms. Letlow. Thank you, Mr. Chairman.
    And Mr. Secretary, I share your belief that education is 
the answer, and my heart is for our kiddos and how we get them 
on a clear path to success. And we talked today about several 
programs that offer a variety of support for students and 
families, but these programs don't reach all of our schools, do 
they? Especially in my area, which is mostly rural.
    And I support options that allow parents to have control 
over what school best meets their needs for their family. So, 
in turn, I support school choice, which you shared with Mr. 
Moolenaar earlier that you do not support.
    In higher education, which is my background, we attach 
money to the student, FTEs. Is there a way that we could use 
the same principle for elementary education? Why do we continue 
the model of funding poor-performing schools and denying 
parents the choice to choose the best school for their child?
    And before you answer this, I just want to share some 
concerning statistics from my home State, Louisiana. Six 
hundred seventy-five thousand kids are in public schools. We 
have 170,000 that are in a D or F school. Why can't I, as a 
parent, take my child out of that school and choose a different 
path for them, when we know all of these amazing programs that 
we have talked about, that I believe in many of them, are not 
making their way to every school in Louisiana?
    So do I just have to choose to keep my child in a failing 
school in the hope that these schools are going to get better? 
Because in Louisiana, they have not. They have remained 
stagnant over the last 10 years. So I am just curious, how can 
we work together find a solution here?
    Secretary Cardona. Yes. Thank you very much, Congresswoman 
Letlow.
    And I, too, feel it is really important that we continue to 
work together, that we find common ground on what we can agree 
on. And I just want to make sure I am very clear. I do support 
choice. I am not opposed to choice. I chose a technical high 
school. I didn't go to my neighborhood school, right?
    So I am a product of school choice, and I do believe 
parents should have choices to attend where they want. What I 
don't support is public school dollars being taken away from 
the local public school and funding a private option because 
what ends up happening is those students who remain in that 
local public school will have less support, which will then 
create greater failure.
    And I think that is kind of where we are right now. When we 
are talking about the potential cuts here, if we cut Title I, 
the reading levels will go lower because there are less 
teachers. We will have less qualified teachers.
    So I am in favor of parental choice. I really am.
    Ms. Letlow. So you are in favor if a child is in a D or an 
F school in my home State, that I, as a parent, can move them 
to a different public school that is not in a D and F?
    Secretary Cardona. Oh, absolutely. In Connecticut, we 
supported magnet programs. We supported charter programs when I 
was Commissioner and I had more specific role in funding for 
particular schools. What I am not in favor of is public school 
dollars being used to fund private schools.
    And I think there are deliberate attempts in this country 
to break down our public schools in an effort to privatize and 
commercialize education. Every school should have high-quality 
standards, high-quality educators, and I am fighting for a 
budget here that makes sure that the schools that you 
represent, those that you are talking about with the Ds and Fs, 
have a better day with greater support, greater accountability, 
high-quality teaching.
    I mean, we know the components. As a fourth grade teacher, 
as a school principal, as a district superintendent, I know 
what it takes to make schools great. And I want to make sure 
that we have the resources targeted to those strategies that we 
know work. That is my intent.
    Ms. Letlow. So going off of Mr. Moolenaar, what he 
mentioned earlier, I want to also share the 90 percent of these 
kids who are in D and F schools in Louisiana are from 
economically disadvantaged areas. So we are hurting those kids 
that we are, in turn, trying to help.
    And it has been 10 years, Mr. Secretary, and I am just 
concerned that we are not improving, that we are actually going 
backwards. And if anything, COVID hurt us.
    Secretary Cardona. Right.
    Ms. Letlow. So I definitely think there has got to be 
another alternative. And if it is charter schools, if it is 
vouchers, why can't we explore those things? Why can't we look 
into that if we are failing our students right now?
    Secretary Cardona. I share your concern. I recognize that, 
unfortunately, the pandemic exacerbated disparities, and many 
times black and brown students or students in underserved areas 
are hit the hardest. This is why when we rolled out the 
American Rescue Plan dollars, we made sure that the dollars 
were going to the schools that needed it the most.
    Similarly with this budget, if you look through our budget 
proposal, you will see Title I. I mean, we are asking for 
$20,500,000,000. Seventeen billion dollars for IDEA, students 
with disabilities. Students that you are referring to.
    Title I. I would argue that a high percentage of the 
schools that you are talking about are Title I schools.
    And Pell Grants. Intended for those who are less fortunate 
or don't have as much dollars. So our budget reflects focusing 
on those schools, and I share that passion with you, that 
experience with you, and I look forward to working with you to 
find areas where we can support the students you represent.
    Ms. Letlow. I appreciate that. I hope maybe you would be a 
little bit open-minded about other possibilities as well.
    Thank you so much. I yield back.
    Mr. Aderholt. Mr. Simpson.
    Mr. Simpson. Thank you.
    And I would just like to tell my good friend Mr. Hoyer that 
I did read that Utah message. I read it two or three times, and 
then I had my staff read it.
    One of the things I found interesting is--is I thought it 
was a very well-written veto message. One of the things I found 
interesting in it was they were working to create a commission. 
Hadn't been done yet, but they were working to create one, and 
this commission would look at transgender individuals playing 
in women's sports on an individual basis.
    The impression I got from this was that if the individual 
could compete in women's sports and not dominate them, then 
they would let them compete in women's sports. But if they were 
going to dominate the women's sport, they wouldn't be allowed 
to compete in women's sports.
    That is a commission I don't want to serve on. That would 
be really hard. I understand why they have a hard time trying 
to come to some agreement in that, but at least they are 
looking, and I applaud them for that.
    A couple of quick issues. My district is home to the 
Shoshone-Bannock Tribe located on Southeast Idaho on the Fort 
Hall Indian Reservation. When I grew up, a lot of the Indian 
students came to Blackfoot High School that I went to school 
with.
    While they do have BIE schools, most of the tribe's 
children, as I said, attend non-BIE schools and attend local 
schools. It is my understanding that as a result of those 
schools receiving funding, and they are supposed to be 
consulting with the tribes as part of their grant. One issue 
that has come to my attention is that the schools may not be 
properly consulting with tribal governments. Rather, they are 
hosting a community meeting, presenting some information, and 
calling it a consultation.
    Are you aware of this issue? And if not, I would like to 
encourage you to work with me and my office to ensure that 
local schools are holding proper consultations with tribal 
governments.
    Secretary Cardona. Thank you for that, Congressman.
    I am aware of that issue. I have met with different tribal 
councils. I visited at least four tribal nations and had heard 
from their education folks of this. And then I have spoken to 
folks who represent the 90 percent of Native American students 
who attend traditional schools who say on paper, it says we 
should be consulted more, but we are not seeing it. I have had 
them come to my department to share specifically, and I have a 
lot of interest in this because it is the responsibility of the 
State to consult.
    As a matter of fact, they are a great resource. And many of 
our Native American students bring a lot of assets to the table 
that are not being recognized because of the lack of 
consultation. So I will ask the White House Initiative for 
Native American Leader Naomi Miguel to reach out to your office 
to understand that issue better and to work collaboratively 
with you and your team to make sure that the consultation is 
happening the way it should be happening.
    Mr. Simpson. I appreciate that. It is very interesting. I 
spent a couple of days with the chair of the National Endowment 
for the Humanities, and we went out to Fort Hall and visited 
their immersion school where they are teaching the children to 
speak in Shoshone.
    Secretary Cardona. Yes.
    Mr. Simpson. They don't want to lose that language, and we 
shouldn't lose those languages. But it is fascinating to watch 
these young children learning to speak Shoshone and stuff. So 
they do a really good job. So I appreciate that.
    One last question. Do you have any idea how many dollars of 
pandemic relief that were sent to school districts are sitting 
in school districts unspent?
    Secretary Cardona. Yes. So the COVID dollars or the ARP 
dollars that were sent out are being used, and we see the 
drawdown moving effectively. I do believe by the deadline, they 
will be used.
    We set up Covid-Relief-Data.ed.gov.--got to make that 
shorter--so that folks could see. We want to make sure there is 
transparency around it as well.
    But, yes, we do know the drawdown. It has been used for 
safe school reopening. There were more kids in summer school 
this last summer than ever before. Afterschool programs, mental 
health supports. I was talking to someone recently in my 
hometown who is a new school social worker, and he said the 
position was funded through ARPA dollars, and I was pleased to 
see that the dollars are being used to help students and 
families.
    So the drawdown is there. Again, it is Covid-Relief-
Data.ed.gov. I want to make sure that it is open and people 
could see where the money is being used.
    Mr. Simpson. Thank you. Thank you for being here today.
    Secretary Cardona. Of course.
    Mr. Aderholt. Before we adjourn, I am going to turn to the 
ranking member, and she has got a couple of comments.
    Ms. DeLauro. Thank you very, very much, Mr. Chairman, and I 
appreciate the time.
    I just wanted to--there is a number of claims with regard 
to the potential budget cuts, let me put it that way, that 
there is speculation around that. And that some of my 
colleagues on the other side of the aisle claim that the cuts 
would not be implemented evenly across the board.
    That, to me, is even more dangerous. If other programs are 
exempt--and there are lots of people talking about various 
exemptions--we know that education programs, that students and 
families that they rely on are going to be impacted in some 
way.
    But I want to take a look for a very quick moment at the 
issue of speculation on these cuts. We had, as I said, the 
Speaker of the House only yesterday say that we were going to 
revert, that part of his plan--and I have to assume that is 
your Republican Conference plan--will move to apply 2022 budget 
numbers to a 2024 budget.
    That implies overall an 8 to 9 percent across-the-board cut 
if everyone is equal. If you take out defense, if you take out 
veterans, now looking at 25 percent in terms of cuts. There are 
people who want to talk about increasing defense. That would 
mean between a 25 and 30 percent cut to everything else. That 
is reality.
    We already had in the House a vote where 75 percent of 
House Republicans voted for Representative Massie's amendment 
to H.R. 5 that funding for all K through 12 education should be 
terminated by December of this year. A very respected, very, 
very respected think tank, the Heritage Foundation--and this is 
documented. I don't make up this. They testified before this 
committee at the invitation of the majority. This is what 
eliminates the U.S. Department of Education and transfers 
certain programs to other agencies.
    Return all Pell funding to discretionary spending and 
eliminate mandatory add-ons. Eliminate the Federal supplemental 
opportunity grant program. It is--and eliminate the Federal 
GEAR UP program.
    Then you have got a former OMB Director who has another 
think tank called the Center for Renewing America, and there is 
a whole variety of education programs that would be cut in some 
way. And I just say this is a former OMB Director under the 
prior administration who would like to abolish the TRIO 
program.
    So it is not speculation. There appears to be a pattern of 
looking at serious cuts overall, and I just would--this would 
decimate public education, harm students, and we cannot move in 
this direction because I believe there are many of our 
colleagues who don't subscribe to this. And they want to move.
    I would just end with Horace Mann, the great equalizer is 
education. That is what your role has been, Mr. Secretary, 
whether you served as Commissioner of Education or now in your 
current job as the Secretary of Education. And that means that 
we have the opportunity to make sure that the resources are 
there so it is that great equalizer.
    That it doesn't make any difference what your gender, what 
your socioeconomic status is, what your religion, your 
political party, doesn't make any difference. But it is that 
God-given talent that we can help to foster to make you 
successful. That is what the role of the Department of 
Education is, and that is what the role of the Federal 
Government is, and that is what the role of this committee is.
    Thank you, Mr. Chairman.
    Mr. Simpson. Would the gentlelady yield?
    Ms. DeLauro. I would be happy to yield.
    Mr. Simpson. I was just--I appreciate the gentlelady's 
passion, and I think it is shared by many people. We also have 
obviously concerns about inflation and the things that are 
going on and the excessive spending we think that has gone on 
in previous years.
    But could you tell me which seat on this committee is the 
Heritage Foundation seat?
    Ms. DeLauro. I would just say this. First of all, I would 
just say to my colleague this great interest in inflation and 
deficit only arises on sporadic occasions. I heard no one 
complain about a $1,700,000,000,000 windfall for the richest 
one-tenth of 1 percent of the people in this country and many 
of the corporations, the biggest corporations, who pay no taxes 
at all.
    That didn't seem to bother everyone. There is no seat on 
this committee for Heritage.
    Mr. Simpson. Thank you.
    Ms. DeLauro. However--however, there are people who do 
listen to the Heritage Foundation and take their lead. And they 
vote in this institution, and a whole number of them have 
already played their cards of what they want to do. This is a 
pattern that is coming forward of all of these institutions to 
look at going back to 2022 and seriously impairing our ability 
in education and in every other realm of public service.
    Thank you. Thank you, Mr. Chairman.
    Mr. Simpson. Thank you.
    Mr. Aderholt. Thank you.
    Well, Mr. Secretary, thank you for being here. Mr. Kean, 
thank you for being here today, even though you didn't get to 
speak as much as we would like for you to maybe. [Laughter.]
    Mr. Aderholt. But you had it easy, but anyway, I know you 
got a hard job with your being Director of the Budget.
    But anyway, I think we have had a robust hearing today, and 
it has been good to talk about some of these issues and bring 
them to light. And as you can tell, Mr. Secretary, there are 
some real concerns about some of the issues, and certainly, I 
know my colleagues on this side have their concerns that they 
voice as well.
    But as we have chatted on the phone, as you know that I 
know, we ultimately want to find some common ground as we move 
forward on this. And at the same time, as we both have 
mentioned before, we don't want to compromise but do find 
common ground. And so that is what I hope we can as we move 
forward.
    Thanks for being here and look forward to working with you, 
and we stand adjourned.
    Secretary Cardona. Thank you, Chairman.
    [Questions and answers submitted for the record follow:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                         Wednesday, April 19, 2023.

    CENTERS FOR DISEASE CONTROL AND PREVENTION, ADMINISTRATION FOR 
 STRATEGIC PREPAREDNESS AND RESPONSE, AND NATIONAL INSTITUTES OF HEALTH

                               WITNESSES

ROCHELLE WALENSKY, M.D., M.P.H., DIRECTOR, CENTERS FOR DISEASE CONTROL 
    AND PREVENTION
HON. DAWN O'CONNELL, ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE, 
    ADMINISTRATION FOR STRATEGIC PREPAREDNESS AND RESPONSE
LAWRENCE TABAK, D.D.S., PH.D., PERFORMING THE DUTIES OF THE DIRECTOR, 
    NATIONAL INSTITUTES OF HEALTH

                      Chairman's Opening Statement

    Mr. Aderholt. Well, good morning. The subcommittee will 
come to order.
    And first of all, I would like to sincerely thank all of 
our guests here today. Thank you for being here and for taking 
time out of your schedule to share with us a little bit today 
about your outlook for your departments and your agencies and 
especially from the budget aspect.
    And collectively, your offices have the responsibility for 
ensuring that we, as a nation, are prepared to mitigate, 
respond to, and ideally preempt biological and, in some cases, 
manmade threats to the American people.
    Those of us who are blessed with the responsibility of 
public service and leadership understand that while not every 
choice comes with a cost, every choice comes with a price. 
Sadly, I think those who will pay the price for the many 
mistakes made during the COVID pandemic era are the most 
vulnerable among us.
    The child with a disability who couldn't learn over Zoom 
and lost years of progress and who may never be able to regain 
those skills. The young teens just on the cusp of unlocking the 
wonder of learning, who completely checked out of school and in 
all too many tragic cases lost interest in life itself, whether 
because of the depression, anxiety they experienced being cut 
off from their friends and the community.
    And of course, the families that were torn apart by 
arguments over lockdowns and vaccines that were fueled by 
social media and public health messages that patronized and 
mocked anyone who dared ask any questions. Obviously, it was a 
very uncertain time for all of us, and we were going through 
very uncharted waters. And so we have to certainly take that in 
consideration.
    We don't have time during this hearing to enumerate every 
tragic outcome, but I will simply say that public health, 
especially in a time of crisis, is an inherent political 
activity, and public trust is very delicate. And once that 
trust is lost, it is very hard to regain it.
    We must work collectively to admit our missteps and make 
necessary changes to the way we have governed and rebuild the 
public trust. The specific responsibility and focus of this 
subcommittee is safeguarding and ensuring that effective use of 
taxpayer dollars in doing just that.
    Also it should be noted that the price of reckless spending 
is runaway inflation, which is a tax on every American. The 
burden of out-of-control social spending sold as a necessary 
response to the COVID-19 pandemic is borne most heavily by the 
lower income and by the seniors who are living on a fixed 
income.
    The cost of selling political priorities as public health 
necessities is the further erosion of an already-diminished 
public trust. I hope we can have an honest conversation here 
this morning about lessons learned and changes that you have 
made to your respective agencies that are under your leadership 
to make sure these mistakes are never repeated and that the 
public trust can be rebuilt.
    Today is our annual budget hearing to discuss your 
respective budget proposals for fiscal year 2024. It is 
disappointing to see that the Biden administration once again 
putting forth a partisan budget proposal that seems to be 
little more than a lengthy liberal wish list.
    For example, the budget proposes to implement partisan 
priorities such as climate change, gun research, and even a 
Sexual and Gender Minority Research Office within the NIH. 
Basic biomedical research at the NIH is essentially flat-
funded, while the new ARPA-H, which was created only last year, 
is proposed for a $1,000,000,000 increase.
    We recognize the importance of investing in the next 
generation of vaccines supported through BARDA investments. 
However, it is notable that the proposed increased investment 
for BARDA is dwarfed by the requested creation of a 
$400,000,000 slush fund to be used as the Secretary, as he sees 
fit.
    With the expansive and elastic definition of public health 
the administration has adopted, I have little confidence that 
such flexibility would be used to exclusively prepare for 
pandemic preparedness and biodefense as the words are 
understood by the American people.
    Finally, I question the magnitude of the increases 
requested for the Centers for Disease Control and Prevention. 
While some of the requests put a priority on core capacities 
necessary to respond to the threats of infectious disease, 
unfortunately, many of the requested increases are outside 
CDC's core mission.
    For example, the budget request nearly triples the amount 
of funding for firearm research. You are also asking 
$250,000,000 for new youth violence prevention programs and 
$135,000,000 for climate activities, which are rebranded as 
environmental health.
    I think the question we have to ask, are these kind of 
activities in the same category as combating chronic diseases 
threatening our most vulnerable population or reducing 
antibiotic resistance? I would argue that they are much 
different and that we should focus our CDC resources on 
infectious diseases, transmittable diseases, and certainly 
chronic diseases rather than controversial political-charged 
activities.
    With all that said, I do sincerely look forward to our 
conversations today and have a chance to talk about some of 
these issues and to discuss how we can do better in the future, 
and that is a lesson certainly for all of us.
    And at this time, I would like to recognize my friend and 
ranking member of this subcommittee and the full committee, 
from Connecticut, for her opening statement. Ms. DeLauro.

                    Ranking Member Opening Statement

    Ms. DeLauro. I thank the chair for holding this hearing, 
this critical hearing, and I am pleased to welcome our 
witnesses--Director of the Centers for Disease Control and 
Prevention, Dr. Rochelle Walensky; the National Institutes of 
Health Director, Dr. Lawrence Tabak; and the Administration for 
Strategic Preparedness and Response, ASPR, Assistant Secretary 
Dawn O'Connell.
    So welcome, and thank you for the work that you are doing. 
Thank you for being here today.
    You have all dedicated your lives to really what is sacred 
work, making our communities healthier and safer by 
strengthening public health, treating illness and disease 
through research and development, and advising on and 
delivering emergency assistance during disasters and public 
health emergencies.
    And given the painful health crisis we faced over the last 
3 years, your collective dedication during this difficult 
period has been integral to bringing our Nation forward. When I 
think back to where we were 2 years ago, I know it is thanks to 
your agencies that we have made such progress. To support this 
important work and continue to make our communities healthier, 
this committee made historic investments through the 2022 and 
the 2023 appropriations packages in our public health 
infrastructure and the health and well-being of American 
families. But the price of not doing so is too high.
    In the 2023 Government funding law led by this committee, 
we increased funding for the CDC by $760,000,000. That funding 
bolsters our Nation's public health infrastructure and its 
capacity. It strengthens our public health workforce. It helps 
State and local health departments keep our constituents safe. 
It modernizes our public health data so that information is 
shared quickly and interventions to address public health needs 
are implemented in a timely manner.
    And as NIH continues to be at the forefront of 
transformative medical research, we also included an increase 
of $2,500,000,000 to bolster those lifesaving scientific 
research the agency leads. This includes historic investments 
to support breakthroughs in the Cancer Moonshot Initiative, 
Alzheimer's, ALS, HIV, and universal flu vaccine development.
    We also included funding to continue confronting urgent 
health crises, including through gun violence prevention and 
opioid misuse research. These are national crises that we must 
continue to tackle head on.
    And because ASPR has been repeatedly called upon to respond 
to emerging threats, this subcommittee provided increased 
funding over the past several years, including an 18 percent 
increase in 2023 to advance ASPR's efforts.
    Today, we gather to discuss the 2024 budget request for 
CDC, for the NIH, and for ASPR. Dr. Walensky, I am pleased to 
see that the CDC's request includes $1,900,000,000 increase to 
bolster our Nation's public health and help our State and local 
public health agencies strengthen theirs. I don't think it is 
recognized that our State and local public health agencies are 
the backbone of the work that CDC and the work of what our 
public health infrastructure looks like.
    You have made strides in infant, maternal, and behavioral 
health and gun violence prevention. As you and I agree, CDC's 
impact reaches far beyond its fight against infectious 
diseases. Because of this, your budget would strengthen our 
public health agencies so that we can support food safety, 
early detection and prevention of cancer, and opioid use 
prevention.
    As I have said before, we must be ready for any current and 
future crisis. We must end the cycle of complacency that leaves 
us scrambling when a crisis hits.
    Assistant Secretary O'Connell, I am so glad to see that the 
request also includes new resources within ASPR to prepare 
specifically for future pandemics and biological threats. Your 
work is so critical to keeping us healthy and safe, as our 
country has simultaneously confronted COVID, mpox, and an 
infant formula shortage, which your agency fought by helping to 
increase safe supply of formula for babies.
    Dr. Tabak, as I mentioned before, NIH is so critical to 
advancing solutions to the most pressing health issues that 
face our communities. I appreciate your focus to prioritize 
innovation, including in nutrition research to reduce diet-
related diseases.
    But given the importance of strong investments in 
biomedical research, I need to mention my worry that the 
proposed increase of less than 2 percent for the NIH is 
insufficient and threatens the projects this committee has made 
through significant sustained investment in biomedical 
research. Over the past 8 years, this committee has increased 
the overall funding for NIH research by 60 percent, and we did 
that on a bipartisan basis. Finding treatments and cures for 
cancer, Alzheimer's, diabetes, infectious diseases, substance 
use disorders, and other debilitating illnesses should never be 
partisan issues. They impact every one of us.
    Americans depend on the work that CDC, NIH, and ASPR does. 
They rely on you to stay healthy. You improve the quality of 
our lives. You ensure that we are constantly developing new 
treatments. You protect us from public health threats, 
including from the COVID pandemic, which has so tragically 
taken more than 1 million American lives over the last 3 years.
    That is why I must mention how deeply concerned I am over 
some of my House Republican colleagues' calls for massive 
spending cuts to many of the programs that keep families and 
communities healthy. These cuts would be deadly and would be 
felt by everyone, including children, families, seniors, 
veterans, and our rural communities.
    And I just might add, we deal with a lot of things through 
appropriations--roads, bridges, helicopters, all kinds of 
areas--but nowhere is it more important than to address the 
issues that you all deal with because you are in the business 
of saving lives. There isn't anything more important that we do 
at the Federal level, which is why we cannot sustain 
substantial cutbacks to the programs that you are engaged in.
    Yesterday--or 2 days ago on Wall Street, Speaker McCarthy 
reiterated Republicans' intent to cut funding back to the 2022 
level and to impose caps for the next 10 years. Make no 
mistake, caps are just another name for more cuts. Caps are 
cuts.
    I am not sure that some of my Republican colleagues realize 
the impact that these cuts would have, so I would just like to 
run through some of them. If implemented, 5,000 fewer research 
grants would be given out yearly and would impact the funding 
thousands of existing recipients can get. This means less 
research to cure cancer, Alzheimer's, diabetes, heart disease, 
and so many other debilitating illnesses.
    The cuts will dramatically impact the CDC's ability to 
support States, local agencies, weaken our public health 
infrastructure and capacity. More than 70 percent of CDC funds 
go to our public health partners, including those agencies. 
Such extreme cuts would make our communities much less healthy.
    Progress in ASPR programs that improve our Nation's 
preparedness for public health emergencies include BARDA, 
BioShield, pandemic influenza. That would be taken back years, 
leaving our country so much more vulnerable to the impact of 
health crises. These cuts threaten so much of the progress that 
we have made in recent years.
    Please listen to what I am saying. They would be deadly. We 
should learn from the lessons of the pandemic, not send the 
health of our Nation back years. It is unconscionable that we 
could support such cuts to these critical agencies.
    I know and I believe that our witnesses agree. I thank you 
for the dedication. And I think I know and I believe that so 
many of my colleagues on both sides of the aisle agree as well.
    So thank you for your dedication. Look forward to hearing 
your testimony.
    With that, Mr. Chairman, I yield back.

                         CDC Opening Statement

    Mr. Aderholt. Thank you, Ms. DeLauro.
    And I would like to begin with Dr. Rochelle Walensky, who 
is the 19th Director of the Centers for Disease Control and 
Prevention and the 9th Administrator for the Agency for Toxic 
Substances and Disease Registry.
    Dr. Walensky served as the Chief of the Division of 
Infectious Diseases at Mass General Hospital from 2017 to 2020 
and was Professor of Medicine at Harvard Medical School from 
2012 to 2020. She served on the front line of the COVID-19 
pandemic and conducted research on vaccine delivery and 
strategies to reach underserved communities.
    So, Dr. Walensky, thanks for being here, and we look 
forward to your testimony.
    Dr. Walensky. Thank you. Chair Aderholt, Ranking Member 
DeLauro, and distinguished members of the committee, it is an 
honor to appear before you today to discuss how the President's 
budget for fiscal year 2024 will better position our Nation to 
respond to known and novel health threats.
    The Centers for Disease Control and Prevention and its 
partners have stabilized the foundation of the U.S. public 
health system, which in late 2019 was in a weakened condition 
after years of underinvestment. Thanks to supplemental funding 
over the past 3 years, Americans today are better protected 
from public health threats.
    For example, funds supported the distribution and 
administration of more than 670 million vaccines and 
introduction of effective treatments. Americans are now 
buffered from the risk of severe disease and death from COVID-
19. Further investments in data systems have supported real-
time health data through electronic case reporting in all 50 
States, and county-level information is available to decision-
makers in every U.S. community.
    These are just two examples of how one-time supplemental 
investments have improved our Nation's public health and our 
infrastructure. These investments to date support critical 
capabilities around outbreak response, workforce, data, and 
forecasting. From monitoring illness in mothers and babies to 
measuring life expectancy, to monthly reporting of overdose 
data, these investments are changing how we do public health 
now and into the future.
    CDC has also been providing funding which reaches every 
community in the United States to hire the workforce that they 
need to address their most crucial public health needs. These 
funds are already making a difference.
    In February 2023, Ohio utilized resources to provide 
unanticipated surge staffing to support the East Palestine 
response. Alabama has already hired 23 community health workers 
for staffing for improving operations, and this number will 
grow to 135 by the end of the grant. Tennessee has already 
hired 64 staff and will use some of its funding to support 
rural health research.
    While CDC has always quickly deployed experts to public 
health emergencies, the number, pace, and nature of these 
emergencies is escalating. Likewise, Americans' expectations 
for rapid Government response has grown as well.
    At this moment, CDC employees are in Equatorial Guinea and 
Tanzania to support separate ongoing outbreaks of Marburg 
virus, a close cousin of Ebola, and to prevent them from 
spreading. Recently, CDC deployed support for Michigan in 
response to an outbreak of blastomycosis at a local paper mill 
affecting about 850 employees.
    CDC's employees embrace the opportunity to serve, whether 
in an emergency or in day-to-day work of keeping infectious 
diseases and other public health hazards at bay. But to 
continue this work, we need your help. CDC's fiscal year 2024 
budget request is the right budget for where we are now. It 
includes $11,600,000,000 in discretionary budget authority, 
prevention and public health, and public health services 
evaluation funds. This budget request prioritizes investment in 
cross-cutting functions and core public health capabilities at 
Federal, State, and local levels.
    The budget request also increases CDC's effectiveness as a 
public health response agency. For example, it will enable us 
to provide danger pay to staff who respond to deadly outbreaks 
and build on progress we have made in collecting and swiftly 
sharing back to jurisdictions data for their own faster 
decision-making. The budget would also authorize a new program 
to provide the 13 recommended vaccines to uninsured adults.
    CDC is implementing recommendations from our partners to 
build a CDC that is ready, capable, and responsive through our 
priority areas identified in CDC Moving Forward to share 
scientific findings and data faster, to enhance laboratory 
science and quality, to translate science into easy-to-
understand policy, to prioritize communications, to develop a 
workforce prepared for future emergencies, and to promote 
results-based partnerships.
    The President's fiscal year 2024 budget will leverage the 
work it started during the pandemic to modernize CDC to protect 
the American people. Public health investments have a profound 
and lasting impact on all of our lives. Investing in data, 
workforce, and infrastructure gives us power over the 
conditions that allow diseases and injuries to thrive. 
Investing in public health means longer, healthier lives for 
everyone.
    Thank you, and I look forward to your questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                         ASPR Opening Statement

    Mr. Aderholt. Thank you, Dr. Walensky. Thanks for your 
testimony.
    We also have joining in the panel today Dawn O'Connell. Ms. 
O'Connell has served as the Assistant Secretary for 
Preparedness and Response within the U.S. Department of Health 
and Human Services. In that role, she is the Secretary's 
principal adviser on public health emergencies, and her office 
leads the Nation in preventing, responding to, and recovering 
from the adverse health effects of manmade and naturally 
occurring diseases.
    Prior to this role, she served as a senior counselor to 
Secretary of Health and Human Services for COVID-19, also she 
was the Director of the U.S. Office for Coalition for Epidemic 
Preparedness and Innovation.
    Secretary O'Connell, we are glad to have you here and look 
forward to your testimony.
    Ms. O'Connell. Chair Aderholt, Ranking Member DeLauro, and 
distinguished members of the committee, it is an honor to 
testify before you today on ASPR's work and our fiscal year 
2024 budget request.
    But first, let me thank you for the funding you provided to 
ASPR in the fiscal year 2023 omnibus. These dollars are 
allowing us to continue our many critical programs that help 
the Nation prepare, respond to, and recover from public health 
emergencies and disasters.
    Today, ASPR is working on more high-consequence, no-fail 
missions than ever before. ASPR must have the necessary funding 
to keep up with the evolving and expanding threat landscape. 
That is why we have asked for a $4,270,000,000 in fiscal year 
2024. And with this fiscal year 2024 budget request, I am 
trying to solve three key problems.
    The first problem I am trying to solve is how ASPR 
maintains the capabilities we built during COVID so we have 
them for future responses as well. Many of these capabilities 
were funded with COVID dollars and will go away with that 
funding unless we can transition them to our annual budget.
    One example is our supply chain capabilities. Throughout 
the pandemic, we used supplemental appropriations to invest in 
and strengthen the domestic industrial base and supply chain 
for key medical supplies. This work was born out of the initial 
supply chain pinches the country experienced in March 2020 when 
the whole world needed the exact same products at the exact 
same time, and they were all manufactured elsewhere.
    As we are seeing supply chain challenges in other medical 
products outside of COVID, it is important that we maintain the 
capabilities we have built and broaden them so we can apply 
them to head off shortages or supply chain pinches in the next 
outbreak or disaster we face. We need to move these programs to 
our annual budget to keep this capability, so we don't have to 
build it from scratch again when we are hit by the next public 
health emergency, outbreak, or disaster.
    That is why we are requesting $400,000,000 for pandemic 
preparedness and biodefense within the fiscal year 2024 budget 
to support continued efforts and activities in this area.
    The second problem that I am trying to solve with our 
budget request is how we stop losing time and start preparing 
for the next biological threats. Among the reasons we were able 
to move out so quickly with the countermeasures against COVID-
19 was because so much work was already under way on 
coronaviruses due to prior outbreaks of SARS and MERS.
    We know the next viral families most likely to cause a 
significant biological threat. While we have time, it is 
important to get the same head start we had on coronaviruses 
with these other families. We need funding to develop prototype 
vaccines, therapeutics, and diagnostics that we can put on the 
shelf and pull down when or should a virus from one of these 
families emerge and begin to spread.
    The fiscal year 2024 request includes $20,000,000,000 to 
support preparedness against biological threats, of which about 
$10,500,000,000 would come to ASPR to begin work against these 
viral families.

                  ASPR TRANSITION TO STANDALONE AGENCY

    And finally, the third problem I am trying to solve with 
our budget request is making sure that ASPR has the funding we 
need to fully transition into a standalone agency. It would be 
management malpractice for us to look like the same 
organization we were at the start of the pandemic. We have 
learned too much and grown too much in these last 3 years to 
move backwards as an organization.
    The Secretary, in recognition of all of the work we are 
doing in our expanded mission space, made us an agency last 
summer. This was to ensure that we have the independence to 
build the human resources, contracting, and finance 
capabilities we need to be able to quickly respond to whatever 
public health emergency or disaster is at hand.
    The fiscal year 2024 budget requests an additional 
$35,000,000 in operations to start building out our 
acquisitions and IT workforce, two functions critically 
important to our success as a standalone agency within HHS.
    Let me thank you again for your strong support of ASPR in 
previous budget cycles and assure you that this year's budget 
request is targeted to solve key problems as the ASPR 
organization continues to do all it can to help the country 
prepare for, respond to, and recover from public health 
emergencies, disasters, and whatever comes next.
    I look forward to working with you as you draft the fiscal 
year 2024 appropriations bill.
    Thank you again for inviting me to testify today. I look 
forward to answering your questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
                         NIH Opening Statement

    Mr. Aderholt. Thank you very much.
    And last, but not least, joining the panel today is also 
Dr. Lawrence Tabak. He is performing the duties of the Director 
of the National Institutes of Health, officially taking office 
on December 20, 2021.
    Dr. Tabak has served as the Principal Deputy Director and 
the Deputy Ethics Counselor of NIH since 2010. He previously 
served as the Acting Principal Deputy Director of NIH and, 
prior to that, as the Director of the National Institute of 
Dental and Craniofacial Research from 2000 to 2010.
    So, Dr. Tabak, we are honored to have you here and look 
forward to your testimony as well.
    Dr. Tabak. Thank you, Chair Aderholt, Ranking Member 
DeLauro, and distinguished subcommittee members. I am honored 
to be here today representing the National Institutes of 
Health.
    Our mission at NIH is to seek fundamental knowledge about 
the nature and behavior of living systems and apply that 
knowledge to save lives and improve health. Fundamental, 
translational, and clinical research are critical components of 
the biomedical research enterprise.
    However, fundamental or basic research rarely makes 
headlines. Understanding how proteins fold and are subsequently 
decorated or how gene activity is controlled doesn't often 
improve human health immediately, but fundamental research is 
essential for breakthrough discoveries that lead to treatments 
and cures.
    An independent analysis by researchers at Bentley 
University found that NIH funding contributed to the 
development of every new drug--all 356--approved by the FDA 
from 2010 through 2019. NIH supported the foundational evidence 
that pharmaceutical companies leveraged to develop lifesaving 
drugs and many thousands of patents.
    I have spoken to this subcommittee previously about how 
fundamental research from NIH-supported scientists and 
collaborators positioned the U.S. to develop COVID-19 vaccines 
on an unprecedented timeline, but there are many other examples 
of how fundamental research has led to improvements in the 
health of Americans. One such case is the breakthrough stroke 
treatment that resulted after decades of work to understand the 
basic biology of how enzymes can dissolve blood clots.
    Researchers first described the enzyme that would become 
known as tissue plasminogen activator, or tPA, in 1946. Three 
decades later, cancer cells grown in the lab were found to 
produce large amounts of tPAs. A decade after that, NIH-
supported clinical trials led to the approval of tPA to treat 
heart attacks. And then, in 1990, the tPA transformed the 
treatment of stroke, allowing most patients who are treated 
within 3 hours to make full recovery with far-reduced 
healthcare costs.
    Many of our most important advances have come when we were 
not even thinking about a direct application. For example, 
decades ago, NIH funded research on how bacteria protect 
themselves from viruses. No one involved in that work could 
have predicted that that effort would lead to tools that would 
revolutionize all of medicine.
    Because of research on recombinant DNA in the 1960s, it 
became possible to produce drugs at large scale, like insulin 
and tPA. Starting in the 1980s, continuing research on gene 
editing tools more recently led to CRISPR, an extremely 
versatile method that is paving the way for cures for multiple 
diseases, including sickle cell and antibiotic-resistant 
urinary tract infection.
    Discoveries build upon each other in ways that we cannot 
necessarily predict. Your sustained public investment in 
fundamental research is essential to the discovery and 
development of new medical treatments. To foster the 
application of fundamental research, NIH continues to support 
translational research studies and collaboration with industry 
to advance crucial interventions for the public.

                                NALOXONE

    As most of you know, naloxone is a lifesaving treatment 
that can quickly restore normal breathing when someone 
overdoses on opioids. This drug is an essential tool in the 
fight against the opioid overdose crisis, which claims 188 
lives in the United States every day.
    Injectable naloxone was used for years, but an easier 
intervention was needed. In 2013, scientists from the National 
Institute on Drug Abuse created a stable formulation of 
concentrated naloxone for use in a nasal spray injector 
developed by an industry partner. Working together, they 
conducted clinical trials to evaluate the nasal spray 
formulation, providing pivotal data to support FDA approval of 
Narcan in 2015. And just a few weeks ago, the FDA approved 
Narcan for use without prescription.
    NIH-supported discoveries affect nearly all of our lives 
from research studies that laid a foundation for future 
biomedical advances to clinical trials that evaluate 
potentially lifesaving interventions. Your continued support of 
our mission to help people live longer and healthier lives is 
crucial.
    I thank you for your time and welcome your questions.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Dr. Tabak.
    And what I will do is I will just open it up, my questions, 
and we will go by the 5-minute rule. And we each will be given 
5 minutes. So we will try to keep your answers as succinct as 
possible so that we can try to get around to everyone at least 
on the first round.

                           CDC COVID MISSTEPS

    So I will begin. And I would like to just pose a question 
for each of you to answer, and I just--as I mentioned, looking 
back, we learned things that we--mistakes we have made that 
maybe even obviously there was some accomplishments that were 
made as well. But what do you see or you think was the greatest 
misstep from your agencies that was made during the COVID 
pandemic?
    And second of all, could you mention any changes that you 
are looking at or you have implemented so these mistakes would 
not happen again?
    So I will just open it up to whoever would like to go 
first.
    Dr. Walensky. I am happy to take that on. Thank you very 
much for that question.
    As you know, there were many challenges associated with 
this pandemic. We started with a frail public health 
infrastructure, an underinvested public health infrastructure 
that presented challenges, and we had many tragedies, 1.1 
million deaths.
    As part of the CDC Moving Forward initiative, we looked at 
the capabilities of what CDC has done over the last 3 years and 
have done the work to prepare CDC to be the agency, the public 
health agency of the future.
    Two key initiatives there have been related to moving our 
science faster so that people can see our science in real time. 
We saw that as we put out technical reports on our mpox. We 
were the first in the world to report on how the vaccine was 
doing. We have decreased our scientific clearance time by 50 
percent, and we have more work to do in that area.
    Another area is in communication. It is the case that in 
2018, many Americans didn't know what CDC was and didn't know 
what CDC stood for. And all of a sudden, during the pandemic, 
we had people coming to our website to try and understand what 
the latest guidelines were.
    We are now needing to communicate to the American people, 
not just to our public health partners, not just to our 
academic partners. As part of that, we are doing an overhaul 
now of our CDC website, which has 200,000 scientific Web pages, 
making sure that those Web pages are accessible to the 
communities that need them.
    And we have increased our communications towards more 
accessible communications for all Americans. There is much more 
work to be done, but I want to yield to my partner.
    Thank you.
    Mr. Aderholt. So communication would be one of them. What 
was the first one?
    Dr. Walensky. Moving our science out faster.
    Mr. Aderholt. Thank you.
    Ms. O'Connell. Thank you, Chairman. I am happy to go next.

                          ASPR LESSONS LEARNED

    So I think one of the things that the ASPR organization 
learned early on is that we need a fully stocked, fully 
purposed for the moment Strategic National Stockpile. Early in 
the pandemic in March 2020, everyone was looking for the same 
medical supplies at the exact same time, and they weren't in 
the stockpile in the ways that people expected. That was one of 
the things that we have been growing from and learning from in 
our experience.
    We continue to invest heavily in the supplemental funding 
that you guys have given us to be able to restock and make sure 
that the SNS is ready with the PPE it needs for whatever comes 
next.
    One of the critical pieces of that work that we are doing 
is that we are doing it with domestically manufactured PPE 
wherever possible. We think it is critically important that we 
begin to manufacture these critical medical supplies here in 
the United States, and we have invested over $16,000,000,000 in 
our domestic manufacturing, expansion of the industrial base.
    And so those are things that we are continuing to apply as 
we evaluate, but I can assure you we are doing the lessons 
learned constantly, looking at mistakes that have been made, 
and trying to improve as we go.

                         RESILIENT SUPPLY CHAIN

    Mr. Aderholt. Let me just follow up on that. You mentioned 
about the lack of preparedness. Of course, that was really 
leading up to March 2020, as you mentioned. But during the time 
of the COVID itself, after COVID starts, what if any missteps 
do you see?
    Ms. O'Connell. Well, we continue to need to make sure that 
we have a resilient supply chain, and so one of the big focuses 
that we have and one of the reasons why we have made this 
request in our fiscal year 2024 budget is to be able to 
institutionalize this work in ASPR. It is critical in disasters 
that we have what we need when we need it.
    I have made a reorganization that we did. A few months ago, 
I made the Industrial Base Expansion Management and Supply 
Chain Office a permanent office within ASPR, with the Director 
reporting to me. So we are going to keep our eye on these 
issues moving forward.
    Mr. Aderholt. Dr. Tabak.

                          NIH LESSONS LEARNED

    Dr. Tabak. From our perspective, early on, a number of 
investigators, either with direct or indirect NIH support and 
very well-intended, launched rapid trials that unfortunately 
were underpowered. And with the benefit of hindsight, I think 
we could have done a better job engaging with the extramural 
research community to try and do a better job of coordinating 
to ensure that these types of trials were properly powered from 
the get-go.
    Going forward, we have been engaged in a clinical trials 
reform, if you will, within the agency to see how we can do 
these things better. And this was one of the elements that 
informs that discussion.
    Mr. Aderholt. Great. And so are you all implementing those 
changes now?
    Dr. Tabak. We are. We are beginning to do so. It requires 
quite a bit of discussion across the agency and with members of 
the extramural community.
    Mr. Aderholt. Thank you. All right. I will turn now to my 
ranking member, Ms. DeLauro.

                           2024 FUNDING CUTS

    Ms. DeLauro. Thank you very much, Mr. Chairman.
    And thank you to the three of you for letting out where you 
want to try to move forward and what we try to need to do to 
move forward in an effort to not find ourselves in similar 
circumstances that we did 3 years ago.
    Which is why I am very much concerned, as I said, that we 
have some members of our House majority demanding massive 
funding cuts in the 2024 appropriations bills. And if you apply 
the 2022 numbers, that we could look at cutting domestic 
funding by at least 22 percent below current levels.
    So as leaders of the agencies that are focused on 
protecting and improving our health, I would like to have each 
of you give us an idea about the real impacts, consequences of 
the cuts being proposed with regard to use of that 2022 number 
for 2024.
    And I would like to have you describe this in human 
consequences. What are the consequences to children, to 
families, to seniors, to the millions of people across the 
country?
    Dr. Tabak, how would you--how would these proposed cuts 
impact the millions of patients who depend on NIH's research?
    Dr. Walensky, with approximately 70 percent of CDC's 
funding going out to public health partners, how would these 
cuts be felt in our communities?
    Assistant Secretary O'Connell, how would the cuts make us 
less prepared for a public health crisis or a new outbreak of 
avian influenza?
    Dr. Tabak. Cuts of that magnitude would, of course, require 
that we dramatically reduce the number of new grants that we 
would be able to fund. We would estimate roughly a diminution 
of 5,000 grants. In part, that is because we would want to 
preserve the ongoing investments so as not to lose them, 
although they would be subject to some cut as well.
    The net result, of course, is delay of potential 
interventions that could help people. The net result is a 
chilling effect on the biomedical community. Will a young 
person want to go into science if they watch their mentors 
struggle with support? And unfortunately, in situations that 
dramatic, younger investigators would likely be selectively 
disadvantaged.
    Ms. DeLauro. Dr. Walensky.
    Dr. Walensky. Thank you. As you know, Ranking Member 
DeLauro, most of the resources that CDC receives goes directly 
out into the States and local jurisdictions. I think we can all 
agree that we were not in a state of pandemic preparedness from 
a public health standpoint at the beginning of this pandemic.
    Ms. DeLauro. When you say jurisdictions, you are talking 
about States and cities?
    Dr. Walensky. And counties.
    Ms. DeLauro. And counties.
    Dr. Walensky. And counties, local jurisdictions. Yes, 
exactly. Sometimes they go through the States to the counties. 
Sometimes they go directly to counties and local jurisdictions 
to your people.
    So we have made huge investments over the supplemental 
funding during COVID to bolster that public health 
infrastructure in workforce, in personnel, in data systems, to 
build the public health system that we need for the future to 
address our being prepared for the next pandemic.
    To cut those back would be to regress, to backslide to an 
area of not being prepared again for a pandemic. Specifically, 
we have resources in this budget that will--last year, we 
screened a million women--uninsured women for breast cancer. 
Those things would not happen.
    Last year, we were able to send disease detectives into 
your jurisdictions to help with outbreak investigation. We will 
have fewer of those to go. We will have less resources to do 
interventions to prevent opioid use, to prevent--to allow 
people who are using opioids to link to care.
    And finally, one of the biggest equity challenges that we 
had during this pandemic in vaccine distribution was in the 
rural-urban divide. We will not have those resources in rural 
health if we cut those resources in this budget.
    Thank you.
    Ms. O'Connell. Thank you, Chair DeLauro--Ranking Member 
DeLauro, for the opportunity to respond.
    A real concrete example, as Dr. Walensky mentioned, the 
Marburg outbreak that is currently happening in Tanzania and in 
Equatorial Guinea. Over the last 6 months, we have had a second 
viral hemorrhagic fever, an Ebola Sudan outbreak in Uganda. 
Both Ebola Sudan and Marburg lack licensed vaccines and 
therapeutics.
    BARDA has made a request for $162,000,000 in this year's 
budget to advance two promising candidates from Phase I into 
Phase II to protect Americans. Everyone is aware that all of 
these outbreaks are just one airplane ride away. So if we lose 
funding and move back to fiscal year 2022, we lose the 
advantage of having the potential protection that these 
investigative therapies and vaccines could bring.
    Ms. DeLauro. Thank you. My time is up.
    Thank you, Mr. Chairman. I yield back.
    Mr. Aderholt. Okay. Mr. Fleischmann.

                               NIH TRIALS

    Mr. Fleischmann. Thank you, Mr. Chairman.
    And Dr. Tabak and Dr. Walensky and Secretary O'Connell, 
thank you so much for appearing before us today.
    Dr. Walensky, I want to thank you for the phone call that 
we had about a month or so ago, and we addressed the portfolio 
and a lot of our mutual concerns. And I so appreciate that, 
appreciate the call.
    As most of you know, I represent east Tennessee, 
Chattanooga and Oak Ridge not too far away from Atlanta. And I 
have enjoyed my time, now about a decade, on this distinguished 
subcommittee.
    My first volley will deal with the NIH. The NIH plays a key 
role in bolstering the Nation's clinical trial capabilities to 
ensure that we have the ability to rapidly translate new 
medical discoveries into drugs, vaccines, devices, and 
diagnostics for patients at the bedside. The Clinical and 
Translational Science Award Program at NCATS is focused on that 
mission.
    The CTSA program consists approximately of 60 hubs at 
medical research institutions across the country. We are 
fortunate in Tennessee that Vanderbilt University Medical 
Center in Tennessee is one of these hubs. Vanderbilt is also 
helping to lead the NIH Trials Innovation Network.
    Dr. Tabak, can you speak about how NIH uses the Clinical 
and Translational Science Award Program to advance clinical 
trial capabilities, sir?
    Dr. Tabak. Well, the CTSA program, as you note, is a 
nationwide consortium. And for example, the efforts 
collectively of the CTSAs during the response to the pandemic 
were very important. They provided, for example, electronic 
health record data to the N3C platform, which allowed us to 
rapidly assess the status of the disease.
    We also have used the CTSA program as, if you will, the 
laboratory to learn better ways of performing clinical trials, 
and then these best practices are disseminated throughout the 
network and beyond. And then, in addition, the CTSAs are a site 
for training the next generation of clinical investigators, and 
people beyond just the institution that holds the CTSA program 
benefit because of relationships that each of these centers 
makes with surrounding institutions.
    Mr. Fleischmann. Thank you, sir.
    A follow-up. How can we do a better job of expanding 
clinical trials to improve rural communities, which generally 
do not have access to care, sir?
    Dr. Tabak. So, in this instance, of course, the key is to 
engage people at the local level. Traditionally, research of 
this type has been done at tertiary and quaternary care centers 
around the country. What we are learning increasingly that it 
is important to reach out to the community hospitals and either 
provide them with the necessary training so that they can 
participate in this type of research in partnership or, indeed, 
alone as their own individual network.
    And we have some experience with that, for example, in the 
response to the opioid crisis where the clinical research has 
been done in rural communities looking at how best to treat 
babies with so-called NOWS syndrome.
    Mr. Fleischmann. Thank you.

                            CANCER RESEARCH

    Doctor, now I would like to talk briefly about something 
that is near and dear to my heart, cancer research. I speak 
with Dr. Jordan Berlin at Vanderbilt on a regular basis, and we 
talk about different forms of cancer and where are progress and 
sometimes the lack thereof. Which areas of cancer research, 
Doctor, have seen the greatest progress in the last 5 years? 
Where is the greatest potential in cancer research in the next 
5 years? And what will it take to get us to maximize that 
potential, sir?
    Dr. Tabak. Well, of course, there is tremendous hope and 
promise in various forms of human immunotherapy, where we teach 
your own body's immune defense system to seek out and destroy 
cancer cells. As part of the so-called Cancer Moonshot, the 
need to diagnose cancers earlier is very much at the forefront, 
and it is very likely that platforms where one can do a simple 
blood test to potentially detect multiple types of cancer, 
which need, of course, additional testing, that will probably 
pave the way to the future where we can find cancer sooner to 
ensure treatment quicker.
    Mr. Fleischmann. Thank you. And by the way, I wish you 
every success in those endeavors.
    I yield back.
    Mr. Aderholt. Mr. Hoyer.
    Mr. Hoyer. Mr. Chairman, thank you. Thank you very much.

                        CORRECTING PAST MISTAKES

    Mr. Chairman, I am constrained to respond to your statement 
at the beginning. I think much of it is accurate and that we 
need to make sure that whatever mistakes were made are 
corrected and that we address those mistakes. But I am 
constrained to say that, unfortunately and sadly, the chief 
executive of our country responded in an irresponsible, 
reckless, and dismissive fashion in February and in March, 
telling the American people that this was going to be resolved 
in just days, and it would go away.
    That obviously was not the truth. We lost more people as a 
result of this pandemic than we lost in World War II. So, yes, 
we need to learn from our mistakes, but we also need to learn 
that we cannot be dismissive of the challenge that confronts us 
in the future, and we must respond to it effectively.
    I also believe that the Obama administration had an outline 
on how to respond and what steps to take that was dismissed and 
eliminated. Nobody needs to comment on that. It is not 
question. It is an observation.
    I have a--have had since 2010 an agenda that the Democrats 
have pursued. It is called Make It in America. The pandemic 
showed us that we were relying on the unreliable. Not only the 
unreliable allies as manufacturers, but also unreliable supply 
lines.
    Secretary O'Connell, I want to congratulate you on pursuing 
vigorously manufacturing here in the United States of America 
so that we do not confront that situation again. Can you 
briefly expand upon that? Because I chair an organization that 
was formed by Leader Jeffries, which is about implementation to 
that evident need of Making It in America.
    Ms. O'Connell. Thank you, Congressman.
    Yes, absolutely, this is one of the critical learnings 
coming out of the early days of the pandemic is that we 
absolutely need to have these critical supplies manufactured 
here in the United States. We have been able to--and thanks to 
the support of Congress--invest supplemental dollars, 
$16,000,000,000 supplemental in domestic manufacturing, over 87 
different projects from PPE to advanced pharmaceutical 
ingredients, critical components that we need to be able to 
have the resources available in the United States when we need 
them.
    And we have--so one of the worries I have, as I put this 
budget forward, is how do I maintain that capability? I have 
got these 87 projects. So when we reorganized ASPR as a result 
of becoming an agency, I made sure that we had the standalone 
office within ASPR that does industrial base management and 
supply chain work. So we continue to be able to provide the 
technical assistance needed to keep those 87 projects moving.
    Part of the $400,000,000 that we have requested will go to 
supporting that technical assistance. It would be wonderful if 
in the future annual budgets would include additional funding 
to be able to invest in future projects because we are just at 
the beginning of this, of needing to reestablish this 
industrial base here in the United States.
    Mr. Hoyer. Madam Secretary, thank you for that.
    We are also going to have a stockpile that evolves so that 
new stuff doesn't become so old that it is no longer necessary. 
You need to get that back on the market. So I will follow up 
with you on that.
    Dr. Walensky, thank you for your service. Thank you for 
bringing your extraordinary talent to public service.
    I am going to ask quick questions, and you give quick 
answers because we don't have any time.

                             MENTAL HEALTH

    What is the CDC doing to address the effects of COVID-19 
beyond the immediate health effects in terms of mental health, 
in terms of other health, longer-term health aspects?
    Dr. Walensky. Many of our programs in the community--mental 
health, substance use, youth violence--many of these things, 
prevention of adverse childhood events, those are some of the 
things that we are doing looking at data and how we can prevent 
those adverse childhood events and prevent the downstream 
impact of those childhood events.
    Linking people within the community, making sure people 
have community within their schools, working in what works in 
schools, projects within the schools, how it links with youth 
within the schools, their community, ensuring economic 
stability, family unity within the community. There is a lot of 
work that is happening.
    Maternal mortality again another issue. The Hear Her 
campaign. There is a lot of work happening in maternal health 
in mental health, in opioids, as well as the prevention of 
chronic diseases that lead to severe outcomes of COVID-19.
    Thank you.
    Mr. Hoyer. Thank you.

                       NIH EXTRAMURAL GRANT CUTS

    Again, because my time is short, it is almost out. NIH, I 
am very concerned about the cuts to the extramural grants that 
will adversely affect the inclination of people to go into 
basic biomedical research. I think it is a crisis, and we will 
see other countries going past us very quickly in terms of the 
capability they have in terms of personnel.
    Dr. Tabak.
    Dr. Tabak. It is a real issue. We already have challenges 
in attracting young people to biomedical research. In fact, my 
National Advisory Committee has a special working group to look 
at how we can best shore up the career path for people entering 
postdoctoral training and beyond.
    Mr. Hoyer. Just briefly, in closing, Mr. Chairman, I have a 
chart that shows how drastically, since my last service on the 
committee many years ago, the payline for extramural has 
declined precipitously where it used to be. And experts say a 
third would be where we ought to be. We are in the teens in 
most institutes.
    Thank you.
    Mr. Aderholt. Dr. Harris.
    Mr. Harris. Thank you very much.

                           BALANCING BUDGETS

    And thank you all for being here with us.
    Look, I wish I lived in the fairy land of President Biden's 
budget. I wish I did. I wish I could pretend we don't have a 
$31,000,000,000,000 deficit, that our cost on managing that 
interest is going to top $1,000,000,000,000 within the CBO 
window. I wish I lived in that fairy land.
    We don't live in the fairy land. In fact, when the 
Washington Post, the day after the President's budget--which, 
by the way, was a month late, which is why we are meeting late 
here--the Washington Post said the United States--this is their 
editorial. Now I rarely agree with the Washington Post 
editorial board. But, boy, a stopped clock is right twice a 
day, and they are right on this one.
    ``The United States has a debt problem. Biden's budget 
won't solve it.''
    I am going to ask you all a simple question. You all handle 
budgets. Dr. Tabak, do you balance your budget every year at 
the NIH?
    Dr. Tabak. We are obligated to.
    Mr. Harris. Thank you. Dr. Walensky, do you balance your 
budget?
    Dr. Walensky. We are obligated to.
    Mr. Harris. And Ms. O'Connell, do you balance your budget?
    Ms. O'Connell [nodding yes].
    Mr. Harris. So you all realize you have to balance the 
budget because you can't print money, but somehow the President 
believes we don't have to balance the Federal budget. In fact, 
all of you--Ms. O'Connell, I don't know if you did a lot of 
math, but you two did a lot of math in your training, right? 
You realize the President's budget that he submitted never, 
ever balances--ever, ever, ever?
    It is one of the first presidential budgets to never 
balance in the future. You all did enough math to know that is 
not sustainable. So our goal is to say, look, we have to 
reprioritize spending. And I wish we could spend every dollar 
of that President's budget--well, most of every dollar--on 
everything, but we don't have the money.

                   ROUTINE VACCINATIONS FOR CHILDREN

    So I am going to just start with the scientific questions. 
Dr. Walensky, we have talked about this before. Since we met in 
our office, the World Health Organization has recommended 
against routine vaccinations for children. Is the CDC going to 
change its recommendation to comply with that?
    Dr. Walensky. I think the World Health Organization comment 
was to be country specific. Certainly, countries that can't 
vaccinate or haven't vaccinated for polio have zero-dose 
children to not prioritize COVID. We are in a----
    Mr. Harris. So you are not going to change your 
recommendations based on the World Health Organization?
    Dr. Walensky. No, our recommendations--given the resources 
we have in this country, our recommendations for pediatric 
vaccinations will stand. Because we have clean water and----
    Mr. Harris. Sure. Okay, I am talking about COVID in 
particular. I am not talking about other vaccines. I am talking 
about COVID in particular because my concern is that, as we 
discussed, about those COVID studies that recommended 
vaccination were based on immunobridging. The World Health 
Organization said quite specifically that almost all infants 
and children now have COVID antibodies, and that is why--that 
was the basis of their recommendation.
    So I am going to disagree with you. I think that is a move 
that has more politics than it has science.

                             INDIRECT COSTS

    Dr. Tabak, we want to maintain the grants, but we have to 
somehow constrain the budget. So I am going to ask you, when 
Stanford University has a $37,800,000,000 endowment, why are we 
paying a higher indirect cost to them than they--for your NIH 
grant than they would if they did an agriculture grant, which 
is capped at 30 percent? Many private foundations cap it at 10. 
Some don't allow any indirect costs.
    So why shouldn't this committee, in an effort to maintain 
the number of grants while cutting back, ask these 
universities--Stanford University, $38,000,000,000 endowment; 
University of Michigan, $17,000,000,000; Washington University, 
$12,000,000,000; Duke University, $12,000,000,000--why 
shouldn't they pay their fair share? Why shouldn't they have 
some skin in the game of research, especially since in other 
areas, one that I oversee in agriculture, we cap it at 30 
percent?
    Why shouldn't we do that in order to constrain our budget 
to, again, move out of the fairy land that President Biden 
lives in and move into the real world.
    Dr. Tabak. As you know, Dr. Harris, NIH does not set 
indirect cost rates.
    Mr. Harris. I understand that, but why--but we could, in 
fact, cap it. Congress could cap the--just like they do in the 
agriculture. When Stanford University has $37,800,000,000--that 
was fiscal year 2022. I don't know how they did in the market 
last year. That is a pretty significant chunk of money. One 
would ask why are we--why do we have to pay such high indirect 
costs? And I don't know what Stanford is because, quite 
honestly, NIH is a little not forthcoming with information on 
indirect costs.
    Don't appreciate that because taxpayer dollars pay those 
indirect costs. Why should we do it? Why shouldn't Stanford--
why should we pay any more than 30 percent indirect cost?
    Dr. Tabak. Indirect cost recovery is based on a formula, 
and we don't control it.
    Mr. Harris. All right. But we could.
    I yield back, Mr. Chairman.
    Mr. Aderholt. Okay. Mr. Pocan.
    Mr. Pocan. Thank you very much, Mr. Chair, and thank you to 
the panel.

                   IMPACT OF CUTS ON OPIOID PROGRAMS

    I guess I might say it this way. I wished I lived in a 
world where you could cut expenses 25 percent and not actually 
hurt real people. The problem is I think a lot of the cuts that 
are going to be proposed are going to hurt real people.
    One in particular, Dr. Walensky, is around trying to deal 
with opioid abuse. Forty-five million Americans have a 
substance abuse problem. Over 100,000 people die from overdose 
every year, including recently an old friend of mine I found 
out over--during COVID, her daughter died of an overdose.
    CDC awards grants. You track overdose data. We raise public 
awareness. We do lots to help in this, especially as much as 
people love to talk, rightfully so, about fentanyl in the 
communities.
    Can you talk a little bit about the programs at CDC that 
would be reduced or eliminated if Republicans were successful 
in slashing funding for affecting opioid use?
    Dr. Walensky. Thank you, Congressman.
    So 107,000 deaths last year. This was just reported, as you 
note. This is exacerbated a problem that was rising during the 
pandemic and--rising before the pandemic, was exacerbated by 
the pandemic.
    We do a lot of work on the prevention. On the up scale, 
this is an all-USG response in terms of our opioid work. But a 
lot of work in the prevention in the community, in 
understanding where the challenges are and in linking people to 
care, in training and Narcan use, and in treating and creating 
communities so that people have places to go.
    One important thing we also do is Overdose Data to Action. 
I just mentioned 107,000 opioid deaths. What we see in our 
emergency departments is 10 times that number for nonfatal 
overdoses. And so if we don't know where those are coming into 
the emergency departments, we can't target our interventions. 
Our Overdose Data to Action is an intention to find those 
emergency departments, have them report to us so that we can 
target those interventions to where they are needed most.
    Thank you.
    Mr. Pocan. The effect is in our local communities most 
directly?
    Dr. Walensky. In your emergency departments everywhere, 
yes.
    Mr. Pocan. Thank you.

                        PUBLIC HEALTH WORKFORCE

    Second, a Harvard study found that nearly half of public 
health agency employees left their jobs over the last few 
years. Can you talk a little bit about, again, what CDC does--
just briefly because I want to get to one other question--to 
attract, retain, and support public health professionals that 
we have a workforce?
    Dr. Walensky. We have resources from the 2023 budget where 
we have worked to promote our workforce. That is--promoting a 
workforce as diverse as the community that we serve. That 
workforce really needs to be trained in many different things.
    In your local area, the Upper Peninsula of Michigan, we are 
doing work right now on a blastomycosis outbreak that people 
might not have seen coming, right? But we have a workforce that 
is there. So we have training that is happening at CDC and 
local training. We have training in partnerships to promote 
loan repayment programs so we can retain people, and then we do 
training in the local health departments and work with the 
local health departments to allow them to expand as well.
    Mr. Pocan. If you received a 25 percent cut in this area?
    Dr. Walensky. You would have less people doing it. As you 
noted, we were 60,000 public health work jobs in deficit when 
the pandemic started. Half the people who were there have left. 
We have 15 percent of our CDC workforce ready to retire.
    Mr. Pocan. Thank you.

                               BAYH-DOLE

    A question for Dr. Tabak. Thank you for being here. Really, 
I think, what is great is there is a lot of bipartisan support 
for NIH. There always has been since I have been here in 
Congress, and we see the work in our communities. And thank you 
for that.
    However, I do have to say I have some concern around the 
fact that NIH has never in the last four decades used their 
authority under Bayh-Dole to break monopolies on taxpayer-
funded treatments. I was disappointed to recently see us pass 
up on the opportunity yet again by denying a petition to lower 
the price of Xtandi, a cancer drug that costs Americans four 
times more than in other countries.
    Can you just talk--I know the President is putting a 
working group together, interagency working group on this. But 
can you talk about what your role will be within that group, 
and when you will expect results? But also how can you move the 
needle on lowering drug prices now without waiting for the 
interagency?
    Just so you know, I ask every year this question of whoever 
is in the NIH if we are going to use this and just want to 
raise that as you are new here.
    Dr. Tabak. Well, and Bayh-Dole is not the instrument, in 
our view, to regulate drug pricing. It would be a very blunt 
instrument, one which we think would in the long run inhibit 
relations with industry. And so this is why the Xtandi petition 
was denied.
    But as you point out, we do need a whole of government 
approach to figure this out, to see what instances where Bayh-
Dole might make sense. And so the Department, together with 
colleagues at the Department of Commerce and NIST, will be 
working together to look at this. There is actually an 
interagency working group on Bayh-Dole, and hopefully, this is 
where we will be able to come up with a logic tree that would 
enable a way forward for future effort.
    Mr. Pocan. Timeline on that?
    Dr. Tabak. Pardon?
    Mr. Pocan. Timeline?
    Dr. Tabak. So that effort is beginning now.
    Mr. Pocan. Thank you. I yield back.
    Mr. Aderholt. Mr. Clyde.

                             COVID ORIGINS

    Mr. Clyde. Thank you, Chairman Aderholt, for holding this 
hearing and to the witnesses today.
    Mr. Tabak, did American taxpayer dollars go toward funding 
the Chinese Wuhan Institute of Virology?
    Dr. Tabak. Yes.
    Mr. Clyde. All right. More specifically, was there gain-of-
function research done at the Wuhan Institute of Virology, 
which received American taxpayer dollars?
    Dr. Tabak. No.
    Mr. Clyde. No. All right. Did the COVID-19 virus originate 
from the Chinese Wuhan Institute of Virology?
    Dr. Tabak. I have no idea.
    Mr. Clyde. All right. What do you know about the origin? I 
mean, you are the NIH.
    Dr. Tabak. Well, again, the origins, there are two 
prevalent theories. A lab accident or, as you say, a lab leak 
versus a zoonotic transfer from animals to humans. In my mind, 
the available evidence favors the latter, but of course, our 
minds are open to the former possibility.
    Mr. Clyde. It favors the latter as in that it came from----
    Dr. Tabak. A zoonotic transfer.
    Mr. Clyde. So that is what you favor, just a natural 
transfer from--from, what, bats to the human beings?
    Dr. Tabak. Through things like accipiters and such animals 
like that, yes.
    Mr. Clyde. Okay. All right.

                           VIRUS TRANSMISSION

    Director Walensky, in March 2021 on MSNBC, you stated that 
``Vaccinated people do not carry the virus. They don't get 
sick.'' Do you remember making that statement?
    Dr. Walensky. Yes, under the--I do--well, I remember such a 
statement, but I don't know if I remember that one.
    Mr. Clyde. Okay. Was that statement correct?
    Dr. Walensky. At the time, it was. It was a wild-type virus 
that we had. It was even before the Alpha variant, it was the 
initial wild-type virus, and all the data at the time suggested 
that people who were vaccinated, even if they got sick, 
couldn't transmit the virus to someone else.
    Mr. Clyde. All right. Is that statement still correct?
    Dr. Walensky. Well, so we have had an evolution of science 
and an evolution of the virus. We have since that wild-type 
virus had the Alpha variant, the Delta variant, now the Omicron 
variant, and numerous subvariants. That statement is no longer 
correct with the Omicron subvariants we have right now.
    Mr. Clyde. Okay, all right. A recent review of face mask 
studies by the Cochrane Collaboration suggested that common 
face masks worn by the public probably make little or no 
difference. Do you believe Americans should still be wearing 
face masks? A yes----
    Dr. Walensky. Can I just comment for a minute on that 
Cochrane Review?
    Mr. Clyde. Sure.
    Dr. Walensky. Cochrane is known as the gold standard, and I 
think it is notable that the editor-in-chief of the Cochrane 
actually said that the summary of that review was--she 
retracted the summary of that review and said that it was an 
inaccurate summary.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    The review of the Cochrane, which looked at randomized 
trials of face mask use versus not use, only had a couple of 
studies in it that actually were for SARS-CoV-2. Many of them 
were for influenza. But importantly, many of those studies 
people were actually not wearing the face masks when they were 
in the intervention. So, as I like to say, a parachute only 
works if it is used.
    Mr. Clyde. Okay. So can you answer the question?
    Dr. Walensky. Right now, we have recommendations for face 
mask use based on hospital burden. We have, fortunately, 99 
percent of places around the country, populations around the 
country that are not in high hospital burden, and we would not 
recommend face masks at a population level in those situations.

                           ECOHEALTH ALLIANCE

    Mr. Clyde. All right. Mr. Tabak, earlier this year, the 
Inspector General's report found that between 2014 and 2021, 
the NIH did not adequately follow its policies with respect to 
three grants totaling about $8,000,000 to EcoHealth Alliance. 
EcoHealth Alliance had a relationship with the Wuhan Institute 
of Virology in which it sub-awarded $600,000 to research 
coronaviruses in the years leading up to the COVID-19 pandemic.
    NIH terminated the EcoHealth grant in April 2020, then 
later reinstated it, only to suspend it again after setting 
conditions for resumption that EcoHealth claimed it could not 
meet. NIH permanently terminated the award as of August 2022 
for compliance issues, including the Wuhan Institute of 
Virology's failure to provide NIH with laboratory notebooks 
related to funded experiments.
    On September 21, 2022, NIH issued a new grant to EcoHealth 
Alliance for a project entitled, ``Analyzing the Potential for 
Future Bat Coronavirus Emergence in Myanmar, Laos, and 
Vietnam.'' The grant provides EcoHealth Alliance $653,000 
covering a period through August 31, 2027.
    And I ask unanimous consent to submit for the record the 
following project details from the NIH website, entitled 
``Analyzing the Potential for Future Bat Coronavirus Emergence 
in Myanmar, Laos, and Vietnam.''
    Mr. Aderholt. Without objection.
    Mr. Clyde. Thank you.
    After NIH previously failed to ensure its policies and 
procedures were properly followed with respect to EcoHealth 
Alliance and given the recent Inspector General's report 
highlighting that EcoHealth Alliance failed to ensure its 
subawards were compliant with Federal regulations, I must ask 
why are we awarding this agency an additional $653,000 of 
taxpayer money?
    Dr. Tabak. We accepted all of the GAO audit findings. We 
have made changes to our administrative approach to ensure that 
these things don't repeat. We typically, once an organization 
has met the issues that were found deficient, we continue our 
relationship with them.
    We are not--we can't disbar an organization. Again, 
disbarment is done by another office within the Department of 
HHS.
    Mr. Clyde. All right. And I yield back.
    Mr. Aderholt. Ms. Frankel.
    Ms. Frankel. Thank you, and thank you to our guests today 
for all your good work.

                        CAP ON FEDERAL SPENDING

    Now--especially in these challenging times. So our Speaker 
McCarthy has recently declared that the Republicans in the 
House would cap Federal spending at fiscal year 2022 levels and 
limit spending growth over the next decade to 1 percent 
annually. I suggest that is going to bring--that would bring 
misery and hardship to millions of Americans. Today, we are 
talking about the cuts to your agencies, cuts that are going to 
cause the most vulnerable in our community--women, children, 
and seniors--to suffer the most.
    Less spending on healthcare will mean more breast cancer, 
more cervical cancer, more maternity deaths, more suicides, 
more drug overdoses, more pandemics, more violence against 
women, and less hope for Alzheimer's patients. Sorry to be a 
downer.
    Okay. These proposed budget cuts have real consequences, 
human misery and hurt, especially for folks who are under 
resourced.

                          YOUTH MENTAL HEALTH

    All right. I am going to go on with my questions, and this 
is to our CDC Director. In February, CDC published a report 
that is sad and alarming. It found that in 2021, nearly 60 
percent of adolescent girls felt persistently sad or hopeless, 
double that of boys and a 60 percent increase since 2011. 
Nearly 1 in 3 girls seriously considered suicide, also up 
nearly 60 percent from a decade ago.
    One in 5 girls experiencing sexual violence, also an 
increase. Girls feeling increased pressure to use alcohol and 
drugs. Over half of the LGBTQ students have experienced poor 
mental health, and 1 in 5 have attempted suicide in the past 
year.
    And I would respectfully suggest that the recently enacted 
abortion bans in dozens of States will exacerbate these mental 
health issues now that girls are going to have to worry about 
and be forced to have to raise a family or bring a baby into 
life before they are ready.
    So, question. What recommendations are CDC working on to 
address these mental health issues, and how would these 
suggested budget cuts make it harder?
    Dr. Walensky. Thank you, Congresswoman.
    As I have noted, these mental health challenges, especially 
that we have been able to see and publish through our Youth 
Risk Behavior Survey, have been alarming, and we are working in 
the communities in areas with mental health with youth, but 
also with adults, to work towards economic stability, towards 
keeping kids in school, education, early childhood education, 
family resiliency, as well as prevention of adverse childhood 
events within the family.
    Mental and physical health, as you note, in the 
communities, and then really measuring these things so that we 
know where those resources are targeted and needed the most. 
Community engagement, understanding what is happening around 
the communities.
    We are not already reaching all the communities that need 
support. When we can't reach the communities that we are 
already reaching, we will have more and more of these outcomes.
    Ms. Frankel. And let me suggest that the great State of 
Florida is already pushing school districts to abandon the 
CDC's Youth Risk Behavior Survey, but what is new in Florida? 
How would a budget cut hurt these efforts?
    Dr. Walensky. With the abandonment of the Youth Risk 
Behavior Survey, we don't get a sense--we are flying blind. We 
don't see where our--we wouldn't see data on these youth mental 
health challenges. We wouldn't know where we needed to target 
the resources.
    So, unfortunately, it would be not seeing a window as to 
where places need help and not allowing us to then target the 
resources to give those communities the help that they need.

                    CANCER SCREENING AND PREVENTION

    Ms. Frankel. Next question also to you has to do with the 
increase in cervical cancer in women, and what is CDC doing to 
support patient navigator programs, including the National 
Breast and Cervical Cancer Early Detection Program? How would 
the budget cuts affect that?
    Dr. Walensky. So, last year, we were able to screen about a 
million uninsured women for breast and cervical cancer. A lot 
of the work we do is also in vaccination to prevent cervical 
cancer to begin with. That intersects with Cancer Moonshot, 
intersects with youth remaining healthy for HPV cervical cancer 
prevention programs.
    Ms. Frankel. And what will the budget cuts do to that 
program?
    Dr. Walensky. With the investment, we anticipate that we 
might be able to serve an additional 140,000 women and prevent 
2,500 invasive breast cancer events. Without it, those will 
occur.
    Ms. Frankel. Thank you. I yield back.
    Mr. Aderholt. Mr. Moolenaar.
    Mr. Moolenaar. Thank you, Mr. Chairman.
    And thank you all for being here today. I appreciate it 
very much.
    First, Dr. Walensky, thank you for the work that you are 
doing in Michigan right now with the outbreak. And as we have 
discussed, I think the work of the disease detectives and the 
assistance for communities is very important, and I certainly 
support those efforts.

                         UNSPENT COVID BALANCES

    To me, that is very high on the core mission of the CDC, as 
we have discussed. I have some concerns about mission creep in 
other areas, and that is something that I am sure we can talk 
more about that down the road.
    But I want to begin with last week, President Biden signed 
a resolution, strongly bipartisan support, ending the COVID 
national emergency. According to a GAO report published in 
February 2023, Congress has appropriated nearly 
$350,000,000,000 to the Public Health and Social Services 
Emergency Fund intended to develop vaccines, drugs, devices, 
tests, PPE.
    As of January 31st, there remains nearly $20,000,000,000 in 
unexpired, unobligated funds within the Public Health and 
Social Services Emergency Fund. Assistant Secretary O'Connell, 
can you provide the committee with a detailed accounting and 
summary of the unspent COVID-19 emergency supplemental balances 
that remain available to ASPR?
    Ms. O'Connell. Thank you so much, Congressman, for that 
question.
    I can assure you that, first of all, we are grateful for 
the support that we have received in the supplemental funding, 
and we have allocated the dollars that have come to ASPR 
against the current needs. Money has either gone out or is on 
its way out, except in two critical places. So I want to be 
clear about this.
    There are two places where we have taken the supplemental 
funds and used them against multiyear needs. One is in the 
industrial base expansion work I talked about. The investments 
that we have made in these construction projects are multiyear 
investments. It doesn't make sense to spend all of the money 
all at once until the factory lines are stood up, until the 
supply lines are running, until we know that the manufacturing 
is a success. So we have reserved some funds for that.
    The second place where we have reserved funds is in our 
Strategic National Stockpile. So I think folks are aware that 
the stockpile is a series of warehouses located across the 
country, in your districts, in your areas, so we can move 
product as quickly as possible in times of emergency.
    In order to take on the PPE that we did, in order to 
restock the stockpile so it would have what we needed, we have 
taken on more warehouses. Each warehouse has an additional 
lease, and with inflation, the lease prices have gone up.
    It is important that we reserve some of the funds to be 
able to maintain these warehouses so we don't have to destroy 
this PPE in fiscal year 2024 and 2025. So those were two places 
where ASPR has held on to funds.
    Mr. Moolenaar. Okay, thank you.

                            PROJECT NEXT GEN

    And then also, last week, the White House announced 
$5,000,000,000 for a program for next-generation COVID-19 
vaccines and therapeutics, Project Next Gen. Are you familiar 
with that?
    Ms. O'Connell. I am.
    Mr. Moolenaar. Okay. Can you describe what your role was in 
that process? Because Congress, most in Congress read about it 
in the paper, weren't really briefed about it. But were you 
involved with the creation of that?
    Ms. O'Connell. So one of the things that we have been 
signaling, and we have continued to signal when we have 
requested additional funds, is the importance of doing this 
research in the next generation of therapeutics and vaccines. 
We have been grateful for the current tools that we have, but 
this virus has been unpredictable and continues to mutate, as 
Dr. Walensky went through the various variants and subvariants 
that we are experiencing. We are afraid that we are one 
mutation, two mutations away from our vaccines and therapeutics 
no longer being as effective as we need them to be.
    So what this work would do would be invest in broader 
protection in vaccines and therapeutics in order to protect the 
American people moving forward.
    Mr. Moolenaar. And where--where will it be housed? Where 
will this be housed?
    Ms. O'Connell. It is an effort that will be led within the 
Department. And Dr. Tabak and I will share some responsibility. 
NIH has a role. ASPR will have a role. FDA would have a role. 
CDC would have a role. So it is something that will be done 
across the Department.
    Mr. Moolenaar. And was this statutorily set up, or is this 
something that interagency developed, and where did--what was 
the source of the $5,000,000,000 funds?
    Ms. O'Connell. So the $5,000,000,000, I think we have been 
very clear that we are running out of COVID dollars. We have 
indicated that over and over again. But we didn't have the 
winter surge we expected, and we had additional funds.
    Now that we are winding down the public health emergency, 
now that we are moving these products to the commercial market, 
we looked across the remaining balances and are working to make 
sure that we are spending them as effectively as possible. And 
we think creating the next generation of tools to protect 
Americans from COVID is a reasonable use of these next dollars.
    Mr. Moolenaar. Thank you.
    Mr. Chairman, I will yield back.
    Mr. Aderholt. Mrs. Watson Coleman.

                        ENDING THE HIV EPIDEMIC

    Mrs. Watson Coleman. Carrying the infrastructure up here. 
Thank you very much. I want to thank each of you for your very 
interesting and very important work that you do.
    Dr. Walensky, I want to talk to you a little bit about HIV 
because we have made such tremendous strides. We are almost 
there, right? We are almost there.
    So what, in your budget, are you proposing to do to get us 
there now? And what would be the impact of reducing your 
funding for that effort back to the 2020 funding levels that 
are proposed by some of our colleagues on the other side?
    Dr. Walensky. Thank you so much. This is something near and 
dear to my heart, as you know.
    As part of the End the HIV Epidemic, CDC works with 57 of 
the highest--of the jurisdictions with the highest amount of 
new HIV diagnoses. This is both State and counties that have 
the highest HIV diagnoses in the country. Our work is to 
prevent, detect, respond to, and treat these people who have 
new diagnoses with the HIV and people who are at high risk for 
HIV.
    Unfortunately, we see a discrepancy in how communities are 
able to tackle the HIV challenges, and those who have the 
highest risk of HIV are often those that don't have access to 
the prevention interventions that are needed. I am talking PrEP 
and, actually, the new injectable PrEP.
    Through the pandemic, we have been able to be creative and 
do things like self-testing. We had over 137,000 self HIV tests 
that were done during the pandemic so people could make new HIV 
diagnoses by themselves.
    We also used tele-PrEP. We were able to use the resources 
towards prevention activities where people didn't have to come 
in for a prescription every week. Injectable PrEP again, 
something like long-acting PrEP so people can get the 
prevention for longer periods of time. So all of these 
resources are baked into the 2024 budget, as well as all of the 
ancillary services that are needed for PrEP use, including 
laboratory monitoring as well as STI interventions as well.
    Mrs. Watson Coleman. Can you quantify the reduction in 
service, should you being forced to deal with the 2022 funding 
level?
    Dr. Walensky. We would have to get back to you on those--on 
those numbers, but I anticipate that that would mean thousands 
of new HIV infections that would otherwise be averted.

                            CANCER RESEARCH

    Mrs. Watson Coleman. Thank you. Thank you.
    Dr. Tabak, I wanted to talk to you about endometrial cancer 
research because we are making such tremendous strides in the 
whole cancer field, which we find new and different cancers 
each and every day. But it is my understanding that the 
endometrial cancer, there have not been these same declines, 
and in fact, the American Cancer Society's statistics show that 
over the last 10 years there has been more than 140 percent 
increase in endometrial cancer incidence and mortality.
    And there is also significant disparities in endometrial 
cancer, finding that black women have the highest rate among 
those who experience that particular type of cancer. And 
previous studies have shown that we are also much less likely 
to receive evidence-based care and two times more likely to 
die.
    We talked to the NIH on a number of occasions about 
clinicals, about research, and about those who get to choose 
who gets to research and whose research gets chosen, 
particularly as it related to what we consider to be an under-
included population of African Americans. I would very much 
like to know what your plans are for your research, how you are 
planning to tackle what represents a disparity, how your 
funding now proposes to deal with it, and how a diminution to 
2022 funding could possibly impact the work that you could do?
    Dr. Tabak. Well, we certainly are aware of the disparities 
that you point out and are, of course, concerned about it. 
Advances for addressing endometrial cancer include three 
immunotherapy treatments for advanced endometrial cancer, which 
the FDA has approved within the last couple of years.
    We have several relevant networks and trials. For example, 
the Epidemiology of Endometrial Cancer Consortium. We also have 
a Specialized Program of Research Excellence in endometrial 
cancer. And then, finally, there is the Discovery and 
Evaluation of Testing for Endometrial Cancer in Tampons, the 
so-called DETECT study. And so all of these are moving us in 
what I think is the correct direction.
    And then, as you may know, a recent study from NIEHS found 
that women who use chemical hair straightening products had a 
higher incidence of endometrial uterine cancer compared to 
those who don't report using these products. Now, of course, we 
need to do further research to see if it is merely an 
association, or if there is some causality involved.
    Mrs. Watson Coleman. I think that that is my question. What 
are you planning? Quantitatively, what would that mean 
differently than what you have been doing, and how would that 
be impacted if you were not given what you are asking for in 
resources?
    Dr. Tabak. Right. So, again----
    Mrs. Watson Coleman. And with that, I would yield back 
after you answer that question.
    Dr. Tabak. So, again, our unit of currency, of course, are 
grants awarded. And as I have indicated, if cuts of that 
severity occurred, we would lose about 5,000 new grants, no 
doubt among them some related to this topic.
    Mrs. Watson Coleman. Thank you, Doctor.
    I yield back, Mr. Chairman.
    Mr. Aderholt. Ms. Letlow.
    Ms. Letlow. Thank you, Mr. Chairman.
    Thank you so much for our panel for being here with us 
today.

                             COVID ORIGINS

    Coming out of the pandemic, there have been valuable 
lessons learned on how to attack and stop the spread of future 
pandemics. I have a personal story related to the pandemic, as 
do millions of others across this country who have a vested 
interest in finding out COVID-19's origin so we can hopefully 
prevent another pandemic like this from happening again.
    Just this past February, the Department of Energy released 
a report detailing how COVID-19 was likely the result of a lab 
leak in China. The GAO also issued a report in January of this 
year detailing how there had been other lab leaks resulting in 
infections and death.
    According to a New York Times report, it was known early on 
in 2020 that the CCP refused an American response team to 
assist in a response to the initial outbreak, where we could 
have had a better understanding of the infection and how to 
combat the spread. It seems to me that the CCP quickly realized 
there was an infection spreading, did not alert the U.S. 
Government until weeks into the spread, and then proceeded to 
not be compliant with our requests for information, data, and 
assistance.
    Over the past few years, Congress has been raising the 
alarms about lab leaks, especially when it was discovered that 
EcoHealth Alliance was sub-awarding our Federal funding to the 
Wuhan Institute of Virology. The American people, especially 
those of us who lost loved ones, deserve answers and want 
answers to know that the U.S. Government is prepared for future 
threats.
    Dr. Tabak, what is the status of the NIH's progress and 
plans going forward in finding the origins of the initial 
COVID-19 outbreak, and what is the NIH doing to redouble our 
efforts to ensure Americans are protected against these threats 
in the future?
    Dr. Tabak. We continue to support research that may provide 
insight as to what the origins were. We don't know what the 
origin was. And it is possible that it occurred from a so-
called lab leak or, as I prefer, a lab accident. But it could 
also have, as I mentioned, resulted from zoonotic infection.
    And unfortunately, we don't know the difference as yet, in 
part because of, frankly, the government of China not 
cooperating with us. They hold a key to unraveling this 
mystery.
    Ms. Letlow. How much of your funding is going towards those 
studies?
    Dr. Tabak. We have--we do not have any specific study 
looking at origins, per se. We do support evolutionary 
biologists who study viral evolution, and these are the 
individuals who are typically called upon to comment on this 
type of issue.
    Ms. Letlow. I understand that the NIH provides grant 
opportunities worldwide for research. However, I do have grave 
concerns about providing those opportunities to adversarial 
nations with a vested interest in seeing harm to the United 
States. What is the NIH doing to ensure our Federal funding 
does not go to research-based countries that are adversaries, 
such as the CCP?
    Dr. Tabak. So we, of course, are very sensitive to this. We 
have very minimal funding in China right now, and as was 
indicated earlier, the funding to the Wuhan Institute of 
Virology has been terminated for cause. And we are redoubling 
our efforts, as part of the GAO audit of our EcoHealth Alliance 
award, to ensure that our prime awardees do greater oversight 
of their subawardees, the subrecipients.
    The way the system works now is that NIH doesn't 
necessarily reach in to the subawardees. It is the primary 
awardee that is obligated to do that. We don't have the 
authority, frankly. Although, again, in instances where we see 
missteps, we can then write special terms so that we can sort 
of interpolate ourselves into more of that type of oversight.
    Ms. Letlow. But we do have minimal funding, you said, in 
China?
    Dr. Tabak. Yes. The current funding, I will get to you for 
the record. I have it. I am just not finding it.
    Ms. Letlow. For the record----
    Dr. Tabak. I will get it to you. It is a very modest 
amount.
    Ms. Letlow [continuing]. I have grave concerns with that. I 
feel like the American people definitely want to know the 
origins of the virus, and I would hope that there would be 
studies done on that.
    Dr. Tabak. As do we at NIH. We are intensely interested in 
that question.
    Ms. Letlow. But you said there weren't any studies going 
towards the origin.
    Dr. Tabak. There are no specific studies. But again, the 
community of evolutionary virologists that we fund, those are 
the people who would be doing these types of analyses.
    Ms. Letlow. Okay. I yield back.
    Mr. Aderholt. Mr. Harder.

                        SCIENTIFIC BREAKTHROUGHS

    Mr. Harder. Fantastic. Thank you so much, Mr. Chair.
    And thank you to all our witnesses for being here.
    Dr. Tabak, I am a big fan of the NIH, and I think I speak 
for everybody on this panel when we wish you the greatest of 
success in your goals. But I will say I am concerned by the 
pace of scientific research that we are seeing.
    One recent study that I read in Nature suggested that there 
has been up to a 90 percent slowdown in the pace of research 
breakthroughs funded by the NIH in major fields in recent 
decades. There has been tremendous innovation in how science is 
funded differently in the private sector and philanthropy. Just 
in recent years, we have seen Fast Grants, the Arc Institute 
between Berkeley, Stanford, and UCSF.
    One idea, among many, that has been proven successful is 
setting prizes or bounties for specific breakthroughs. I know 
the NIH has done a little bit of this in the past, sort of 
basically saying you get $1,000,000 if you achieve particular 
milestones and a specific disease breakthrough, but only 
awarded if that is actually achieved.
    Dr. Tabak, what have you learned from some of the 
innovative scientific funding models that we have seen outside 
in the private sector and in philanthropy, and do you see a 
greater role in the NIH for innovation prizes or other changes 
in the funding mechanisms?
    Dr. Tabak. Well, we have created some of those innovative 
funding mechanisms that others have adopted, which is great. 
But we also watch experiments of this type and then bring them 
into the agency. So we have, in fact, done more prizes in 
recent years. There are certain types of science that lend 
themselves to prizes.
    We have also made use of the so-called ``shark tank'' 
approach, if you will, an innovative funnel which drove the 
development of billions of over-the-counter tests for COVID. 
And now that technology can be employed for other reasons going 
forward.
    And of course, there is this grand new experiment of ARPA-
H, which will be using a completely different funding model 
from what the NIH does, where program managers are empowered to 
seek out bold, new ideas and monitor that directly, presumably 
speeding things in a serious way.
    So we do make use of these other approaches, and we will 
continue to adopt things as they emerge.
    Mr. Harder. That is terrific to hear. I think my concern is 
that that is such a small percentage of the NIH's budget, 
right? We are talking about $50,000,000,000. My count--and 
correct me if I am wrong--less than 1 percent goes to these 
types of prizes or awards. The vast majority go to late career 
investigators.
    And over time, that process seems to have gotten to be a 
lot more lower risk and not as focused on some of the high-
risk, high-reward models. Is that fair, and what can be done, 
what opportunities do you see for the NIH to experiment a 
little bit more with how to change up the funding mechanism and 
try to reward more early career investigators and other types 
of funding?

                  REWARDING EARLY CAREER INVESTIGATORS

    Dr. Tabak. We have made the support of early career 
investigators a major focus of the agency. Each year, we set a 
goal of funding at least 1,100 new early stage investigators. 
Last year, we funded 1,600. And so we will continue to do this. 
This is a sort of preferential payline, if you will, to ensure 
that we are constantly getting new ideas into the system.
    Mr. Harder. What percentage of the NIH budget would you say 
goes to those 1,600 awards?
    Dr. Tabak. Oh, it is a small percentage. I would have--I 
certainly understand that. But additionally, so just to give 
you another example of something that we have done 
innovatively, is we have created an award which requires no 
preliminary data, which basically frees a new investigator from 
having to work on the problem that they did for their 
postdoctoral and/or graduate experience.
    This no preliminary data effort really frees people to be 
as creative as possible, and we are beginning to see some very 
interesting findings there. And so what happens is you pilot 
things. If it makes sense, you continue to expand it.
    Mr. Harder. I totally hear you. Let us expand a lot more. I 
think when I looked at the opportunities I think so much of the 
NIH budget is going to paying for work, as opposed to paying 
for success, is going through folks that are far late in their 
stage as opposed to these early career investigators. And if 
this is 99 percent of the NIH budget is going towards the same 
funding mechanisms that have existed for the last couple 
decades, there is an opportunity not for 100 percent, but for 
10, 20 percent of the NIH budget. And I would love to work with 
you to identify some of those success stories that we might be 
able to scale up and pilot.
    Dr. Tabak. We would be pleased to do so. Thank you.
    Mr. Harder. Thank you. Thank you for your work.
    I yield back.
    Mr. Aderholt. Thank you. We are going to need to conclude 
by noon. So what I am going to do on the second round, I want 
to let us go to the 3-minute round so we can try to get as many 
questions as possible before we do have to adjourn.
    So I will begin. Dr. Walensky, let me pose this one to you.

                   MATERNAL MORTALITY DETERMINATIONS

    I understand the maternal mortality is documented by CDC's 
National Center for Health Statistics and National Center for 
Chronic Disease Prevention and Health Promotion Pregnancy 
Mortality Surveillance System. That is a mouthful, but that is 
my understanding.
    The accuracy of this data depends on the reliability of 
data provided on death certificates, which can be prone to 
error or can be incomplete. Are there limitations on the CDC's 
determination of maternal mortality in the United States?
    Dr. Walensky. So we work--our National Center for Health 
Statistics works with our National Vital Statistics program to 
try and get accurate vital statistics on everyone. And through 
our data modernization efforts, actually we have been able to 
increase the vital statistics that we are getting to 70 percent 
within 10 days. That is up from 10 percent just 10 years ago. 
So we are actually now working closely with those data systems, 
and that is an impact of our data modernization.
    Of course, there are challenges in how those deaths are 
categorized. But what we have seen, given those challenges, 
remains static in terms of how people may or may not categorize 
them. And there are international vital statistics criteria for 
how these things get categorized for maternal mortality. So 
those are standardized.
    We certainly do rely on our local jurisdictions, on local 
providers, on clinicians to make a determination based on the 
Vital Statistics recommendations on how they should be 
categorized, but they could be prone to error. But any vital 
statistic could be prone to error. And what we have seen is 
that error wouldn't be systematically different now than it has 
been over time, and so when we see differences in trends, that 
is when we get worried. We have seen increases in maternal 
mortality.
    Mr. Aderholt. Yes. But you would say there would be 
limitations?
    Dr. Walensky. There are limitations for any reporting of 
any death for any cause.
    Mr. Aderholt. So would that also agree that there are 
limitations on the CDC's ability to identify abortion-related 
deaths?
    Dr. Walensky. I would have to get back to you on the 
details of that because I would want to make sure that I would 
know exactly how those are characterized.
    Mr. Aderholt. Yes, I would be interested in knowing that.
    Dr. Walensky. Happy to.
    Mr. Aderholt. So, all right. I am going to go ahead and 
yield to Ms. DeLauro.
    Mr. Hoyer. Mr. Chairman.
    Mr. Aderholt. Yes.
    Mr. Hoyer. I will yield 3 minutes to the chair--to the 
ranking member, if that is possible?
    Mr. Aderholt. Oh, yes, sure.
    Ms. DeLauro. Thank you to Mr. Hoyer.

                               AVIAN FLU

    Let me make just a comment. I wanted to ask about avian flu 
and universal flu vaccine and antimicrobial resistance, if I 
can. And Dr. Walensky, Assistant Secretary O'Connell, status of 
avian flu? What do we know? What do we need to do to be better 
prepared?
    Dr. Tabak, strong supporter this committee has been to 
develop universal flu vaccine. Where are we in developing that 
flu vaccine? And I will ask you to just be brief in your 
answer.
    Dr. Walensky. So we are tracking the avian flu challenge. 
This is the largest avian flu outbreak that we have seen 
historically. We have now about 12 cases across the world. The 
most recent one is a gentleman in Chile, and we are working 
closely with our collaborators in Chile.
    We do a lot of work on both preparation as well as 
surveillance, where with influenza detection, scale-up of 
laboratory testing, so that we are prepared. Most recently, we 
posted a technical brief on the status of the avian flu not 
just in birds, but in other zoonotic spillovers like sea lions, 
as well as minx. And that technical report was just recently 
updated on Monday. Happy to provide the link for you.
    Thank you.
    Ms. O'Connell. And thank you, Ranking Member.
    In close collaboration with our CDC colleagues, we are 
watching this very carefully and doing a couple of different 
things. We are in a position now where we have egg-based, cell-
based recombinant vaccine candidates. So we are better 
positioned now than we have been before in our vaccine space.
    But we want to push that one step further, and as part of 
our fiscal year 2024 request, we are asking for funding that 
will allow us to continue to invest in mRNA technology, which I 
think everybody is aware will allow us to flip between strains 
very quickly. We think that is going to be a critical piece of 
our defense in any avian flu spillover that we have.
    We also continue to invest in antivirals to make sure that 
we have what we need on hand should we need to treat anybody 
with avian flu.
    Ms. DeLauro. Dr. Tabak.

                         UNIVERSAL FLU VACCINE

    Dr. Tabak. Among the many things that we are doing toward 
universal flu vaccine is a trial that began, a Phase I trial 
that began almost a year ago, using a chemically inactivated, 
multivalent whole influenza antigen. And it is going to read 
out in June. So it will be very interesting to see what those 
results are.
    We have, of course, been exploring mRNA platforms, again 
because of the capacity to take multiple strains and put them 
together to present as an immunogen.
    Ms. DeLauro. Based on what you have said about moving 
forward in all of these efforts, I think it is important that 
we reflect on really what the scale of the cuts that we are--
that are really being talked about. It is not just in terms of 
this reinforcement by the Speaker of the House, I just want you 
to know.
    And we had the Heritage Foundation as a witness here just 
not too long ago at the behest of the majority. This is about 
NIH funding. Funding should be reduced by at least 
$20,300,000,000, including the elimination of the Center for 
Minority Health and Center for Complementary and Integrative 
Health, and defunding of alternative medicine throughout the 
CDC.
    For CDC, $3,000,000,000, reduce funding for diseases 
receiving disproportionate shares, HIV, TB; reduce or eliminate 
funding for social diseases; and reduce or eliminate global 
health funding.
    There is a reality, my friends, out there that you have to 
come to grips with. We certainly do. And the Center for 
Renewing America, former head of OMB, Mr. Vought, would--CDC, 
$4,400,000,000. It would be a decrease of $2,600,000,000 for 
CDC. Repurpose chronic disease mission. Eliminate Global Health 
Center. NIH, reprioritize NIAID's mission. Eliminate foreign 
influence in public health.
    Long and the short of it, these are realities that it is 
not just speculation, that these cuts are intentional. And so 
it is going to be imperative that the consequences are very 
relevant because this is not--the pattern is there. It is not 
true that every member, both sides of the aisle, concurs with 
that. But those who don't need to be made aware of what this 
is, what this is all about.

                        ANTIMICROBIAL RESISTANCE

    I have got let me ask you about antimicrobial resistance 
and where that is with your agencies here.
    Dr. Walensky. We had made great strides in our combating 
antimicrobial resistance prior to the pandemic. Methicillin-
resistant staph, vancomycin-resistant enterococcus, C. 
difficile, as well as Candida auris. That was one of the 
largest threats that we were all worried about before the 
pandemic.
    There was just a recent pre-print that demonstrated that we 
have 27 new antibiotics in the pipeline in clinical trials--
that is compared to 1,300 new cancer drugs--and only 6 of them 
combat antimicrobial resistance.
    During the pandemic we lost those great strides. We slipped 
back, and we have a lot of work to do to catch up.
    Ms. DeLauro. Anyone else? Go ahead.
    Ms. O'Connell. I would be happy to. So BARDA has invested 
over $1,800,000,000 across 150 different products to try to 
bring them forward. And they do this in three different ways.
    They funded an accelerator, which brings these early stage 
products forward that they can then look at for their advanced 
research and development efforts to see if they are products 
that are worthy of pulling forward and through the pipeline. 
And then the Project BioShield allows them to procure the 
actual finished product.
    So they are doing a lot in this space, and it is critical 
for our disaster preparedness that we have and continue to have 
this way to fight the bacterial infections.
    Ms. DeLauro. Again, thank you for what you are doing to 
move the needle forward to try to play catch-up. We need to 
here.
    Let us be mindful of where it goes because, as I said, we 
are not talking about roads, bridges, helicopters, dairy price 
supports, or anything else. We are talking about people's 
lives. And that is what we do on this committee, and this 
committee's efforts is to make sure that you have the resources 
that you need in order to be able to save lives in this 
country.
    Thank you.
    Mr. Aderholt. Mr. Ciscomani.
    Mr. Ciscomani. Thank you, Mr. Chair.
    And thank you to all of you for being here with us today.
    Ms. O'Connell, welcome, and Dr. Tabak, thank you for being 
here.

                           FENTANYL EPIDEMIC

    Dr. Walensky, nice to see you again. Thank you for--enjoyed 
the meeting yesterday. I appreciate your reaching out and 
talking about some of the important issues here.
    We were discussing towards the end of our meeting yesterday 
about fentanyl. So if I can just touch on that for a little bit 
here? We discussed the fentanyl epidemic here--we touched on 
it--that the U.S. is facing right now. Of course, the U.S. has 
had roughly 107,000 drug overdose deaths in 2021, and many of 
those deaths were attributed to fentanyl.
    My county of Pima County--that is my home county--fentanyl 
overdose deaths is the number-one cause of death among young 
people. So it is a tragedy. I have met with parents of young 
people that have--they have lost their family members to this 
terrific, terrific situation.
    So since coming to Congress, I have had meetings with also 
treatment centers in my district, and my constituents have 
indicated that the opioid-related deaths have only increased 
last year. I don't believe my district is alone in this 
finding. While official numbers have not yet been released by 
the CDC for last year's mortality data, I know my colleagues 
and I are here today waiting for that data. I brought this 
question up to Secretary Becerra as well.
    So I want to ask you a two-part question. What is the CDC 
doing to address the ongoing fentanyl crisis, and do you have 
any details on when we can expect that data?
    Dr. Walensky. Thank you, Congressman.
    I will tell you that as part of our data modernization 
efforts, we have been able to speed up the pace at which we are 
able to get those overdose data out from months down to weeks. 
So you should be seeing those soon.
    Just in terms of the work that we are doing, a lot of the 
work is at the community level. Resources from CDC to States 
and local jurisdictions to navigate people into prevention 
services, into linkage to care services, syringe exchange 
services should they need them. And that is a lot of the work.
    And then some of the work is to actually see where those 
things are happening. So we have work in our Overdose Data to 
Action, which we are looking to expand some resources with the 
fiscal year 2024 budget to say where are people actually coming 
into the emergency department. Because while you just 
capitalized on the--or spoke about the 107,000 deaths, we see 
about 10 times that coming into emergency departments that are 
not overdose deaths, but are, in fact, overdose-related events.
    And we want to go to the communities where those are 
happening so that we can do a lot of the prevention work, 
intervention work to prevent those turning into deaths.
    Mr. Ciscomani. So I thank you for that, and I believe that 
this needs to be a full prone approach on tackling this issue. 
It starts with something that another hearing going on on this 
same topic of border security and what is happening in our 
ports of entry and our border, and I think that is mainly also 
where it begins for sure in terms of touching our country. But 
then, when it reaches our communities, it is concerning on the 
effects of this.
    I think that there is a lot more that can be done. Now, in 
your opinion, would you be open to recommending to the 
President and Secretary Becerra to declare a health emergency 
based on the epidemic that we are seeing in fentanyl overdose 
deaths all across the country?
    Dr. Walensky. My understanding is we already have a public 
health emergency for opioid--for opioid disorder, and so I 
think that is already ongoing.
    Mr. Ciscomani. So, for fentanyl, is that included in that?
    Dr. Walensky. I think it would--I don't know the exact 
language. I would have to get back to you on that.

                            NARCAN TRAINING

    Mr. Ciscomani. Yes, I would like to see that because that 
would add additional resources in ways that we can combat this. 
We briefly touched on the small businesses in my community now 
are also being trained to carry Narcan and be able to 
distribute it if something happens on their property.
    Law enforcement is obviously in that as well. But if law 
enforcement, that is not part of their usual training and now 
it is, imagine the small business owners who now say this has 
to be at your location as well to help someone in an overdose. 
If that wasn't bad enough, now we know that with the lacing of 
fentanyl with other drugs, especially xylazine, it is just--
Narcan becomes not effective.
    So this is--I feel like in some ways the bad actors out 
there are a step ahead of us on this, and we need to not only 
catch up but to get ahead of the game and play offense.
    So in the last few seconds that I have on my time, I would 
like to touch on what else we can do besides the health 
emergency. There is more that I think needs to be done and that 
I am looking at you for answers on that.
    Dr. Walensky. Great. So the overdose--the opioid challenge 
is a part of a whole USG approach. As you may know, ONDCP just 
last week at the Rx Summit pronounced xylazine as an emerging 
public health crisis. So more work is ongoing on that.
    We, at CDC, work on the prevention side. And among the 
things we do, as you just noted, is Narcan training so that 
people can work on the prevention side, as well as the linkage 
into care. And then we work across USG through SAMHSA and other 
resources for an all of USG approach on that. We would be happy 
to work with you.
    Thank you.
    Mr. Ciscomani. Thank you. Chairman, I yield back.
    Mr. Aderholt. Mr. LaTurner.
    Mr. LaTurner. Thank you, Mr. Chairman. I appreciate it.

                        ANTIMICROBIAL RESISTANCE

    Assistant Secretary O'Connell, I want to also ask, as the 
Honorable Ranking Member of the whole committee did in her last 
question, about antimicrobial resistance. It is an important 
issue.
    Antimicrobial resistance, or AMR, is contributing to 5 
million deaths per year globally and significantly increasing 
our healthcare costs. Novel antibiotics will allow us to cure 
patients and discharge them from the hospital, improving their 
lives and reducing costs more rapidly. This is why last 
Congress, I supported the bipartisan PASTEUR Act. The PASTEUR 
proposal would be transformative to the fragile and failing 
antimicrobial ecosystem, revitalizing antimicrobial R&D and 
helping ensure American people have the products we need to 
treat resistant infections.
    How would you describe the threat of AMR, and how will ASPR 
help strengthen the antimicrobial pipeline?
    Ms. O'Connell. Congressman, thank you so much for that 
question.
    I think AMR is one of the big public health threats that we 
are currently facing. So much of what we rely on in modern 
medicine would be at risk if we lost access to antibiotics. 
Complex surgeries, organ transplants, chemotherapy, all of that 
would be on the table if we didn't have antibiotics available 
to stave off potential infection. So it is a critical component 
for us.
    And from the ASPR perspective, it is either a primary or 
secondary effect of many of the threats that we currently face. 
So it has been a critical thing for BARDA to be able to invest 
in, both in this acceleration of the CARB-X accelerator to 
bring those early products forward, in the advanced research 
and development to make sure we have these novel candidates 
available, and then in the Project BioShield to make sure that 
we have them on hand in the Strategic National Stockpile moving 
forward for any of these threats that we face.
    The fiscal year 2024 budget asks for a combined 
$305,000,000 for BARDA to be able to continue to invest in this 
work. I think that is critical. Their work so far, as I 
mentioned, is $1,800,000,000 across 150 different products that 
have led to the licensure of 3 products and 3 510(k) FDA 
clearances for devices.
    So there has been some success. There is more that we 
should do, and I just want you to know that ASPR is committed 
to continuing this work.
    Mr. LaTurner. Thank you.
    I will stick with you. Earlier, Mr. Hoyer--I find myself in 
an unlikely position. I had been following up on lines of 
questioning--but they were important--from both of you. 
[Laughter.]

                              SUPPLY CHAIN

    Mr. LaTurner. He talked about our reliance on foreign 
nations for stocking key active pharmaceutical ingredients and 
chemical compounds that are vital to medical supply chains. For 
example, heparin is an essential medicine used for treating 
blood clots, administered 300,000 times a day in the U.S. and 
used by 25 percent of all pregnant women. Yet we are completely 
dependent on China for the entirety of our supply, as heparin 
is sourced from pigs, and 50 percent of the global pig 
population is in that country.
    I understand that ASPR's Office of Industrial Base 
Management and Supply Chain is working to coordinate efforts to 
ensure domestic supply and promote manufacturing of vital 
pharmaceuticals like heparin to reduce our reliance on 
adversarial foreign nations. What specifically is this office 
doing today to work with private industry to support domestic 
supply chains?
    Mr. Hoyer. Great question. [Laughter.]
    Mr. LaTurner. Thank you. Thank you. Appreciate you approve.
    Ms. O'Connell. And thank you for the question. So among the 
87 projects that I mentioned of this industrial base expansion 
bringing domestic manufacturing here to our shores, we have 
invested $500,000,000 in API contracts. So making sure that we 
are able to bring, as you said, these critical raw materials 
and components into the U.S. and be able to manufacture them 
here. So that continues to be a place where we are focused and 
we are invested.
    Again, we have made a request for the $400,000,000 in the 
fiscal year 2024 budget. A portion of that would go to 
maintaining the office that you mentioned, our Industrial Base 
Expansion and Supply Chain Office, so it can continue to 
provide technical assistance to see these construction projects 
that we have started and invested in to make sure that they can 
continue to be on a path to success so we can free ourselves 
from some of this dependence on these other countries.
    Mr. LaTurner. I appreciate that.

                       RESEARCH DOLLARS TO CHINA

    Dr. Tabak, you earlier--I want to drill down on something 
that you said. It sounded as though you said that you have no 
issue with research dollars going to China. Can you expand on 
what you meant?
    Dr. Tabak. I don't know if that is specifically what I 
said, but as part of our competitive grants process, if there 
is a unique opportunity, a question that can be solved only in 
the particular foreign country, we do support science in 
foreign countries. And as I did mention to Congresswoman 
Letlow, our investment in China right now is very modest.
    And I apologize for not giving you the number. I have now 
found it. If I may? One-point-two million, 3 awards, and an 
additional $4,100,000 based on 22 subawards, and that is fiscal 
year 2022.
    Mr. LaTurner. I am out of time. I yield back, Mr. Chairman.
    Mr. Aderholt. Thank you. As I mentioned, because of time 
restraints we are going to allow everybody that has already 
asked one question 3 minutes on the next round, and I will go 
to Mrs. Watson Coleman next.

                     MATERNAL AND PERINATAL HEALTH

    Mrs. Watson Coleman. Thank you, Mr. Chairman.
    Dr. Walensky, this is for you. CDC recently released its 
report that in 2021 the U.S. had one of the worst rates of 
maternal mortality in the country's history. And the report 
found that 1,205 people died of maternal causes in the U.S. in 
2021. That represents a 40 percent increase from the previous 
year.
    The maternal death rate, however, for black Americans is 
much higher than other racial groups. In 2021, it was 69.9 per 
100,000, which is 2.6 times higher than the rate for white 
women. And medical experts contribute these trends in racial 
disparities to social factors and to failures within the 
healthcare system.
    Funding supports the capabilities of the Perinatal Quality 
Collaboratives to improve the quality of perinatal care for 
mothers and babies in their States, and currently, New Jersey 
is one of our leaders. And it is one of the State-based PQCs 
working with the CDC to improve processes in the healthcare 
system to prevent maternal death and reduce racial disparity.
    Dr. Walensky, what would cuts mean for such an important 
program? Would cuts impede the CDC's ability to expand State-
based PQCs in other States?
    Dr. Walensky. Thank you, Congresswoman.
    First, let me just say before the pandemic, we were seeing 
the race and maternal mortality increase. We saw that through 
the pandemic as well. And the work that you are describing--and 
grateful to New Jersey for being a champion in that work--in 
the Perinatal Quality Collaboratives, looking at increased 
rates of hemorrhage, increased rates of infection, increased 
rates of prenatal delivery, all of which lead to poorer 
outcomes in both mom and in baby.
    A lot of the work that we also do are in Hear Her 
campaigns, where the fiscal year 2024 budget looks to expand 
the campaigns that we have because many of those campaigns 
relate to how we address women who are in distress at the 
time--they know when they are in distress at the time of 
their--during their pregnancy. They are asking for help, and 
without these campaigns, we can't address the help that they 
need.
    And then, finally, our Maternal Mortality Review Committee. 
We actually don't even access all of those data that we need. 
Those review committees that we are looking to expand through 
the fiscal year 2024 budget actually can shine a light and see 
where those women are. So cuts to the fiscal year 2024 budget 
would reduce Hear Her campaigns. They would reduce Perinatal 
Quality Collaboratives. They would reduce our ability to 
actually be able to see where those poor maternal outcomes are 
happening.
    Thank you.
    Mrs. Watson Coleman. Thank you. Thank you, Mr. Chairman.
    Mr. Aderholt. Dr. Harris.
    Mr. Harris. Thank you very much.

                        STATUTORY AUTHORIZATION

    Dr. Walensky, is the CDC authorized by Congress? Do you 
have statutory authorization?
    Dr. Walensky. Um, we----
    Mr. Harris. Because I am told you don't.
    Dr. Walensky. We receive our authorities through the Public 
Health Service Act.
    Mr. Harris. I am going to have to research that because I 
have been told CDC is not specifically authorized, and that is 
why it kind of wanders all over in terms of what it can do. But 
one of the things you do is you have a nutrition area, which I 
appreciate.
    But what--and I just want to ask your opinion. It makes--
the nutrition area makes a big deal about eating healthy, 
watching sugary substances, things like that. So do you find it 
a little strange that the Supplemental Nutrition Assistance 
Program, $100,000,000,000 of American taxpayer dollars, doesn't 
really require healthy eating in the foods that are purchased?
    I mean, about 10 percent--it is estimated up to 10 percent 
is actually soda, $10,000,000,000 a year, Federal taxpayer 
dollars. Do you think that is a wise investment we are making 
in that program?
    Dr. Walensky. So I would have to look at the details of 
that program specifically and the investments that it makes. 
What I would say is that a lot of the work of the CDC is to 
prevent chronic conditions, and so good nutrition is among 
those. We need to prevent chronic conditions because chronic 
conditions lead to poor outcomes, and poor outcomes in 
infectious and noninfectious threats.
    Mr. Harris. Sure. I agree. I fully agree. I just don't 
think we should be spending taxpayer dollars in 
contradistinction to what the CDC thinks is a good diet, 
basically. And you know we have the WIC program, which 
obviously has nutritious food. And so it is not like the 
Government hadn't decided nutritious foods are good for some 
populations.

                                 GENDER

    Dr. Tabak, I am going to ask you the same question I asked 
Dr. Collins last year. It is important that when we do clinical 
studies we investigate both men and women. I understand the 
difference between men and women based on reproductive biology. 
You know, Y chromosome, 6,500 different genes. Obviously, 
because you have an unopposed X chromosome, there is a 
difference in the X chromosome genes between men and women.
    Should we be enrolling biological--men and women in these 
studies based on their reproductive biology or their sex 
assigned at birth in order not to muddy the scientific waters 
of outcomes?
    Dr. Tabak. Differences in gender have existed for all time. 
We have only just begun to realize the nuances.
    Mr. Harris. I am not talking about gender. I am talking 
about sex. I am talking about sex that is described as 
reproductive biology.
    For scientific purposes--and I am sure you understand 
because you are a scientist--if you have 6,500 genes on that Y 
chromosome, and we don't know what they all do, we don't know 
how they all interact, if you don't properly assign that person 
to the sex categorization in looking at a study, wouldn't that 
muddy the waters in the outcome as to whether there is a 
difference between sex as based on reproductive biology in the 
outcome of the study?
    Dr. Tabak. Depending on the nature of the study, you would 
want to know that information.
    Mr. Harris. Thank you very much.
    I yield back.
    Mr. Aderholt. Mr. Clyde.
    Mr. Clyde. Thank you.

                              VIRUS ORGINS

    Dr. Walensky, does finding the source of a virus help you 
defend against it?
    Dr. Walensky. We have to defend against the virus 
regardless of the source. I think it would be helpful to 
understand----
    Mr. Clyde. But the question is----
    Dr. Walensky [continuing]. The root of the source in order 
to defend against it.
    Mr. Clyde. So it is helpful?
    Dr. Walensky. Yes. In order for prevention activities.
    Mr. Clyde. Great. Thank you.
    Dr. Tabak, you said when I asked you was there gain-of-
function research done at the Wuhan Institute of Virology, 
which received American taxpayer dollars, you said no.
    Dr. Tabak. Correct.
    Mr. Clyde. You stand by that statement?
    Dr. Tabak. Yes, sir.
    Mr. Clyde. Okay. Then why in this letter, October 20, 2021, 
that you said EcoHealth Alliance was testing if spike proteins 
from naturally occurring bat coronaviruses circulating in China 
were capable of binding to human ACE2 receptors in a mouse 
model. And here is an article that says ``NIH admits U.S. 
funded gain-of-function in Wuhan, despite Fauci's denials.''
    And at a Senate hearing where Dr. Fauci said, ``The NIH has 
not ever and does not now fund gain-of-function research in the 
Wuhan Institute of Virology.'' That was under oath and under 
testimony. On October 20th, the NIH Principal Deputy Director 
in writing directly contradicted it. That would be you.
    So you are telling me that what you are saying in this 
letter is not gain-of-function research?
    Dr. Tabak. Sir, it is not. Gain-of-function research, as 
everybody is concerned about, is with ePPPs. The viruses that 
NIH approved and were studied in the Wuhan Institute of 
Virology, and then they subsequently published on that work, 
were viruses that were very, very genetically distinct from 
SARS-CoV-2.
    They are not related in any way. They could not have given 
you SARS-CoV-2 in the result. And that is why I have made that 
distinction.
    Mr. Clyde. Okay.
    Dr. Tabak. I can't speak to the other articles that you 
cited.
    Mr. Clyde. You told Congresswoman Letlow that you were 
intensely interested in finding the origin of the COVID-19 
virus, but yet you don't have any dedicated resources to 
finding the source. Why?
    Dr. Tabak. Again, sir, our role in this would be to support 
the researchers that have the expertise to do this type of 
work. We are supporting them, and they are doing evolutionary 
studies. The missing piece here are data from China, which we 
do not have access to.
    Mr. Clyde. Well, with all the money that you get, I would 
think that because finding the origin helps you defend against 
it, that you would be using some of the money that you get to 
find the origin.
    Dr. Tabak. We will get back to you, sir, for the record, of 
the grants which are related to this. We have not specifically 
funded anything entitled origins of the virus.
    Mr. Clyde. Thank you.
    And I yield back.
    Mr. Aderholt. Ms. Letlow.
    Ms. Letlow. Thank you, Mr. Chairman.

                            PROJECT NEXT GEN

    Ms. O'Connell, I would like to go back to Project Next Gen. 
I want to know how this--how this work impacts the core mission 
of ASPR to protect against a myriad of threats, not just COVID-
19, especially now that the current public health emergency is 
scheduled to be terminated on May 11th.
    Ms. O'Connell. Thank you. Absolutely.
    So one of the things that we are looking at, and as I 
mentioned in my opening statement, are the viral families most 
likely to cause the next biological threat.
    Ms. Letlow. Right.
    Ms. O'Connell. Among those are coronaviruses, and one of 
the things that would come out of the Next Gen work potentially 
is a broader vaccine that would protect against all 
coronaviruses, not just SARS-CoV-2.
    Ms. Letlow. Right. Look forward to that.
    When does this administration plan to release a detailed 
spend plan on what these allocated funds are being used for?
    Ms. O'Connell. I will have to go back to our department's 
finance team and let you know, and we will be happy to get that 
information to you.

                      STRATEGIC NATIONAL STOCKPILE

    Ms. Letlow. I would appreciate that.
    And then, last October, the Government, the GAO released a 
report titled ``HHS Should Address Strategic National Stockpile 
Requirements and Inventory Risks.'' In this report, GAO found 
that SNS contained most medical countermeasure types 
recommended, but often not the recommended quantity.
    How does the Administration for Strategic Preparedness and 
Response aim to bridge the gaps faced between the required 
amounts and the current stockpile?
    Ms. O'Connell. Thank you so much for that question. That is 
absolutely one of the biggest concerns that I have is that we 
have not been funded appropriately to be able to protect 
ourselves against the current threats that we see.
    We just shared with Congress the PHEMCE multiyear budget, 
which is a 5-year plan for the entire countermeasure 
enterprise, and it shows that the Strategic National Stockpile 
is funded half of what it needs. It needs $2,000,000,000 a year 
in order to keep up with the countermeasures that we require to 
be protected against the current threats, and it currently is 
funded in the $900,000,000 range.
    Ms. O'Connell. Thank you so much.
    I yield back.
    Mr. Aderholt. Okay, thank you. Thank you.
    Ms. DeLauro. I just want to make one----
    Mr. Aderholt. Yes. Just--yes.

                            Closing Remarks

    Ms. DeLauro. Thank you, Mr. Chairman.
    Again, I want to say thank you, and I know the chair will 
wrap it up to our witnesses today. Thank you again for the work 
that you do. Thank you for the prescient view of the budgets 
that you have put forward in order to continue the outstanding 
work that you do.
    I will just--there is a couple of things I wanted to say. I 
would say to my colleague from Maryland who talked about living 
in a fairy land. I believe--and I don't say this because I am 
not in the business of ad hominem efforts. But I think the 
fairy land has been the $1,700,000,000,000 that was dispensed 
to the richest one-tenth of 1 percent of the people in this 
country and the corporations who today do not pay any taxes.
    And as far as I know, there is little appetite from some on 
the other side of the aisle to look at those corporations. 
Making sure that they pay that would give us additional 
revenues to do what we could do with lifesaving--lifesaving 
threats.
    But the fairy land today, the fairy land today is that if 
we believe that you can leave--go back to 2022, leave defense 
out, leave veterans out, leave border security out, leave 
anything else out that people individually care about, then 
some of the issues that have been discussed here today are not 
going to be able to be addressed because that is the fairy 
land. And that is what we need to be guarding against here.
    Just one last point. Mr. Harris, I would say to you, we 
ought to tax sugary beverages, which I introduced many years 
ago to do that, in which case that would cut down on some of 
the health impacts that we see today.
    Thank you, Mr. Chair. I appreciate it.
    Mr. Aderholt. Well, thanks, everybody, for being here. We 
look forward to following up on some of the issues that we had 
left outstanding, and we appreciate your service.
    And the hearing is adjourned.

                                         Wednesday, April 26, 2023.

        PROVIDER RELIEF FUND AND HEALTHCARE WORKFORCE SHORTAGES

                                WITNESS

CAROLE JOHNSON, ADMINISTRATOR, HEALTH RESOURCES AND SERVICES 
    ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, ON BEHALF 
    OF DEPARTMENT OF HEALTH AND HUMAN SERVICES

                      Chairman's Opening Statement

    Mr. Aderholt. Well, good morning.
    It is good to be here this morning with our special guest. 
And I am pleased this morning to welcome the Administrator of 
the Health Resources and Services Administration, Carole 
Johnson, to talk about the Provider Relief Fund and also about 
healthcare workforce issues in general.
    The Provider Relief Fund was originally created in the 
CARES Act to reimburse healthcare providers for increased 
expenses or lost revenue as a result of COVID lockdowns and 
COVID treatments.
    I think the original intent of the fund was actually 
commendable. We wanted to maintain a robust, high-quality 
healthcare system in the face of a novel pandemic. We also 
needed to ensure that providers were able to continue care 
despite the many challenges and the unknowns that were posed by 
COVID at the time.
    The committee recognized that it is difficult to administer 
a new program of this magnitude in a short timeframe. But 
hindsight is 20-20. With the passage of time, we are seeing 
many instances of improper payments, wasted funds, and funds 
remaining in the Provider Relief Fund that are being used for 
purposes other than what it was originally intended.
    For example, just last week, the Department of Health and 
Human Services announced that it will spend 1.1 billion from 
the PRF for ongoing free COVID vaccines and treatments for 
uninsured adults through 2024.
    I think it is very interesting that Health and Human 
Services is going to provide payments for new vaccines and 
treatments while outstanding provider claims for treating the 
uninsured remain unpaid.
    I am further concerned by reports of significant misuse of 
Federal funds previously under the COVID-19 Uninsured Program. 
I have some questions about what your agency will do to ensure 
that these mistakes are not repeated with additional funds.
    This announcement, that the PRF will pay for activities not 
expressly authorized by Congress, is just one more example of 
an ever-growing list of ways the Biden administration is 
overreaching its executive authority, from blanket loan 
forgiveness to free abortions in the VA, and now promises of 
free college and free healthcare. This administration appears 
to recognize there are no legal boundaries.
    Finally, today I want to address the issue of healthcare 
workforce shortages in many rural areas. These areas, including 
my home State of Alabama that I represent, continue to 
represent many challenges that are worsened by these shortages, 
including access to quality healthcare, lack of specialty care, 
nursing shortages, high rates of opioid addiction, lack of 
facilities, and a disproportionate burden of chronic disease 
relative to the rest of the country.
    I know from the hearing we held last month on rural issues 
that your agency oversees several Federal programs that touch 
on these very areas, and I appreciate your attention as you 
talk in your testimony today, and I look forward to our 
conversation as we move forward on this.
    And, at this time, I would like to a recognize my friend 
from Connecticut, the ranking member, for her opening remarks.

                    Ranking Member Opening Statement

    Ms. DeLauro. Thank you so much, Mr. Chairman, for holding 
the hearing.
    And welcome to today's witness, Ms. Carole Johnson, 
Administrator of the Health Resources and Services 
Administration, or HRSA. And happy that you took over the job 
in January of 2022.
    Thanks for being here. Thank you for dedicating your career 
to the work of saving lives by increasing access to high-
quality healthcare, especially for historically underserved and 
rural communities across this country. You make our communities 
healthier and safer by expanding a skilled healthcare 
workforce.
    You are here in part today to discuss healthcare workforce 
shortages, an issue that impacts communities all over the 
Nation.
    Even before the pandemic, healthcare workforce shortages 
were a major concern. In 2019, the American Association of 
Medical Colleges predicted a shortage of 122,000 physicians by 
2032.
    And that is just physicians. As you know, 1.5 million 
healthcare jobs were lost in the first 2 months of the 
pandemic. While we are mostly back to prepandemic staffing 
levels, issues still endure.
    And though the Bureau of Labor Statistics projected that 
275,000 additional nurses are needed before 2030 to meet 
demand, it is increasingly more difficult to hire new qualified 
nurses.
    Given the need to address these and other enduring 
shortages made much worse by the pandemic, this committee made 
significant investments through the 2022 and 2023 
appropriations bills to strengthen HRSA's health workforce 
programs.
    This included a nearly $100,000,000 increase in the 2023 
package passed and enacted in December. We increased funding 
for nursing and midwife programs, mental and behavioral health 
workforce education and training, and Children's Hospital 
Graduate Medical Education programs to train resident doctors.
    But more must be done. That is why I am pleased to see the 
President's budget for 2024 prioritizes training programs for 
the healthcare workforce.
    I would like to run through some of the funding.
    The request includes $190,000,000 more for mental and 
behavioral health workforce education and training to address 
our mental health and substance use crises by expanding 
healthcare professionals.
    You also requested an additional $50,000,000 for nursing 
programs, including to increase the nurse faculty essential to 
growing our workforce. To be honest, I am concerned that 
increase is not large enough given the need for a robust 
nursing workforce.
    I am pleased to see your request for $50,000,000 in new 
funding to expand the National Health Service Corps, which 
offers scholarships and loan repayment to professionals who 
commit to serving in underserved areas. As you note in your 
testimony, National Health Service Corps participants are more 
likely to remain practicing in high-need communities after 
their service is completed.
    And your budget would invest in innovative approaches to 
recruit, support, and train new providers. Americans depend on 
the skilled and robust healthcare workforce that keeps us safe 
and healthy.
    That is why I must mention how deeply concerned I am over 
some of my House Republican colleagues' calls for massive 
spending cuts to many of the programs that keep families and 
communities healthy. These cuts would be harmful to children, 
families, seniors, veterans, and our rural communities--and 
they would be deadly.

                         PROPOSED FUNDING CUTS

    Just last week, Speaker McCarthy introduced a bill to cut 
funding back to the 2022 level and to impose caps for the next 
10 years--caps that are really just more cuts. And apparently 
we are getting prepared to vote on that piece of legislation 
today.
    Though we should be doing everything to support healthcare 
workers and expand the workforce, these spending cuts would gut 
nursing programs, exacerbating our shortage of skilled nurses. 
There would be fewer mental health providers and substance 
abuse specialists as the country continues to combat an opioid 
and a fentanyl crisis. And it would mean fewer doctors and 
other healthcare professionals choosing to serve in rural and 
underserved communities because we removed incentives to serve 
there.
    These proposed cuts would reverse much of the progress we 
have accomplished over the past 2 years, progress that began as 
we recovered from the COVID-19 pandemic.
    Ms. Johnson, when you came into office hospitals and 
healthcare providers across the country were overwhelmed by 
COVID patients. At the peak of the pandemic, more than 4,000 
Americans were dying every day from COVID. Many hospitals, 
healthcare providers, nursing homes would have gone bankrupt 
without emergency intervention from the Federal Government.
    That is why I am proud that while I served as chair of the 
Labor-HHS Appropriations Subcommittee we responded quickly and 
forcefully to the COVID-19 pandemic, including by creating the 
Provider Relief Fund in March of 2020 to support our healthcare 
providers and to avoid a complete collapse of our healthcare 
sector.
    In 2020, this committee provided a total of 
$178,000,000,000 for hospitals, health clinics, skilled nursing 
facilities, nursing homes, and other healthcare providers. 
Unfortunately, the Trump administration did not allocate those 
funds according to congressional intent.
    The truth is this subcommittee should be questioning HHS 
officials from the Trump administration. First and foremost, 
they sent too much money to hospitals that did not need it and 
not enough money to the areas that did.
    As reported by both The Wall Street Journal and The 
Washington Post, hospitals were reimbursed based on their 
overall revenues and their Medicare billing rates instead of 
their financial need, which put safety net hospitals at a 
severe disadvantage.
    It has become overwhelmingly evident that hospitals that 
serve a disproportionate share of uninsured patients and 
Medicaid patients needed much more support.
    It should concern all of us that the financial need and 
condition of providers were not properly assessed. And 
children's hospitals, behavioral and mental health providers, 
dentists, and some of our smaller hospitals were left behind.
    I know this firsthand from providers in Connecticut. 
Connecticut's 17 small and medium-sized hospitals struggled 
immensely, especially in the early months of the pandemic, when 
the Trump administration used arbitrary dates to determine 
eligibility for, quote, ``hot spots funding.''
    When the Biden administration took office, you changed this 
process to ensure that aid was targeted to the providers most 
in need, and though this change was critical for some hospitals 
and healthcare providers, it had already been far too late.
    And now Speaker McCarthy and some of my Republican 
colleagues are trying to rescind unspent COVID funds, which 
would further exacerbate the challenges faced by hospitals and 
healthcare providers that serve people most in need.
    As I have made clear, I will not stop fighting these 
drastic proposals that would hurt the communities that most 
need our help.
    Ms. Johnson, we have a lot of ground to cover today on 
these two topics. Look forward to working with you to ensure 
that we continue to invest in our healthcare workforce, support 
our healthcare providers.
    Thank you so much for being here.
    With that, Mr. Chairman, I yield back.
    Mr. Aderholt. Thank you.
    And, as I said, we are honored today to have Carole 
Johnson, who is the Administrator of the Health Resources and 
Services Administration, what we will refer to as HRSA. It is a 
Federal agency in the U.S. Department of Health and Human 
Services that is focused on health equity, supporting 
healthcare services for historically underserved communities, 
and working to build a robust and diverse healthcare workforce.

                HRSA Administration's Opening Statement

    So, Ms. Johnson, we will turn it over to you, and we look 
forward to your testimony.
    Ms. Johnson. Chairman Aderholt, Ranking Member DeLauro, and 
members of the subcommittee, thank you for the opportunity to 
talk with you today about our investments in training and 
retaining the healthcare workforce and our efforts to sustain 
the Nation's critical healthcare infrastructure through 
pandemic relief investments.
    I am Carole Johnson, Administrator of the Health Resources 
and Services Administration, and as the Chairman noted, we are 
the agency in the Department of Health and Human Services that 
supports delivering healthcare in the Nation's highest-need 
communities, building a healthcare workforce, improving 
maternal and child health, caring for individuals with HIV, and 
meeting the healthcare needs of rural America.
    I would like to begin by thanking the members of this 
subcommittee for your longstanding bipartisan support for 
HRSA's programs. With your help, we have made significant gains 
in expanding access to healthcare services, particularly in 
communities that have struggled for far too long to recruit and 
retain healthcare providers and access high-quality care.
    Yet we know there is more work to do, including to help 
further support and expand the healthcare workforce.
    One of HRSA's highest priorities is growing the healthcare 
workforce and connecting skilled healthcare providers to 
communities in need.
    With the support of this subcommittee, our programs have 
trained and deployed healthcare providers across a wide array 
of disciplines, including primary care, nursing, and behavioral 
health.
    Our budget prioritizes training more medical residents and 
incentivizing practice in rural and underserved communities, 
alleviating bottlenecks in the nursing training pipeline, 
investing in growing the behavioral health workforce, and 
spurring innovation in health workforce training.
    First, the President's budget takes the important step of 
renewing and extending the National Health Service Corps. For 
more than 50 years, the National Health Service Corps has 
provided scholarships and loan repayments to students and 
clinicians in return for them practicing in health professional 
shortage areas.
    We are also training medical residents directly in the 
communities that need them most through the Teaching Health 
Center Graduate Medical Education Program, which funds primary 
care residency programs in settings like health centers, 
recognizing that most primary care takes place in community 
settings.
    To further support the primary care physician pipeline, our 
budget invests in rural residency training through our Rural 
Residency Planning and Development Program, which supports 
rural hospitals and facilities in creating new medical 
residency programs.
    With our funding and support, rural facilities that would 
not otherwise have the bandwidth or capacity to launch 
residency programs are able to do so, which is an important 
resource, helping rural communities to develop the next 
generation of rural health practitioners.
    Second, we recognize the need to expand the nursing 
workforce, and the budget proposes an increase of $50,000,000 
over fiscal year 2023 to support this goal.
    This includes a new investment that would help create more 
nursing faculty and clinical preceptors for the teaching 
faculty that oversee the clinical training of nurses.
    Time after time, we have been told by nurse leaders and 
frontline healthcare administrators that the lack of faculty--
and especially the challenge of recruiting clinical faculty--is 
a key roadblock in growing the nursing workforce. More people 
want to become nurses, and we need to support the 
infrastructure to help them to do so.
    The budget would also train more certified nurse midwives 
as part of our larger strategy to improve access to care and 
respond to the maternal mortality crisis.
    Third, we are also proposing to train significantly more 
mental health and substance use disorder providers through the 
President's budget, including both clinicians, like 
psychologists and licensed clinical social workers, as well as 
the critical community-based workforce, like peer support 
specialists.
    A lot of important work is underway to expand access to 
mental health and substance use disorders, and the needs are 
well-known, but we have to invest in building the workforce to 
help meet these critical needs.
    Fourth and finally, the budget includes an exciting new 
opportunity to spur innovation in healthcare workforce training 
models by funding new ideas and proposals to support creative 
ways to build a more modern and robust workforce pipeline.

                          PROVIDER RELIEF FUND

    Turning to the Provider Relief Fund. As was noted, in the 
earliest days of the pandemic Congress created the Provider 
Relief Fund to help healthcare providers manage the impact of 
the pandemic. It was a lifeline to many healthcare providers 
who experienced financial losses and increased expenses due to 
the virus.
    Since the program was established, HRSA has made over 
800,000 payments to more than 440,000 providers across the 
country, and funding has reached every State and congressional 
district, and it has been critical for providers to continue 
delivering essential care to their communities.
    As the implementing agency for the fund, HRSA has worked to 
responsibly get resources to providers in a timely way while 
taking stewardship of Federal funds very seriously.
    Program integrity is an essential component of the Provider 
Relief Fund. And in order to ensure that payments are made 
fairly and to safeguard taxpayer dollars, HRSA implemented a 
variety of program integrity and risk mitigation measures, both 
before and after making payment. Providers are subject to 
robust requirements, and failure to comply exposes providers to 
recovery and debt collection.
    Thank you for the opportunity to discuss HRSA's work, and I 
look forward to the conversation.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Aderholt. Thank you, Ms. Johnson. Again, thank you for 
being here today.
    I will begin with our rounds. We will do 5-minute rounds, 
so that we can try to make sure everyone gets in a question.

                        COVID UNINSURED PROGRAM

    My first question deals with the unspent PRF balances. HRSA 
insisted that it had to shut down the COVID-19 Uninsured 
Program for testing and treatment claims effective March 22 
back in 2022, and that was due to lack of funding.
    As a result of this last-minute announcement, many 
hospitals, physicians, and other medical providers around the 
country were unable to submit claims for services they provided 
in good faith to patients in reliance on this program.
    My question is, why did HRSA shut down the COVID-19 
Uninsured Program with almost no advance notice to the medical 
community under the guise of insufficient funding, given that 
the Department now tells us there is actually more than enough 
funding remaining in the Provider Relief Fund to be reported to 
other programs, especially when these other programs are not 
even authorized?
    Can you talk to us a little bit about that?
    Ms. Johnson. Thank you for the question, sir. And thank you 
for the opportunity to talk about where we were at the 
beginning of 2022, when we were requesting additional 
supplemental funding to sustain the Uninsured Program.
    We were at that point seeing a tremendous impact from the 
omicron surge with respect to claims for the Uninsured Program. 
As you know, in most healthcare programs there is a claims lag 
between when providers provide services and when they submit 
claims.
    And so at that time we were seeing a tremendous surge in 
claims associated with omicron, at the same time that we were 
trying to make Phase 4 of the Provider Relief Fund general 
distribution payments and have resources available for the 
reconsideration process that we initiated to make sure that 
providers had the opportunity to come back in if they thought 
that there was an issue with their provider payments.
    And so, at that time, we were spending around 
$2,000,000,000 a month on the Uninsured Program. And given the 
time lag in filing claims because claims are often filed months 
after they were processed, we had an unknown liability out 
there for claims, and we had the claims lag.
    So pre-omicron, we got about 16 million claims in a 3-week 
period. In the 3 weeks between when we closed the fund--when we 
announced the closure of the fund and when the fund closed, we 
got 35 million claims.
    And so, as a matter of good fiscal budgeting, we just 
didn't have the resources to be able to say we could sustain 
that with this unknown liability out there.
    And so today, although there are considerably fewer dollars 
left in the Provider Relief Fund, we are in a more stable 
place, because we have been able to make many of the Phase 4 
payments and we know the amount of claims that have come in in 
the Phase 4 reconsideration process. And at the same time as 
our program accountability work is underway, we are getting 
provider returns.
    And so, with that, about 2 percent of the Provider Relief 
Fund is being used for the new initiatives that you point to 
that the administration has announced.
    Mr. Aderholt. Well, it is my understanding that Moderna and 
Pfizer have pledged to make COVID vaccines free for the 
uninsured through patient assistance programs. If that is the 
case, why is the new program for the uninsured to access COVID 
vaccines funded by the government even needed?
    Ms. Johnson. Yeah. Thank you for the question, sir.
    I would have to--the details of how the Uninsured Program, 
this new bridge access program, will be funded and operated, I 
would have to refer to CDC.
    But I will say what we saw throughout the pandemic was 
that, while the vaccines were purchased in bulk, the vaccine 
administration fee to the provider who administers it is an 
additional cost. And so that cost continues going forward 
regardless of the purchasing arrangement.
    Mr. Aderholt. Okay. All right. But you said that you need 
to get some more information from CDC on that or some 
clarification?
    Ms. Johnson. Well, on the particulars of the vaccine 
acquisition, I would defer to them. But there will continue to 
be vaccine administration costs, because throughout the 
pandemic providers have always been reimbursed directly for the 
cost of administering the vaccine.
    Mr. Aderholt. Also, correct me if I am wrong, but I 
understand the program runs through December of 2024. Is that 
correct?
    Ms. Johnson. Yes.
    Mr. Aderholt. Why was that date or that timeframe selected?
    Ms. Johnson. I believe part of that is about ensuring that 
there is as smooth as possible transition as products move to 
the commercial market.
    Mr. Aderholt. Okay. All right. I yield back.
    And Ms. DeLauro.

                        GOVERNMENT FUNDING CUTS

    Ms. DeLauro. Thank you, Mr. Chairman.
    Ms. Johnson, Speaker McCarthy and the Republican House 
majority are demanding massive government funding cuts in 
fiscal year 2024 appropriations bills.
    Last week, as I mentioned, the Speaker introduced a bill to 
cut funding back to the 2022 level, to impose caps for the next 
10 years.
    To be clear, this bill would require them to cut health 
programs by at least 22 percent, possibly closer to 30 percent 
or more.
    Question. As HRSA Administrator, give us an idea about the 
real impacts of the cuts being proposed by some Republicans. 
What would happen to community health centers, nursing 
programs, mental health and substance use disorder counseling 
programs?
    And, if you don't mind, please describe the human 
consequences to children, families, seniors, veterans, and 
millions of people across the country.
    Ms. Johnson. Thank you for the question, Congresswoman, and 
the opportunity to speak about this.
    I will say the consequences are impacted by the fact that 
this subcommittee, in a bipartisan way, has helped us grow 
these programs in recent years. And so, as a consequence, a 
reduction of that size in the health center program would have 
a direct impact. We believe our estimates are about 2 million 
of the individuals served by health centers would potentially 
lose access to their care, including over 600,000 people who 
live in rural communities.
    Our Nurse Corps Program, which is where we do loan 
repayment and scholarships for nurses in return for practicing 
in critical high-need areas, we think we would have to cut the 
number of scholarships we award in that program by about a 
quarter. We think the number of people who got loan repayment 
and are out in the field would drop from about 3,900 to about 
2,500 nurses supported by that program.
    We believe our Behavioral Health Training Program, which is 
where we are training a host of clinicians and community 
support providers, would drop by about 1,700 at a time when we 
are really working to grow the behavioral health infrastructure 
in the country to respond to the mental health and substance 
use disorder needs across the country.
    I would also point out the Substance Use Disorder Treatment 
and Recovery Loan Repayment Program--this is our STAR Loan 
Repayment Program--is incredibly popular. We get significantly 
more applications for it than we can fund, but we expected to 
make about 160 new awards going forward. We would have to make 
probably about 35 less of those awards.
    Our Ryan White Program is how we fund AIDS drug assistance 
programs, and we suspect that a little over 50,000 people would 
be unable to receive their antivirals or the insurance 
assistance we fund for them.

                        UNOBLIGATED COVID FUNDS

    Ms. DeLauro. Okay. Let me just also, because the House 
Republican bill would rescind all unobligated COVID funds, 
including all the unobligated funds of the Provider Relief 
Fund.
    What would be the result of rescinding the remaining funds 
in the PRF? Does that mean that HRSA would not be able to 
allocate billions of dollars to healthcare providers based on 
reconsideration of their applications for relief funding?
    Ms. Johnson. That is correct, Congresswoman. One of the 
things that we have tried to do very consistently--we tried to 
be very consistent in the Provider Relief Fund in how we treat 
all providers.
    And some providers--so we have the final payment 
allocations to providers in Phase 4 that we are at the tail end 
of doing. And then all of those providers had the opportunity 
to come in and ask for a reconsideration, make a request of us 
to relook at their application if they thought there was an 
issue. And we have all those pending applications.
    And we did that in Phase 3. We want to make sure that 
providers get that same fair shot in Phase 4.
    Ms. DeLauro. Do you have any idea where those providers 
are, what parts of the country?
    Ms. Johnson. We get those kind of requests from across the 
country.
    Ms. DeLauro. How many are outstanding?
    Ms. Johnson. In the Phase 4 reconsideration requests, we 
have received 2,000 requests.
    Ms. DeLauro. You have 2,000 requests, and those 2,000 
requests would have to be jettisoned, if you will, as a 
consequence.
    Ms. Johnson. That is correct. That is correct. They won't 
all necessarily be paid. We review them as part of the 
reconsideration process.
    Ms. DeLauro. Okay.
    Ms. Johnson. And those where an error is identified, we 
would correct for. But there are 2,000 of them that have asked 
for that opportunity.
    Ms. DeLauro. Okay. I will yield back, Mr. Chairman.
    Mr. Aderholt. Mr. Fleischmann.
    Mr. Fleischmann. Thank you, Mr. Chairman.
    Administrator Johnson, thank you for visiting with us 
today.

                         LONG-TERM CARE SECTOR

    Our country's aging population and the workforce shortages 
in the long-term care sector are well documented, including in 
the President's recent executive order. We both agree on 
increasing access to high-quality care and supporting 
caregivers. Still, I am concerned about increased regulatory 
requirements and quality metrics without the necessary support 
and incentives to help address the workforce shortage causes.
    In addition, I have seen some data that shows the assisted 
living sector was underfunded from the Provider Relief Fund 
compared to other care settings.
    My question is, what is HRSA doing to ensure that assisted 
living operators have the necessary resources and support to 
overcome the ongoing financial impact of COVID and the 
workforce shortage to continue to offer seniors high-quality 
care?
    Ms. Johnson. Thank you so much for the question. It is such 
a critically important area of services and the workforce to be 
able to deliver them.
    I just start on the Provider Relief Fund. My understanding 
was in 2022 there were some issues about assisted living 
facilities having access. That was adjusted beginning in our 
Phase 2 payments. So by Phase 2, 3, 4 the allocations that we 
have operated, the assisted living facilities have been able to 
come in as others have.
    With respect to the workforce, it is a really important 
area of workforce development. Historically, we at HRSA have 
funded the more advanced practice portion of the workforce and 
worked closely with the Labor Department on the portions of the 
workforce where people are in early career ladder programs, so 
CNAs and other critical parts of the long-term care workforce.
    But what we have done increasingly in this administration 
is build a better relationship, a longer-term, stronger 
relationship with the Department of Labor so that we are 
creating career ladders so that we can get people into the 
workforce as certified nursing assistants, move them up to 
LPNs, move them into the RN workforce.
    And so our goal is to really help leverage all Federal 
investments in ways that are sort of centered around the worker 
and not centered around how our programs are funded.
    Mr. Fleischmann. Thank you.

                            OPIOID EPIDEMIC

    My second question involves the opioid epidemic. Tennessee 
is among the hardest hit States when it comes to the opioid 
epidemic. Approximately 70,000 Tennesseeans are addicted to 
opioids, leading to an increase in incarceration, emergency 
room visits, overdoses, and, sadly, death.
    Can you talk about HRSA's Rural Communities Opioid Response 
Program or other initiatives that HRSA might be supporting to 
address this epidemic?
    Ms. Johnson. Thank you. Thank you for raising that 
question.
    I think there are a couple of things I would want to 
highlight on this point.
    This is obviously a whole-of-government response. We all 
have responsibility here to respond to this crisis. But what we 
see as our critical role at HRSA is supporting the workforce, 
which is vitally important to getting services to people; to 
supporting rural communities, which sometimes, when there is a 
State program that funds broadly, some critical, smaller rural 
communities don't always have access to that, and we are able 
to provide funds directly to small rural communities; and 
supporting access and services in underserved and rural 
communities.
    So on the workforce side, our National Health Service Corps 
Program has dedicated resources to substance use disorder 
providers, meaning that we are able to offer loan repayment for 
substance use disorder providers who practice in high-need 
communities.
    Similarly, we have our Behavioral Health Workforce Training 
Program, where we are training more substance use providers, so 
that we are thinking holistically about the pipeline and not 
just about getting current providers into the communities they 
need.
    And then our Rural Opioid Response Program, as you 
mentioned, that is a way that we are able--and what we really 
like about that program is we are able to go to rural 
communities and say: What is it you need? Where are your gaps? 
And we are able to fund and respond to that.
    Mr. Fleischmann. Thank you very much. Appreciate the answer 
to those questions.
    And, Mr. Chairman, I will yield back.

                             PROPOSED CUTS

    Mr. Aderholt. Mr. Hoyer.
    Mr. Hoyer. Thank you very much, Mr. Chairman.
    And thank you very much, Ms. Johnson, for your service to 
our country and to those who have health needs in this country, 
which are very large.
    I am a big proponent of--and I quote the former Governor of 
our State, Ted Agnew. He said: When the cost of failure far 
exceeds the price of progress.
    And in the cuts that have been proposed, as far as I know, 
there is no estimate of the consequential additional costs that 
they will incur as a result of not servicing.
    Let me refer specifically to a study that I am sure you are 
familiar with. The American Journal of Public Health, in a 2016 
study, showed that people who went to public health centers 
were 33 percent lower spending on those folks by Medicaid and 
found 25 percent fewer inpatient admissions of those who went 
to these health centers and 24 percent lower spending overall.
    Now, I don't have the figures of what that means. I don't 
know whether you have computed that. You may not. But it is 
worth looking at, because the cost that would be incurred as a 
result of the cuts that are proposed are not simply that which 
was cut, but that which resulted in additional costs for that 
cut.
    Do you have any thoughts on that?
    Ms. Johnson. So thank you for the question.
    The data does increasingly show the more studies come out 
about the way our community health centers help prevent ED, 
emergency department, use help prevent other utilization of 
higher-cost settings, because people, once you connect someone 
to a usual source of care, they are more likely to get 
preventative care, they are more likely to have a place to go 
for services or a place to call rather than showing up in an 
emergency department.
    And so it is a critical investment in healthcare services, 
both for the health of individuals, but also for our overall 
expenditures.
    On a related note, sir, I would say the other sort of 
undocumented cost associated with not making these full 
investments is, with the health workforce, we are training 
people today who won't be in the field for several years. And 
so, if we don't invest in that training now, the cost will be 
felt along the long term.
    Mr. Hoyer. Thank you.
    Now, am I correct that you mentioned a figure of 2 million 
patients that would not be served? Is that accurate?
    Ms. Johnson. That is correct.
    Mr. Hoyer. So that effectively the costs--the consequential 
cost of that, 2 million people, very, very substantial number, 
in my view probably in excess of the savings that would 
purportedly be made.
    Does that stand to reason?
    Ms. Johnson. I understand your point. I don't know the 
exact data, but we can look at that.

                      TRAINING PEDIATRIC DENTISTS

    Mr. Hoyer. Okay. We had a young man, 12 years of age, in 
Prince George's County, which I represent, Deamonte Driver, had 
a toothache. His mom tried to find a dentist. She couldn't find 
a dentist, probably because she didn't know really how to, 
because some dentists certainly would have served.
    He had a toothache. It went for some period of time, and it 
became abscessed. He went to the emergency room. The abscess 
went to his brain, and he died.
    You train pediatric dentists. It is one of the biggest 
health problems that young people are experiencing, more than 
asthma, more than some other afflictions.
    Can you speak to the--you just spoke to it briefly--to the 
supply of pediatric dentists that you are trying to resolve?
    Ms. Johnson. Thank you for the question, sir. And I 
remember the case incredibly well and how it caused all of us 
in public health to think about not just service delivery, but 
how we were doing outreach to families to make sure families 
knew what was available. And it caused all of us to sort of 
double down on: Are we doing everything we can when it comes to 
oral health providers?
    And we have created new programs in recent years, including 
our Teaching Health Center Program, which is training dental 
residents in the community, with the investment intended to 
help ensure that they continue to serve in the communities 
where they train.
    And there are a host of other programs that we support, 
including our State Oral Health Program, that is really 
designed to help States highlight these issues and bring 
resources to bear on making sure that families can access oral 
health services.
    Mr. Hoyer. Not only here, but throughout the healthcare 
delivery system, what the pandemic showed us, what a critical 
shortage we have in almost every discipline in terms of 
healthcare.
    And, again, Mr. Chairman, my view is investing in making 
sure that those shortages do not continue is a great savings to 
our country and to the budget.
    I yield back.
    Mr. Aderholt. Thank you, Mr. Hoyer.
    Dr. Harris.

                           BALANCING BUDGETS

    Mr. Harris. Thank you very much.
    And thank you for being with us today.
    When you were commissioner of the New Jersey Department of 
Human Services, did you have to balance your budget?
    Ms. Johnson. Yes, sir.
    Mr. Harris. Oh, you did? And in your agency right now, do 
you have to balance your budget?
    Ms. Johnson. Yes, sir.
    Mr. Harris. Okay. And, when you were in New Jersey--I read 
your bio--there were a lot of things you could get accomplished 
under a balanced budget requirement, New Jersey as a State writ 
large. Is that right?
    Ms. Johnson. Yes, sir.
    Mr. Harris. So that you can actually do things if you 
balance the budget, you can actually accomplish a lot of these 
things.
    Now, did New Jersey have a program for loan repayment for 
primary care physicians and providers and for nursing faculty?
    Ms. Johnson. I believe we did, but it was run within a 
different department.
    Mr. Harris. Yeah, you did. New Jersey did.
    So, actually, States can do that, can't they?
    Ms. Johnson. They do, but they do some of it with our 
funding. We provide funding to States for State loan repayment.
    Mr. Harris. Sure. I get it. But States can do it. And some 
States, in fact, do have, like the State of Maryland has a 
separate loan repayment program from the Federal Government. So 
it doesn't really require the Federal Government.
    Now, when you list the things that affect healthcare 
providers right now, I will tell you that physicians my age who 
are in practice tell me that medical inflation is one of the 
greatest impediments to them continuing practice.
    Would you agree that healthcare inflation is actually 
harming our medical practices because Medicare payments do not 
keep up with inflation?
    Ms. Johnson. I can't speak to the specifics of Medicare 
payments, but I can say that anything that costs providers more 
to deliver care is something that we hear from our--the 
healthcare service delivery community that we fund--is it 
creates more pressure on them.
    Mr. Harris. Sure does. And the majority of Americans, when 
you poll them now, know that increased Federal spending was the 
primary cause of inflation. They make that connection.
    Do you agree that that is one of the primary causes of 
inflation?
    Ms. Johnson. I am sorry?
    Mr. Harris. Increased Federal spending is a primary cause 
of inflation in this country.
    Do you agree that increased Federal deficit spending is one 
of the primary causes of inflation? Do you agree with the 
majority of Americans or not on that?
    Ms. Johnson. I am sorry, sir. I haven't looked at the 
question specifically. I can tell you what we hear from 
providers across the country.
    Mr. Harris. Okay. I don't--I just--it was a very specific 
question. So you don't know whether it caused inflation.
    Well, I will tell you, I think the majority of Americans 
are correct. Inflation is actually the leading--I am sorry. 
Federal deficit spending, out-of-control spending, 
$31,000,000,000,000 debt, is a leading cause of inflation and 
instability in the primary markets, which I think is one of the 
major threats to the continuance of experienced healthcare 
providers staying in the profession.
    And I would argue that our out-of-control Federal spending 
does need to be reined in. And I would also argue that the 
States can pick up the slack.

                     TRAINING HEALTHCARE PROVIDERS

    My State has billions of dollars in their rainy day fund. 
They could actually do some of the things that HRSA does, and I 
would proffer they should be doing it given that.
    Now, let me ask you about the role of the private sector in 
GME. Now, as you are aware, a couple of years ago, during the 
COVID pandemic, there was a shortage of emergency room 
physicians. And, in fact, large practices couldn't find them.
    So one of the largest practices just decided they were 
going to train their own. They were actually going to do what 
the Federal Government had been doing woefully inadequately, 
which is train enough healthcare providers.
    And what they did is they converted the emergency medicine 
physician supply from a deficit to now where it is a surplus. 
And that is good it is a surplus, because these are the 
physicians who, in fact, work in urgent care centers, which 
unload our emergency rooms, which you know is a far more 
expensive way to deliver emergency care.
    So what is the role of the private sector in training 
healthcare providers?
    Ms. Johnson. Well, Dr. Harris, I would say that is an 
important part of the solution here, because we clearly need 
more.
    And what our targeted resources do is really look at 
places, for example, in our Rural Residency Program, where a 
rural facility might be able to run a residency program, but 
doesn't have the capacity to stand up and get accredited and 
those types of things. So we invest in helping them do that 
part of the work.
    Mr. Harris. Sure. Let me just interrupt, because I only 
have a few more seconds left.
    So when you talk about these rural programs, do you require 
a State participation in the payment for them? I mean, do you 
require a copay, what we would call in physician parlance a 
copay?
    Do you require States--if you go into a State and you 
provide loan repayment in a rural area, you provide setting up 
a rural residency, do you require the State to have skin in 
that game? Because they are the ones benefiting, their 
residents are the ones benefiting.
    I don't benefit. I love Tennessee, but I don't benefit when 
Tennessee gets an extra primary care provider.
    Do you require States to participate in paying for those 
programs?
    Ms. Johnson. By statute, the State Loan Repayment Program 
that we fund has a State match in it. That was waived during 
COVID, but it is--there is a required State match.
    Mr. Harris. So it is back in effect now, because the COVID 
emergency is over?
    Ms. Johnson. If we have future money for that particular 
part of the program, for the State Loan Repayment Program.
    Mr. Harris. Excuse me. If you what?
    Ms. Johnson. If we have future funding, if we do future 
rounds of funding, because that is the State Loan Repayment 
Program, which is a subset of our National Service Corps 
Program.
    Mr. Harris. Right. But we are requiring, once again, the 
States to pay?
    Ms. Johnson. When we have a new round of funding for it.
    Mr. Harris. Okay. I yield back.
    Mr. Aderholt. Mr. Pocan.
    Mr. Pocan. Thank you, Mr. Chairman.
    And thank you, Ms. Johnson, for being with us.

                   HEALTHCARE WORKER SUPPORT PROGRAMS

    So I want to talk a little bit about the healthcare worker 
shortage still, I think, that exists. Part of it was obviously 
coming out of COVID. I think a lot of people went through an 
awful lot, just like our economy. When the countries across the 
globe reopened, we have worldwide inflation because of that 
supply and demand issue.
    But one of the other issues that I think also is what we 
are paying folks. We talk about the training we absolutely need 
to do. But I think also what we are paying folks can help keep 
people in the profession.
    One of the trends that we have seen, at least in my area in 
Wisconsin that I am concerned about, is these almost temp type 
firms, that someone maybe worked for a hospital, but in order 
to get paid just a little more, they are going to this temp 
firm, maybe not with the same benefit structures, hiring them 
back sometimes in the exact same position at two or three times 
the cost, really raising the cost of healthcare for everyone.
    Have you looked at that at all? And is there something, a 
solution that can happen? Because I am hearing it from the 
hospitals, but also I know ultimately that is not in the best 
interests of the workers, to go from a nice, permanent, full-
time job with benefits to something that is temp in nature. 
Even though there is a short boost in pay, it doesn't solve 
long-term goals.
    Ms. Johnson. I appreciate the question, sir.
    I am very aware of the phenomenon and very aware of the 
impact that it is having on worker mobility and stability in a 
facility and the challenges it is presenting to maintaining a 
health workforce; however, also the opportunities it is 
presenting to workers to be able to maximize their revenue.
    We don't have regulatory or reimbursement authority to 
govern what happens there. But what I can tell you, what we are 
doing at HRSA is we recognize that part of the dynamics that 
are happening in nursing right now. Nurses were heroes across 
the pandemic. They were the front lines. That is who saved us. 
We are here today because of the nursing workforce.
    But what has happened is that we are seeing more challenges 
in being able to train more nurses. And it is not--
interestingly, I think people might say: Well, is that because 
nurses aren't coming into the field because they see how 
challenging it is?
    That is not what we are seeing. We are seeing many people 
raising their hands wanting to be nurses. We don't have the 
infrastructure to support it. There are not enough clinical 
faculty. There are not enough people who can oversee and be 
that mentor in a clinical training facility to be able to train 
new nurses. And when that happens, we see too much turnover of 
new nurses, and that contributes to the larger environment that 
you are referring to.
    That is why our budget is investing in more faculty, more 
clinical preceptors, really recognizing what it takes to 
support the clinical nursing workforce and to make sure that 
nurses feel supported and mentored and well trained to deliver 
the highest-quality care.
    Mr. Pocan. Great. Thank you.
    So, I mean, if we wind up with 22 percent cuts in this 
area, not only can you not expand, but you would actually have 
to contract what you are doing in this area, causing even more 
burden on the healthcare facilities?
    Ms. Johnson. That is correct. We would not be able to do 
the kinds of things that we want and need to do to grow the 
nursing workforce, but we would lose ground as well.
    Mr. Pocan. Gotcha.

                          PROVIDER RELIEF FUND

    One quick question on the Provider Relief Fund.
    Under the Trump administration, the way they distributed 
funds, there was Federal funding that was sometimes used to 
subsidize mergers and acquisitions. I know there is an example 
with Apollo Global Management that owned a hospital; Lifepoint 
Health got $1,600,000,000 in COVID aid. And, instead of using 
that to improve patient care and respond to the pandemic, they 
bought another private equity-owned provider, Kindred 
Healthcare.
    I believe you guys are looking at potentially trying to get 
some funds back from that. I am curious what you are doing in 
that area, because I think that is not the intention of that 
fund, yet we know it was used by some in that way.
    Ms. Johnson. Thank you for raising the question.
    We did hear, and my colleagues who are on the career staff 
who have managed this program for a long time now certainly 
heard the concerns about whether the resources from the 
Provider Relief Fund were driving mergers and acquisitions.
    We added some additional reporting requirements in Phase 4 
when we initiated a new program so that we would be able to 
identify people who have done mergers and acquisitions so that 
that could be part of our risk assessment criteria when it 
comes to accountability in the program.
    Mr. Pocan. Will there be any attempts to try to claw back 
any funds?
    Ms. Johnson. Well, we have a robust program integrity 
mechanism here, and we will look for appropriate use of funds.
    Mr. Pocan. Okay. And would it be appropriate use of funds 
if they used it for mergers and acquisitions?
    Ms. Johnson. So appropriate use of funds should be 
consistent with the statutory requirement that this addressed, 
losses and expenses associated with the virus.
    Mr. Pocan. So if I can get a yes or no if it is possible. 
Will that include funds to do mergers and acquisitions?
    Ms. Johnson. Well, part of the reason why we asked for the 
mergers and acquisition data, sometimes it is quite complex 
data that might point to a reason for having additional 
providers as part of the response. But sometimes it might be 
different and not consistent with the statute, and that is 
where we would have more authority to be able to address it.
    Mr. Pocan. Okay. I look forward to having a more direct 
conversation on that.
    Ms. Johnson. Thank you.
    Mr. Pocan. Yield back.
    Mr. Aderholt. Mr. Moolenaar.

                        COMMUNITY HEALTH CENTERS

    Mr. Moolenaar. Thank you, Mr. Chairman.
    I would also like to submit a letter from the National 
Association of Community Health Centers for the record.
    Mr. Aderholt. Without objection.
    [The information follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Moolenaar. Thanks.
    Thank you, Ms. Johnson. I appreciate you being here.
    I appreciated your comments on the workforce and the need 
to continue to grow the workforce. I just want to highlight 
some of the work that is being done by our community health 
centers.
    Northwest Michigan Health Centers is one such community 
health center that has recently initiated workforce training 
for medical and dental assistants. And due to the workforce 
shortage for the area, they found it more beneficial to train 
and provide professional growth for their staff. And their 
workforce program is a great lifeline for the health center. 
And so I just wanted to highlight the work they are doing.
    I also wanted to follow up with you on one of the questions 
raised when you talked about the Phase 4 reconsideration 
regarding the tail end of COVID.
    You mentioned that there are 2,000 applications for that?
    Ms. Johnson. That is correct.
    Mr. Moolenaar. If you had to guess--I am assuming that 
those are people who were denied initially, and they are 
reapplying--what percent do you think will be adjudicated 
differently?
    Ms. Johnson. I appreciate the question, Congressman. It is 
a fair question. I don't know the answer to that, because it is 
very application specific.
    Mr. Moolenaar. Okay. And do you know the average amount, 
dollar amount, of applications?
    Ms. Johnson. I don't, but we are happy to get back to you 
on that.
    I will say it will be very small providers, very large 
providers. I am not sure the average will be particularly 
telling. But we will be happy to get back to you with it.
    Mr. Moolenaar. But would you agree, if money is in Federal 
budgets or agencies that has not been obligated or allocated 
and it was given under the auspices of a COVID emergency, would 
you agree that those dollars shouldn't be spent just on 
different priorities other than addressing the COVID emergency?
    Ms. Johnson. Well, I would say, sir, that throughout the 
life of the Provider Relief Fund it has been used both in the 
prior administration and this administration for doing some of 
the emergency needs response, including acquisition of products 
and other things. So that has happened across the Provider 
Relief Fund.
    Mr. Moolenaar. Sure. During the emergency. But once the 
emergency is over, would you agree we shouldn't be spending 
those dollars for a different purpose than an emergency?
    Ms. Johnson. Oh, I see your question.
    I would say that there is a part--while the public health 
emergency is ending, we are making a thoughtful transition. It 
has always been the case that there would need to be a 
thoughtful transition from all the emergency response 
mechanisms to the commercial market, and ensuring that there is 
a smooth transition to the commercial market is something that 
I think we all have a vested interest in.
    Mr. Moolenaar. Sure. So, I mean, there will always be 
spending needs. But, I mean, I guess, if I were saying, okay, 
this money was to be spent during an emergency, I think it 
would be somewhat disingenuous to then spend it on something 
that is not during the emergency, but rather just another 
priority spending, which should be handled by the regular 
appropriations process, I would think.
    Does that make sense?
    Ms. Johnson. I see your point, Congressman, but I would 
just say that I think that part of what the goal here is, is to 
make sure there is as smooth a transition as possible.
    I think everyone would agree that commercialization of the 
products associated with the COVID response needs to happen and 
happen in an orderly way. But there are uninsured folks who 
will not be part of that, and so that is partially why this 
smoothing out is being invested in.

                             PROPOSED CUTS

    Mr. Moolenaar. Okay. You have looked at proposed cuts. I am 
not sure exactly what number you are basing that on or what the 
proposal you are evaluating it on. What proposal are you using 
to make those?
    Ms. Johnson. Those numbers are associated with the request 
with an estimate of a 22 percent reduction.
    Mr. Moolenaar. Okay. And where did you get that?
    Ms. Johnson. Those were estimates that we were, in general, 
asked about.
    Mr. Moolenaar. And who asked you to do that?
    Ms. Johnson. It is a really good question. I am not sure. 
We were asked to respond to an across-the-agency--across-the-
department response.
    Mr. Moolenaar. But do you know who asked that? I mean, what 
is that based on, that 22 percent?
    Ms. Johnson. I don't----
    Mr. Moolenaar. Oh, I am asking--if I could ask the witness 
to----
    Ms. DeLauro. Sure, but I made the request of the agencies 
to get information, and that is why Ms. Johnson----
    Mr. Moolenaar. Okay. So that was Ms. DeLauro. Thank you. 
Okay.
    What have you been requested to look at if--if we don't 
address the $32,000,000,000,000 debt that we have, have you 
considered how your budget in the future and training would be 
affected by that if we don't adequately address that problem 
for our country?
    Ms. Johnson. Well, I think, Congressman, there will always 
be a question about the larger backdrop against which 
investments are made. We think that the needs to invest in the 
healthcare workforce and the needs to ensure the health and 
well-being of our communities is always going to be a priority. 
And so that is why we want to make sure that we are investing 
now so that we have people in the training pipeline for the 
years to come.
    Mr. Moolenaar. So I am going to take that as a no, that you 
haven't really looked at what the challenge of a 
$32,000,000,000,000 debt would mean for future investments.
    Ms. Johnson. I don't----
    Mr. Moolenaar. You haven't really analyzed that?
    Ms. Johnson. I don't know that we have been asked that 
question specifically. I do know that we have weathered budget 
issues, up and downs in the years past. And whenever there are 
cuts to health workforce programs, the repercussions are felt 
for years beyond.
    Mr. Moolenaar. Sure. Okay. Thank you very much.
    I yield back.
    Mr. Aderholt. Ms. Frankel.

             BUDGET CUT IMPACTS ON MATERNAL HEALTH WORKERS

    Ms. Frankel. Thank you.
    And to Administrator Johnson, thank you for your good work 
and for being here.
    Ms. Johnson. Thank you.
    Ms. Frankel. Today, or sometime this week, we are going to 
be voting on a bill that is called--what is the name of this 
bill? Well, whatever.
    Ms. DeLauro. Default on America.
    Ms. Frankel. What is it called?
    Ms. DeLauro. Default on America.
    Ms. Frankel. Default on America Act. Okay. Yes.
    And really, this is going to be a terrible choice. It is a 
choice of whether we wreck our economy or we inflict cruel cuts 
on everyday Americans. That is what this is about.
    So I want to get right to your programs and see what the 
proposed 22 or 25 percent cut is going to mean.
    The United States has the highest maternal mortality rate 
in any developed Nation in the world. Women of color are 
disproportionately impacted by maternal mortality. And we need 
more maternal health workers to address the crisis, not less.
    So tell us what these budget cuts would mean, a 22, 25 
percent cut would mean.
    Ms. Johnson. So thank you for the question. One of the 
things that is operationally as a program manager is 
interesting and challenging for us is that we got some 
additional resources in the fiscal year 2023 budget to help 
grow some of these programs, particularly our maternal 
depression program, which provides teleconsultation services 
from mental health professionals to OBs and OB/GYNs to help 
address the mental health needs of pregnant women. So we are 
going to make new awards this year that we may need to roll 
back next year. And so that is a very difficult funding 
environment as a program manager for us to be in, especially 
because that is such a--we have so much demand among States for 
that service, and there is so much interest in people applying 
for it.
    We also have been able to grow our maternal mental health 
hotline with resources from the budget, and we would have to 
roll those resources back. And we are the funder of the Title V 
Maternal and Child Health block grant that helps every State 
across the country. Your State does newborn screening with 
those resources. It does early intervention services. It does a 
host of critical services for zero to 3 that we will have to 
roll back.
    Ms. Frankel. In other words, if Republicans have their way, 
more women will die at childbirth than less. All right, I think 
that is what you just said.
    Next, in recent years, there has been a steady stream of 
new stories reporting the closure of maternity care units in 
hospitals across the country. In the past decade, over 200 U.S. 
hospitals closed labor and delivery departments. And, according 
to the most recent data of the March of Dimes, nearly 500 
births occur in areas of low or no access to maternity care.
    So, first of all, tell me how you have been using your 
investments to change that and what the budget cuts would do, 
the proposed 22 to 25 percent cut proposed by the Republicans.
    Ms. Johnson. Well, thank you, Congresswoman, for raising 
the issue. I mean, if you asked me about what keeps me up at 
night, this is the issue that keeps me up at night, the closure 
of the labor and delivery services in not just rural areas, 
which has been happening for some time and continues to happen 
in rural areas, but more frequently now in like exurban and 
suburban areas, where the distance to get to a labor and 
delivery site is continuing to grow.
    We are investing, particularly in rural communities, in 
building community networks, in putting the payers and the 
hospitals and the emergency services and everyone together 
around the table to find solutions, but they are patchwork 
solutions. We are investing in the healthcare workforce to put 
more providers into the community to be able to do prenatal 
care earlier so we are able to do better planned deliveries.
    But we are doing a host of things around the workforce and 
around service delivery. We are going to make awards soon to 
invest more maternal care services in health centers, but all 
of those things are contingent on budget availability.
    Ms. Frankel. All right. In other words, there are going to 
be less hospitals, delivery labor services than more.
    And, just as a side note to this, in Florida, where we have 
very good sunshine, our new abortion law there, as a result, 
the doctors are leaving like crazy. So, folks, between the 
budget cuts and the abortion restrictions, those of us who live 
in red States are going to have a hard time finding 
gynecologists who deliver babies and who take care of them.
    And, with that, I yield back.
    Mr. Aderholt. Ms. Letlow.

                  CONTRACT LABOR AND CLINICAL FACULTY

    Ms. Letlow. Thank you, Mr. Chairman.
    Thank you, Ms. Johnson, for being here with us. I enjoyed 
our phone call a couple of weeks ago and all that HRSA does for 
my district in Louisiana.
    I want to go back to the contract labor issue. In my 
district alone in Monroe, Louisiana, St. Francis Medical Center 
was quoted $88 an hour for a single contract nurse. Some 
facilities, including St. Francis, are still struggling to 
respond to the workforce shortage, and this is the only option 
to ensure adequate staffing.
    Relying solely on contract labor creates an unstable and 
unreliable workforce. We both know that adequate staffing has a 
direct impact on patient access to care. So while I know we 
have--you have covered this today, exactly what is holding us 
back from delivering on this workforce shortage? I heard you 
mention not enough clinical faculty, and coming from higher ed, 
then is the onus on our universities? Is there anything that 
HRSA is doing to collaborate with the universities in order to 
increase the number of clinical faculties that we have so we 
can train more nurses to get them into the workforce.
    Ms. Johnson. I so appreciate the question because it is 
what we really are honing in on, is how do we get more clinical 
faculty. And it is not just the onus on academic medicine. It 
is about the healthcare delivery sites as well.
    Ms. Letlow. Right.
    Ms. Johnson. And so sometimes, when I talk to hospital 
administrators, they say: I would love to train more nurses in 
my site; I just don't have enough room to be able to do it.
    And so part of our goal is to recruit more people into 
clinical faculty. It is hard, right, because we also want 
people delivering care.
    Ms. Letlow. Right.
    Ms. Johnson. And so it is time away from care. So part of 
what we are able to do is support that work. But we also need 
holistically to focus on how to make sure there is clinical 
training delivery sites. And that is why we are continuing to 
use community health centers and other sites as ways to do 
nurse residency training, places where we can maximize our 
whole clinical footprint for training sites.
    Ms. Letlow. That is interesting. I am not hearing that 
clinical training sites are the issue in my district per se. I 
am not saying it is not across the country, but just that it is 
a matter of training the nurses and the shortage there with 
clinical faculty. I am just wondering, is it an accreditation 
issue? I mean, what is happening with our universities not 
being able to take in more nurses? Just like you said, people 
want to go into nursing.
    Ms. Johnson. Yeah.
    Ms. Letlow. So I would like to hear your thoughts on that.
    Ms. Johnson. You may be hearing something different. I 
would love to hear what you are hearing. But a part of what we 
hear is that, when there is resources to be made as traveling 
nurses or when hospitals are trying to fill slots, the 
competitive salaries for faculty may not be as easy to fit--may 
not make it as easy to fill. And so that is why we do loan 
repayment for faculty. That is why we are really focused on 
programs like our Nurse Corps program for faculty to try to get 
people into faculty roles and maybe not exclusively, maybe 
ensuring they can continue to deliver services as well so that 
they can meet the salary objective that they want.
    Ms. Letlow. So how specifically are you using that program 
to recruit them?
    Ms. Johnson. So the one thing that is really great about 
our Nurse Corps program is it is like our National Health 
Service Corps program, where individuals come to us directly. A 
lot of our programs are mitigated through academic medical 
centers, and then we are sort of dependent on how the center 
runs the program. With Nurse Corps, nurses come directly to us 
to apply for loan repayment.
    Ms. Letlow. Okay.

                      DELTA REGIONAL RURAL HEALTH

    In fiscal year 2022, HRSA funded five grants totaling $2.6 
million for the Delta Regional Rural Health Workforce Training 
Program, which supports the education and training of future 
and current healthcare professionals in rural communities and 
parishes of the Mississippi Delta region. Could you please 
provide an update on the progress these grants have made?
    Ms. Johnson. Thank you so much for the question. If you 
don't mind, I would love to have the opportunity to brief you 
more fully about all the work that we are doing in this space.
    I will say that it is an essential partnership for us. And 
we are grateful to the committee for supporting this work 
because it has allowed us to really focus on identifying what 
the workforce needs are and really being informed by--allows us 
to design our resources to meet the needs rather than us having 
a program and people coming applying to it trying to guess how 
it might align with what their needs are. And so the Delta 
Program is a really critical part of our work.
    Ms. Letlow. Great. How many competitive applications for 
this program are considered highly qualified and scored 
exceedingly well but did not get the funding? How much funding 
would it take to reach those that missed out on the grant 
opportunity?
    Ms. Johnson. I am happy to get back to you with the 
specifics. I know that it is more than we could award.
    Ms. Letlow. Okay. I would appreciate that. Thank you so 
much for your time.
    I yield back.
    Mr. Aderholt. Mr. Harder.

                           CMS REIMBURSEMENT

    Mr. Harder. Thank you so much, Chair Aderholt and Ranking 
Member DeLauro, for hosting today's hearing.
    Thank you, Administrator, for being here.
    I am very focused on the workforce challenges that we have 
in our area. Cities in my district have been designated as 
health professional shortage areas. San Joaquin County has been 
classified as a medically underserved area. And these 
definitions have real consequences. They are definitely 
accurate. One in five hospitals across our region are in danger 
of closing right now. Life expectancy is 7 years less in my 
district than it is 2 hours away in San Francisco. So we are 
paying real costs for our lack of providers.
    I want to learn about how your definitions are used 
elsewhere. So CMS manages reimbursement for all the physicians 
in our area. Does CMS reimburse medically underserved areas 
like ours more than they do areas that are not medically 
underserved?
    Ms. Johnson. As a general matter, I don't believe so. But, 
in the Affordable Care Act, there was a targeted program linked 
to health professions shortage area, but as a general matter, 
that is not part of the standard----

                    NIH AND CDC IN UNDERSERVED AREAS

    Mr. Harder. And, in fact, the exact opposite. Right? I 
mean, because areas like mine are 50 percent or Medi-Cal or 
Medicaid. Physicians are actually paid a lot less in our area. 
What about the NIH? This committee manages the NIH budget. The 
NIH budget is 25 times the HRSA budget. Does the NIH give 
special consideration towards their clinical research being 
done in areas that are underserved?
    Ms. Johnson. I don't know that as a general matter. I know 
that, in this administration, the NIH has reached out to us 
repeatedly to say, how can we better integrate the community 
health centers and others who do work in underserved areas into 
clinical trials? That is something they are very focused on.
    Mr. Harder. I would love to see that because the vast 
majority of NIH budget is San Francisco, New York, Boston, 
areas that have a whole lot more physicians than they know what 
to do with, and not research being done in areas like ours.
    The CDC is another organization that is under this 
committee's jurisdiction. They embed clinical researchers in 
public health departments. Do they embed a lot more in 
medically underserved areas?
    Ms. Johnson. I don't know the answer to that question.
    Mr. Harder. The answer is no. Unfortunately, and this goes 
to what I think is probably the key issue in this hearing and 
on workforce shortages across healthcare, is this is not a 
challenge that is going to be fixed by HRSA. You guys are doing 
terrific work, and I am very grateful for you coming up with 
the definitions of zones like mine that are medically 
underserved. But, if we are really serious about this 
challenge, and I think we should be, then we have to do a much 
better job of trying to embed those criteria in the other parts 
of the healthcare budget. Because 99.9 percent of the Federal 
healthcare budget is not taking into consideration these 
workforce shortages, and that is the root of the issue.
    So I am very grateful for this hearing. I think it is a 
really, really important issue, but I submit to the committee's 
leadership that, if we wanted to address these workforce 
shortages, this is not going to be fixed by changes with HRSA. 
This is going to be fixed by requiring other agencies under 
this committee's jurisdiction to consider HRSA criteria as 
important when actually divvying out those resources. And we 
can do a lot in order to fix this. If we actually make 
reimbursement rates higher in medically underserved areas, if 
we make NIH research go more toward medically underserved 
areas, we can actually entice a lot of doctors and nurses to 
come to areas that are desperately needed. And I hope we are 
successful in doing that.
    So thank you so much for your work, Administrator. Thank 
you for the research and the work that you have done to 
highlight areas like my district that are in desperate need of 
more doctors, and I hope we can take more action to make sure 
that we can address these needs.
    With that, I yield back.
    Mr. Aderholt. Mr. Clyde.

                    HEALTH CARE WORK FORCE SHORTAGES

    Mr. Clyde. Thank you, Mr. Chairman.
    And thank you, Administrator Johnson, for being here today.
    The Health Resources and Services Administration is tasked 
with many important duties, including serving rural communities 
like mine in Georgia Nine.
    While we are looking at your fiscal year 2024 budget, I 
have some concerns about how money is being allocated, 
especially regarding healthcare workforce shortages. We have 
seen a healthcare workforce shortage, including in my State of 
Georgia. For example, the Kaiser Family Foundation predicts 
that Georgia would need an additional almost 700 primary care 
professionals to fully serve the State just this year. So I 
think we really need to be looking for ways to attract and 
retain talent in these areas of need.
    The statistics are alarming. The University of St. 
Augustine for Health Sciences predicts that our Nation will 
need 1.2 million new registered nurses by 2030 to address the 
shortage. Would you agree that where money is spent is directly 
related to what priorities are held?
    Ms. Johnson. Yes, sir. And you will get no argument from me 
that we need to do more and more on the workforce in rural 
communities.
    Mr. Clyde. All right. Thank you.
    The fiscal year 2024 budget request, $24,300,000 for the 
Nursing Workforce Diversity Program to increase nursing 
education opportunities for individuals from disadvantaged 
background, including racial and ethnic minorities.
    With this mind, it leaves me to ask, is the priority of 
HRSA to fill the nursing workforce shortage, or is it to 
address the diversity in the nursing workforce?
    Ms. Johnson. Our priority is to address the nursing 
workforce writ large. Part of that is the program you have 
referenced is about ensuring that we are giving every 
opportunity to people from disadvantaged backgrounds to be able 
to enter the nursing workforce and so that, in many 
communities, the healthcare workforce reflects the community 
served. We do similar work in rural communities to recruit 
people from the community to be able to serve their own 
community.
    Mr. Clyde. Okay. I kind of think maybe focusing just on 
merit and those who want to be nurses, regardless of what their 
background is, will probably help you get more people into the 
workforce.
    Now transitioning to the COVID-19 vaccine, that mandate is 
still in place, correct, for healthcare workers?
    Ms. Johnson. I don't know the answer to that, sir. I think 
so.

                         COVID VACCINE MANDATE

    Mr. Clyde. I believe so. So, if we want to increase the 
number of healthcare workers, I think it would be beneficial if 
we would eliminate those factors that are actually hurting 
recruiting for healthcare workers. And one of those is the 
COVID-19 vaccine mandate. We have seen that time and time 
again. In my district, we had numerous healthcare workers 
depart, the pattern, if you will, or leave the workforce simply 
because of the vaccine mandate. They didn't want to be part of 
what they thought would hurt them. So is that anything you are 
considering whatsoever?
    Ms. Johnson. So, sir, that policy is not in my 
jurisdiction, but I will tell you, as I talk to healthcare 
providers now and I assume you have heard similar, what we hear 
consistently is we need more people in the pipeline. We need 
more people getting trained. And so that is where we are really 
focused on getting people trained up and ready and available to 
be able to practice.
    Mr. Clyde. Right. But just like what we are seeing in the 
military, where we are seeing a reduction in recruiting and 
part of that is because people don't want to be forced to take 
the vaccine in the military--fortunately, that is over now, but 
that still exists when it comes to healthcare workers. That 
mandate is still there. And I think that really needs it be 
looked at and said: Okay. Maybe we need to eliminate that 
vaccine mandate so that people will then be more willing to 
enter the healthcare workforce.
    Now, Administrator Johnson, is the Countermeasures Injury 
Compensation Program providing reimbursement for COVID-19 
vaccine-related injuries?
    Ms. Johnson. It is.
    Mr. Clyde. It is. Okay. It appears in your fiscal year 2024 
budget request that you are asking for over a 100-percent 
increase in that area in your budget. Does this more than 
doubling of funding indicate that the Biden administration is 
anticipating a significant increase in vaccine injuries related 
to COVID-19 vaccines and a significant number--an increase in 
payouts?
    Ms. Johnson. Sir, I believe you are referring to the line 
item in our budget that would go from $7,000,000 to 
$15,000,000.
    Mr. Clyde. That is correct, over 100 percent increase.
    Ms. Johnson. And that is associated with the fact that, for 
the 10-year history of the Countermeasures Injury Compensation 
Program, we had 500 claims. Today, more than 700 million doses 
of COVID vaccine have been delivered. So, while rare, the 
number of claims we have gotten associated with potential 
injuries is higher than the history of the program. So we have 
8,000 claims associated with potential vaccine injuries. We 
need, to ensure that people get timely consideration of their 
application, we need more medical reviewers. We need more 
capacity to be able to give people answers in a more timely 
way, and that is what our request is associated with.
    Mr. Clyde. Thank you. And I yield back.

                             HRSA OUTREACH

    Mr. Aderholt. Mr. Ciscomani.
    Mr. Ciscomani. And my microphone isn't working so I will 
use yours.
    On my committee, TI committee, I was sitting down there so 
I am just glad to have actually a seat at the table. But my 
time is running so I better stop.
    Well, Administrator, thank you so much for being here. 
Thank you for answering our questions. My question is related 
to my own community college where I graduated from. I am a 
proud graduate of Pima Community College over in Tucson, 
Arizona. And one of the programs they offer to students 
includes degrees in nursing, certificates of practical nursing, 
and courses to help prepare nursing assistants as well. They do 
a terrific job at this, and even though Pima Community College 
does a fantastic job in training aspiring healthcare 
professionals, administrators at the community college have 
confirmed with me that they have not been receiving any funds 
from HRSA for their nursing program to help strengthen the 
workforce yet. So my question is pretty simple: What type of 
outreach does HRSA do to make sure the nursing programs are 
aware of the grant opportunities that HRSA offers?
    Ms. Johnson. I am so glad that you raised this question, 
sir, because one of the things that I, in my role as HRSA 
Administrator having been in this role for about 15 months, 
have prioritized is our outreach to eligible entities and being 
more clear in our funding opportunities about who is eligible. 
We tend in many instances to just repeat the statutory language 
that says, you know, all eligible entities, all entities that 
provide these services. And I want to be clear, where community 
colleges are eligible, that we are reaching out proactively to 
community colleges to make sure that they are accessing these 
resources as well. Because it doesn't make sense for our money 
to not be reaching the places where the work is happening and 
where we want to start building nursing career ladders.
    Mr. Ciscomani. Well, I totally agree with that. I have 
several community colleges in my district in several of the 
counties, more on the rural side as well. Would love to just 
make sure that all my community colleges in my district have a 
possible direct contact within your office to reach out and ask 
my questions on HRSA, but also on our----
    Ms. Johnson. I would love to do that. I would love for us 
to have a townhall or webinar with your community colleges 
about all of our programs that they might be eligible for.
    Mr. Ciscomani. That would be great. That is something that 
I would love to take you up on.

                          GRANT SIMPLIFICATION

    Do you have suggestions on how we can make sure that these 
grants are more competitive for newer applicants as well?
    Ms. Johnson. Yeah, thank you so much for the question. We 
are working hard to simplify the application process, step 1. 
Right? Smaller community colleges don't often have the 
resources or capacity to have grant writers as a full-time job. 
People do it at nights, on weekends, and the like. We need our 
applications to be as simple and easy to understand and clear 
about our objectives and what we are trying to fund as 
possible.
    Two, for a long time, we asked you to describe data back to 
us that we already had. We asked you to describe need in your 
community, but we have a lot of Federal data about need in your 
community. So we now make all that data available 
electronically for communities to tell us--for applicants to 
tell us which communities they intend to serve, and we are able 
to see what that data tells us about need in that community. So 
we are continually working to simplify the process so that as 
many applicants as possible are able to come in and that it is 
fair and equitable in terms of reaching as many people as 
possible.
    Mr. Ciscomani. Well, I am excited to hear that because I 
think both my questions--and I appreciate your answers here on, 
one, how to make sure that people are aware, that our community 
colleges are aware of these; I think it is the outreach piece. 
And one goes with the other; if you are outreaching and then 
you are simplifying had the process to make sure that this--
these resources make it back to the communities that are using 
it as well, including Pima Community College over in Tucson 
where I am from. And, again, I am a proud graduate of the 
community college system.
    So that is it for me for this round. Mr. Chair, I yield my 
time.
    Mr. Aderholt. Mr. Ellzey.

                    RURAL HEALTH CARE INFRASTRUCTURE

    Mr. Ellzey. Thank you, Mr. Chair.
    Administrator Johnson, thank you for being here. I was 
reading your bio. You have a long history of service in the 
health community, and I thank you for your service. You have 
dealt with a lot of issues for a long, long time. And your work 
is extremely important, and you seem to be the right person for 
this job. I am glad you are with us here today.
    Ms. Johnson. Thank you for that.
    Mr. Ellzey. Among the programs that I support is those 
dealing with rural healthcare, veterans in rural areas, 
veterans in general, as a 20-year Navy veteran myself, and 
behavioral mental health of rural residents. Availability of 
prenatal and postnatal care and maternal health generally are 
also particular concerns of mine. My district Texas Sixth is 
largely rural. It is just south of Dallas County. And, although 
it includes parts of Dallas and Tarrant County with Fort Worth, 
the other seven counties are mostly rural, about 1,000 square 
miles, 50,000 folks with a nice courthouse right in the center.
    We have great providers throughout Texas Sixth, but they 
face significant challenges because the rural healthcare 
infrastructure is under considerable stress, unless you are 
being served by one of the major hospitals. We are well aware 
of the need for more nurses, doctors and other healthcare 
professionals in underserved rural areas. I think that is 
probably true throughout the country after COVID. There is a 
physician and nursing shortage in Ellis County, which is my 
home county, and its surrounding counties.
    But, as an example of how HRSA can help my community, in 
October 2022, Hope Health, located in Ellis County, received a 
teaching health center planning and development grant from HRSA 
to institute a family medicine residency program in 
partisanship with Baylor Scott & White----
    Ms. Johnson. Yeah.
    Mr. Ellzey [continuing]. Which is one of the big folks in 
the area. And the first class of three residency students will 
begin in July of 2024. And then three more are added each year. 
Hope Health with have a total of 12 residency students in the 
program once it is fully operational with three new students 
being added each year. So I would like to thank HRSA for 
helping us out on that.
    So, expanding a bit on your testimony, how does Health 
Resources and Services Administration's programs address 
challenges and support rural healthcare, veterans in rural 
areas, and behavior and mental health of rural residents, which 
is the really tricky one?
    Ms. Johnson. Thank you so much for the question. Thank you 
for raising the teaching health center program. It really has 
been an innovative way for us to get, you know, grow-your-own-
physician programs into the community directly. And so I am so 
glad to hear that it is working well for you.
    We are laser focused on the mental health and substance-use 
disorder workforce and how we get more providers into rural 
communities. You know, in fact, in the President's budget 
proposal, we propose making mental health and substance-use 
disorder a required service in community health centers and 
funding that support because community health centers have the 
footprint in communities across the country. They are often the 
provider in rural communities. And, if we can build their 
capacity on mental health and substance-use disorder, they see 
a sizeable number of veterans as well, that would be a really 
useful thing.
    In addition, in the budget, we propose providing grant 
resources for behavioral health to rural health clinics. We 
haven't traditionally had grant resources available for rural 
health clinics. During the pandemic, we were able to do that. 
We learned a lot from that. We think there is a lot we can do 
working together with rural health clinics to expand capacity 
and access to care in rural communities.

                     TELEHEALTH AND RURAL BROADBAND

    Mr. Ellzey. Well, I think also we have a hard time getting 
specialists. Like I said, those counties are very, very large; 
1,000 square miles, we have one county with 12,000 people in 
it. They can't get specialists down there. And they are 2 hours 
from the closest specialty clinic. Are you all trying to work 
with broadband providers? And do we couple with----
    Ms. Johnson. Yes.
    Mr. Ellzey [continuing]. Rural broadband and the huge 
amount of money we have spent on that to try to get access to 
that for specialists?
    Ms. Johnson. In addition to being the home of the Office of 
Rural Health Policy, we also run the Office of Telehealth for 
the Department. And so we work closely with our colleagues 
across government on broadband access because the promise of 
telehealth only works if you have broadband access. And we have 
several programs that are focused not just on patients getting 
access to providers but providers getting access to specialists 
and using teleconsultation as a way to bring more specialty 
care into high-need communities.
    Mr. Ellzey. Good. Well, whether we like it or not, 
broadband is now a utility. It is an absolute must have, and 
COVID pointed that out.
    Thank you very much for your testimony and your time. It is 
a pleasure.
    Mr. Chairman, I yield back.
    Mr. Aderholt. Okay. We had our first round, everybody. We 
will go ahead and start our second round. I will begin.

                           IMPROPER PAYMENTS

    I mentioned in my opening remarks this morning about the 
improper payments regarding the provider relief fund. My 
question is, what is the total amount of improper payments that 
HHS has identified in the COVID-19 uninsured program?
    Ms. Johnson. I can tell you--if I can step back and speak 
about improper payments writ large, you know, we conducted an 
improper payment testing in 2022 in accordance with the Program 
Integrity Information Act by reviewing provider relief fund 
payments. We reported those in 2022 in the agency final fiscal 
report, and the improper payment rates where the PRF was 0.32 
percent or $.04 billion. We are conducting another round of 
improper payment for this year's reporting, and this year's 
reporting will also be the first round of improper payment 
reporting for the uninsured program. So I don't have a 
percentage amount for you because the first year we did the 
provider relief fund, and this year we will do the uninsured 
program.
    Mr. Aderholt. Okay. And so when do you expect you will have 
those numbers?
    Ms. Johnson. I believe that these are--let me not commit to 
something without knowing. I will get back to you on the timing 
of that.
    Mr. Aderholt. All right.
    Ms. Johnson. But we report those on a regular annual basis.
    Mr. Aderholt. What procedures do you have in place to 
assure this committee that these new proposals to provide 
services for the uninsured will not result in waste, fraud, and 
abuse that you have seen in the past?
    Ms. Johnson. So the Bridge Access Program that the 
Department has identified as a way to help smooth the 
transition to the commercial market is not a reimbursement 
program that the uninsured program was. The uninsured program 
was stood up in 2022 as a way to incentivize and help ensure 
providers that were seeing uninsured patients had access to 
reimbursement for testing and, at that time, treatment and 
then, over time, vaccine administration and therapeutics. And 
there are a host of program integrity measures associated with 
that program.
    The new program that will be this Bridge Program will run 
through sort of more established mechanisms. So some of those 
resources will be in contract partnerships with pharmacies. 
Some of them will be through traditional partnerships with 
public health departments and health centers. So it really is 
about just ensuring that those places where uninsured 
individuals seek care that there is a mechanism for them to 
receive care during this transition to commercialization.
    Mr. Aderholt. Thank you.

                           PROGRAM INTEGRITY

    I am grateful that law enforcement officials within the 
Department of Justice are now pursuing bad actors who took 
advantage of the COVID-19 uninsured program. Such bad actors 
appear to have stolen funds that were specifically intended to 
reimburse hospitals, physicians, medical professionals who 
provided care to uninsured Americans during the pandemic.
    While the Department of Justice is conducting their 
investigation, I just wondered what HRSA has done as an agency 
to try to in any way recover improper payments, or have they 
done anything to try to recover these payments?
    Ms. Johnson. So, if I could start, sir, with saying that 
the findings you are seeing the Department of Justice announce 
are because of our close HRSA working relationship with the 
Office of Inspector General at HHS. We refer suspicious 
providers to the Office of the Inspector General. The Office of 
the Inspector General works hand in glove then with DOJ on 
indictments and action on those folks. We do the analytics and 
the detailed analysis to be able to share with the Office of 
the Inspector General where we see suspicious activity. They 
then pursue the investigation, and then they work with DOJ on 
the law enforcement action associated with it. And our experts 
have testified at those trials. We have worked very hard to be 
part of an essential part of that program integrity effort to 
ensure that bad actors are held accountable.
    But, stepping back, on our own, what we do on the front end 
of claims is ensure the validity of the provider. The provider 
has to be validated through their IRS taxpayer ID number. The 
provider has to be through their NPI number with Medicare. They 
were checked against all Medicare exclusion lists to make sure 
they are in good standing with Medicare. They had to certify 
and attest to terms and conditions, ensuring that they had 
checked for healthcare coverage for individuals in the 
uninsured program. Every time they submitted a patient roster, 
they had to again attest that they had checked for healthcare 
coverage. We then review those claims prepayment, and we review 
against all those checks and then ensure that they are--check 
them for completeness and the like. And, in fact, 15 percent of 
claims never moved to payment because they were screened out in 
that early intervention.
    Then, on the postpayment review process, we work quickly to 
make sure that we are reviewing and analyzing and looking for 
suspicious claims, looking for places where there are 
suspicious patterns of referral of claims or dates of service, 
and those are the ones that our risk assessment mythology digs 
in on and works closely with OIG on referrals so that actions 
like the ones you saw from DOJ can take place.
    Mr. Aderholt. Thank you.
    Ms. DeLauro.
    Ms. DeLauro. Thank you very, very much, Mr. Chairman.
    I wish we could apply the methodology that you have just 
outlined to other departments in taking a look at what might be 
suspicious claims, et cetera. Really just, bravo.
    Ms. Johnson. Thank you.

                        PEER SUPPORT SPECIALIST

    Ms. DeLauro. Let me ask a question about peer support 
specialists. In my district in Connecticut, I have spoken to a 
lot of the specialists, as well as with individuals who benefit 
from working with the peer support specialist. So I am a strong 
supporter of their work. They are particularly effective 
because they have a personal experience with mental health, 
with substance abuse, homelessness, incarceration, or some sort 
of other behavioral health crisis. So I think that they can be 
regarded as trusted healthcare messengers. Can you talk about 
how a peer support specialist can play a role in responding to 
someone in crisis, helping that person be successful in 
recovery? And how does HRSA support education and training for 
the peer support specialists?
    Ms. Johnson. Thank you very much for raising this, and 
thank you for your support for peer support specialists. Dr. 
Harris mentioned my work in New Jersey. When I was in New 
Jersey, we were able to support, to deploy peer support 
specialists in emergency departments. And, when people came in 
post overdose and naloxone was administered and they were 
revived, they were often very resistant to treatment. The 
emergency room department doctor wasn't always as familiar with 
how to work with someone to get them into treatment.
    The peer support specialists made a huge difference in that 
encounter because that is a person often with experience who 
can say: I have been where you have been. I know what it takes. 
Here is what it is going to look like. Here is what your path 
is going to look like.
    And so we think they are a vital part of the healthcare 
workforce. We think, going forward, community health workers 
writ large, really thinking about that connective tissue 
between the healthcare provider and the community and making 
sure people get to care, retained in care, get back for their 
appointment. We find this in HIV care. We found this throughout 
COVID. It makes a huge difference, and specifically peer 
supports in substance-use disorder treatment, it is just a 
meaningful part of the healthcare workforce.
    Ms. DeLauro. And what is your training?
    Ms. Johnson. We support training through the behavioral 
health workforce training program for peer support specialists. 
And we are able to recruit and help people get into the 
workforce that way. And many of our programs that support 
people in the community health workforce, we also then are 
available to help bring those people up the training pipeline 
into other clinical jobs if they choose to pursue them.
    Ms. DeLauro. Really terrific. Just to say, it would be, 
really would be so detrimental if a program like that couldn't 
continue. That is really at risk.

                  MENTAL HEALTH OF HEALTH CARE WORKERS

    A quick question if I can about mental health care workers. 
We in the American Rescue Plan funded programs to promote 
mental health and address substance use in the workforce. Can 
you talk about your request for a new program to support the 
mental health of healthcare workers, and how are you proposing 
to work with health workers to help them deal with the stress 
and trauma?
    Ms. Johnson. Thank you for raising this. In the American 
Rescue Plan, we had $103,000,000 in awards that we made to 
health systems around the country to focus both on the health 
and well-being of their workforce at a time when we all knew 
how stressed and strained the workforce was and on the 
workplace environment, making the workforce environment as 
worker-friendly as possible.
    The clinical research in evidence here continues to support 
that is both about providing services to workers, but it is 
also about making the workplace less stressful and more worker-
centric and worker-friendly.
    In the interim, Congress passed the Lorna Breen Act, which 
was intended to further develop and support these programs. And 
so our budget proposal would allow us to make additional awards 
in this space to support not just--one of the things that we 
want to do is to make sure we are supporting more community 
hospitals going forward.
    Ms. DeLauro. Is that worker stress or the mental health 
issues attached to the workforce, what is that relationship to 
the nurse shortage?
    Ms. Johnson. Oh, they are all hand in glove. Much of it is 
anecdotal, but the reports that we hear are that, you know, 
that stress and strain, that over--the incredible amount of 
stress and strain on the workforce, the nursing workforce, has 
caused people to make different decisions about their careers 
whether that is--many people stayed in nursing who were 
eligible to retire, they may have made the decision to retire. 
People have moved to administrative jobs in nursing. There are 
a lot of decisions that have been made that are inextricably 
linked to the mental health and well-being of the workforce.
    Ms. DeLauro. It is very interesting because sometimes we 
talk about the nursing shortage, but we are not examining some 
of the causes. And this may be it so that there is potentially 
the view that such a program is really not that necessary or, 
you know, it would be nice if you could do it and not make the 
connection as you just have made with what it means to the 
future of the healthcare workforce and with nurses.
    Ms. Johnson. We think of it not just as a critical need for 
the well-being of the workers; we also think of it as a 
retention program.
    Ms. DeLauro. Thank you very much.
    I yield back, Mr. Chair.
    Mr. Aderholt. Mr. Ciscomani.
    Mr. Ciscomani. Thank you, Mr. Chair.

                            NURSING SHORTAGE

    Ms. Johnson, again, a question actually on the nursing 
shortage, as well, as my colleague was mentioning, if I could 
follow up with that a little bit. One of the most consistent 
issues that I have heard about from stakeholders in industries 
across every sector since coming to Congress is regarding labor 
shortages, just about everywhere, small businesses to large 
businesses. Well, this is no exception. My colleagues and I 
have heard from a number of healthcare providers on the need 
for more doctors, nurses, and staff that support operations at 
healthcare facilities and ensure positive health outcomes for 
patients. It is estimated that, by 2034, the U.S. will have a 
shortage of 124,000 physicians, also, the Bureau of Labor and 
Statistics is projecting over 190,000 annual openings for 
registered nurses through 2030. And, with more experienced 
registered nurses nearing retirement, the need for qualified 
nursing staff is becoming more and more urgent.
    This shortage is even more of an issue for rural areas, as 
you can imagine, like those in my district that struggle to 
attract qualified health professionals to the areas that they 
really need it.
    In your testimony, you mentioned over 50 programs aimed at 
expanding and retaining healthcare workers in areas such as 
primary care, nursing, behavioral health, and dentistry. How 
does HRSA target the funds for these programs to address health 
workforce shortages in rural areas? Is it based on population, 
number of providers, designated rural areas? How does that 
work?
    Ms. Johnson. Thank you for the question. Most of our 
workforce programs are funded under title VII and title VIII of 
the Public Health Service Act, where we give special 
consideration to rural and underserved communities, which 
individuals document in their applications to us. But the other 
thing that we do in the application process is factor in need. 
So it is really important to us that the resources are going 
where they are most needed. And one of the things that is 
really important is that we do this through an objective review 
process. So this isn't me looking at these applications. We 
bring together experts to be able to review applications and 
score them based on that assessment of need, the project plan 
and how people will deliver outcomes for the resources that we 
are providing.
    Mr. Ciscomani. Okay. I think that is--thank you for that 
answer.

                    FINANCIALLY SUSTAINABLE PROGRAMS

    Now the last question here, what is the agency doing to 
make sure that these grants create financially sustainable 
programs that do not depend on Federal support to continue 
serving their populations?
    Ms. Johnson. Yeah, thank you for that. If we didn't include 
sustainability in our grant factors, we would be funding the 
same people forever. So we have to include a pathway and a plan 
for sustainability and factor that into the scoring of 
applications because that is really important to us.
    One of the ways that our resources are most effective is 
building capacity and building infrastructure and putting new 
ideas together and making them actionable so that they can then 
be supported by other traditional payer resources.
    Mr. Ciscomani. Thank you.
    I yield back. Thank you, Mr. Chair.
    Mr. Aderholt. Mr. Hoyer.

                          CONSEQUENCES OF CUTS

    Mr. Hoyer. Madam Administrator, I am not going to ask you a 
question, but I am going to take 4 or 5 minutes. First of all, 
I hope there are a lot of people watching this. I don't know 
that there are. I suspect not a great deal but as somebody who 
represents [inaudible], you get a lot of flak, somebody who 
presents as well as you, who has command of your subject 
matter, who runs a $9,000,000,000 to $10,000,000,000 agency 
would be paid far more than your--and now I hope you heard what 
I said.
    Ms. Johnson. Thank you, sir. I am part of a very broad 
agency who do incredible work.
    Mr. Hoyer. I understand. And I am not surprised at your 
humbleness. But you have given an extraordinary performance, I 
think, here--not a performance in the sense of acting but in 
terms of displaying the depth of your knowledge of your 
subject, of your budget, and of your mission. And every 
taxpayer that is watching ought to be heartened by the passion 
and ability you bring to this job.
    Secondly, let me say we have now spent 2 hours looking at 
your budget. The fact of the matter is, of course, we have 
about a $1,700,000,000,000 discretionary budget, at least half 
of which--probably 60 percent of which goes to the Defense 
Department, which is one subcommittee. And the 11 other 
subcommittees deal with the balance.
    I made the point of Governor Agnew saying: The cost of 
failure far exceeds the price of progress.
    And you have made that point on a daily--on a regular basis 
at this hearing.
    Mr. Chairman, one of the things I have noticed as I have 
sat here is, while there is a proposal to cut drastically the 
domestic programs of America and that investment, it is 
interesting that almost everyone was saving one exception. My 
Republican colleagues, your Republican colleagues, have talked 
about what is needed in their districts, what kind of 
investment that we need to make sure we have health 
professionals available to take care of the health of our 
people.
    So cutting sort of in a broad stroke can sound very 
appealing until you come down to what the ramifications of 
those cuts mean. In this small part of the budget, because, Mr. 
Chairman, as you know, this part of the budget is about 12 to 
13, maybe even 14, percent of the entire budget. And we spend 
all of our time talking about it in the particular at hearings 
like this and very little time talking about the rest of the 
spending, either because it is too controversial or we think 
that it will be increased, i.e. Veterans, we want to take care 
of veterans; i.e. Defense, we want to make sure our country is 
secure.
    But when we Democrats talk about the consequences of cuts, 
it is not because we are not concerned about the deficit; we 
are. I am concerned about the deficit. And I have been 
concerned about the deficit all the time I have been here. And, 
very frankly, both parties have made expenditures; some are 
called tax expenditures, and some are called other spending. 
But both result in the same thing: a disconnect between 
resources and needs, or at least investment.
    So, Mr. Chairman, I am simply taking this time--I don't 
know that anybody is watching; I don't know that anybody cares. 
But, as a country, we have to consider the consequences of not 
investing in things that are absolutely essential. And, as I 
said, and Mr. Natcher said, the education of our young and not 
so young and the health of our people are absolutely critical.
    And that is why I think all of my colleagues, from right to 
left or left to right, depending upon what your perspective is, 
have talked about the needs of their people in their district.
    And, Administrator Johnson, you are one of the critical 
people that sees those needs on a daily basis. And I want to 
join the ranking member and the chairman. We are all concerned 
about fraud, waste, and abuse. We ought to eliminate fraud, 
waste, and abuse. I talked about fraud, waste, and abuse.
    I have four great-grandchildren, I know that it sounds kind 
of--every time they go to the bathroom, there is some waste. 
Oh, they love to pull that roll of toilet paper out; it is just 
a game with them. And I would like to eliminate that, but I 
don't know that I can because they are kids and small kids.
    And we ought to eliminate waste.
    I was heartened by the ranking member when we heard your 15 
percent never got compensated and never got to the place 
because you caught it. And certainly there is some that we did 
not catch, and we ought to catch them because they are stealing 
from those who need. And we ought to put them in jail.
    And there ought to be no thinking by the people watching 
these hearings that we Democrats are not concerned about both 
the deficit--we need to manage that better, and it will take 
tough thinking, which most people don't want to do on both 
sides of the aisle. And it will take administrators like you, 
who know what they are doing, care about what they are doing, 
care about the waste, and understand that we have waste and 
fraud and abuse, not nearly as much as somebody would think. 
And we could never balance the budget just on waste, fraud, and 
abuse, as some found out, like Mr. Reagan found that out. So I 
thank you for your service.
    Mr. Chairman, I thank you for having these hearings because 
I think they are very important, but I would emphasize that we 
are looking at a very small piece of the expenditures and 
ignoring, as the Bible says, the lumber in somebody else's eye.
    Thank you very much.
    Mr. Aderholt. Thank you Mr. Hoyer.

                            Closing Remarks

    And I think the ranking member has some closing remarks 
before we conclude.
    Ms. DeLauro. Thank you so much. You really have been an 
outstanding witness, and thank you for the information, it 
really--sometimes people don't know what HRSA does and how well 
you do it.
    And your discussion about the healthcare workforce 
shortages, our communities need more nurses, not less; more 
doctors, not less. We need more mental health substance use 
providers, not less. And I am very proud that, in 2022 and 
2023, in the appropriations bill, we agreed to invest in the 
healthcare workforce programs. We did it on a bipartisan basis. 
We passed bills in March. We passed a bill in December. And it 
is really unfortunate and sadly that Speaker McCarthy and some 
of the House Republicans introduced a bill this week and 
prepared to vote on it this week that would require massive 
cuts to the healthcare workforce programs. It would mean fewer 
nurses, fewer doctors, fewer mental health and substance use 
providers. That is not--that defeats the mission of HRSA and 
what kind of transformation it can make in people's lives.
    It meets the needs of our communities. It meets the needs 
of individuals. And, in many respects, it saves people's lives. 
So we are grateful to you for that, and we will do everything 
we can to keep those cuts from going into place.
    Thank you very much.
    Thank you, Mr. Chairman.
    Mr. Aderholt. Thank you, Ms. DeLauro.
    And thank you, Administrator Johnson, for being here. We 
appreciate your testimony and answering questions for us. You 
have done a very good job in trying to explain what your office 
does and also how we can be of help.
    So, with that, we will stand adjourned.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 [all]