    [Senate Hearing 118-572]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 118-572

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2025

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

                                    HEARINGS

                                    BEFORE A

                              SUBCOMMITTEE OF THE

                COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                       ON

                               H.R. 9029/S. 4942

     AN ACT MAKING APPROPRIATIONS FOR THE DEPARTMENTS OF LABOR, HEALTH AND
    HUMAN SERVICES, AND EDUCATION, AND RELATED AGENCIES FOR THE FISCAL YEAR
               ENDING SEPTEMBER 30, 2025, AND FOR OTHER PURPOSES

                                   __________

                                    PART 2

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

                                   __________

             Printed for the use of the Committee on Appropriations

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                                   __________

                          U.S. GOVERNMENT PUBLISHING OFFICE
    55-308 PDF                     WASHINGTON : 2025

    ----------------------------------------------------------------------------------

                          COMMITTEE ON APPROPRIATIONS

                        PATTY MURRAY, Washington, Chair
    RICHARD J. DURBIN, Illinois          SUSAN M. COLLINS, Maine, Vice
    JACK REED, Rhode Island                  Chair
    JON TESTER, Montana                  MITCH McCONNELL, Kentucky
    JEANNE SHAHEEN, New Hampshire        LISA MURKOWSKI, Alaska
    JEFF MERKLEY, Oregon                 LINDSEY GRAHAM, South Carolina
    CHRISTOPHER A. COONS, Delaware       JERRY MORAN, Kansas
    BRIAN SCHATZ, Hawaii                 JOHN HOEVEN, North Dakota
    TAMMY BALDWIN, Wisconsin             JOHN BOOZMAN, Arkansas
    CHRISTOPHER MURPHY, Connecticut      SHELLEY MOORE CAPITO, West
    JOE MANCHIN, III, West Virginia          Virginia
    CHRIS VAN HOLLEN, Maryland           JOHN KENNEDY, Louisiana
    MARTIN HEINRICH, New Mexico          CINDY HYDE-SMITH, Mississippi
    GARY PETERS, Michigan                BILL HAGERTY, Tennessee
    KYRSTEN SINEMA, Arizona              KATIE BRITT, Alabama
                                         MARCO RUBIO, Florida
                                         DEB FISCHER, Nebraska

                          Evan Schatz, Staff Director
                  Elizabeth McDonnell, Minority Staff Director

                                     ------

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

                      TAMMY BALDWIN, Wisconsin Chairwoman
    PATTY MURRAY, Washington             SHELLEY MOORE CAPITO, West
    RICHARD J. DURBIN, Illinois              Virginia, Ranking
    JACK REED, Rhode Island              LINDSEY GRAHAM, South Carolina
    JEANNE SHAHEEN, New Hampshire        JERRY MORAN, Kansas
    JEFF MERKLEY, Oregon                 JOHN KENNEDY, Louisiana
    BRIAN SCHATZ, Hawaii                 CINDY HYDE-SMITH, Mississippi
    CHRISTOPHER MURPHY, Connecticut      JOHN BOOZMAN, Arkansas
    JOE MANCHIN, III, West Virginia      KATIE BRITT, Alabama
                                         MARCO RUBIO, Florida

                               Professional Staff

                                Michael Gentile
                                   Erin Dugan
                                  Mark Laisch
                                  Meghan Mott
                               Kathryn Toomajian
                                Amanda Beaumont
                           Lindsey Seidman (Minority)
                            Ashley Palmer (Minority)
                            Tom Pfeiffer (Minority)
                           Emily Slack (Minority)

                             Administrative Support

                                  (Minority)

                                C O N T E N T S

                                  ----------

                                    HEARINGS
                            Tuesday, April 16, 2024

                                                                       Page

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

                            Tuesday, April 30, 2024

    Department of Education: Office of the Secretary.................    99

                             Thursday, May 9, 2024

    Department of Labor: Office of the Secretary.....................   253

                             Thursday, May 23, 2024

    Department of Health and Human Services: National Institutes of
      Health.........................................................   323

                                  ----------

                                  BACK MATTER

    List of Witnesses, Communications, and Prepared Statements.......   383

    Subject Index....................................................   385

        Department of Education: Office of the Secretary.............   385

        Department of Health and Human Services......................   385
            National Institutes of Health............................   385
            Office of the Secretary..................................   386

        Department of Labor: Office of the Secretary.................   387

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2025

                                  ----------

                            TUESDAY, APRIL 16, 2024

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:02 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tammy Baldwin (chair) presiding.
        Present: Senators Baldwin, Murray, Shaheen, Manchin,
    Capito, Kennedy, Hyde-Smith, and Britt.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                            Office of the Secretary

    STATEMENT OF HON. XAVIER BECERRA, SECRETARY

                   opening statement of senator tammy baldwin

        Senator Baldwin. The Appropriation Subcommittee on Labor,
    Health and Human Services, Education, and Related Agencies will
    come to order.
        And I will start by recognizing myself for an opening
    statement, followed by my Ranking Member, Senator Capito.
        Good morning. I want to welcome everyone to the Senate
    Appropriations Subcommittee on Labor, Health and Human
    Services, Education, and Related Agencies' first hearing on the
    Biden administration's fiscal year 2025 budget request.
        We completed our work on fiscal year 2024 Appropriations
    less than 4 weeks ago. The final fiscal year 2024
    Appropriations bill was very much a compromise, but I was proud
    of that bill and the bipartisan work that went into it.
        At the same time, Mr. Secretary, you received your fiscal
    year 2024 appropriations more than halfway through the fiscal
    year. That makes your job harder and it is also a disservice to
    Wisconsinites, West Virginians, and communities all across the
    country that rely on funding and programs the Department of
    Health and Human Services administers.
        We have to do better. And to be clear, last year the Senate
    did its job under the leadership of Chair Murray and Vice Chair
    Collins. We reported overwhelmingly, bipartisan bills out of
    committee last summer.
        I look forward to continuing to work hand-in-hand with my
    Ranking Member, Senator Capito, again this year. We just need
    cooperation from our colleagues on the other side of the
    Capitol, and a key part of that is agreeing to adequate top
    lines that allow us to address important and bipartisan
    priorities.
        Kicking off our fiscal year 2025 process today, I am happy
    to welcome Secretary Becerra for our hearing on the
    administration's fiscal year 2025 budget request for the
    Department of Health and Human Services.
        Secretary Becerra, this budget highlights the need for
    continued investments among a wide range of bipartisan
    priorities that speak to the breadth of activities you oversee
    as the Secretary of Health and Human Services. Working within
    the budget constraints of the Fiscal Responsibility Act, I am
    pleased to see that this year's budget request meets families'
    most pressing needs, like lowering the costs of healthcare,
    tackling the fentanyl and opioid crisis, expanding access to
    affordable child care, and helping connect people with the
    mental healthcare that they need.
        This budget request includes increased funding to address
    our abysmal maternal health and mortality outcomes, including
    expanding the Maternal Health Workforce and improving access to
    care in rural and underserved communities.
        This is Black Maternal Health Week, which should be a
    glaring reminder that every pregnancy-related death is tragic,
    and Black women are three times more likely to die from
    pregnancy-related causes than White women. This budget will
    help improve maternal and child health outcomes, including
    addressing racial disparities.
        This budget recognizes the need for continued investments
    in child care and early learning programs. Sustained annual
    increases like the $1 billion increase for child care and Head
    Start in the fiscal year 2024 Labor, HHS bill are critical. But
    more needs to be done. In Wisconsin, some families are now
    spending more than 35 percent of their income on child care,
    running a family with two young children more than $25,000 per
    year. That is more than college tuition for many families.
        The steep cost not only impacts families, but also
    businesses, and our economy that feel the ripple effect when
    parents can't find child care. This request ensures that we are
    better prepared for and able to rapidly respond to emerging
    biological threats, including supporting the domestic
    manufacturing of medical countermeasures, and other critical
    resources in the public health supply chain.
        It also strengthens our core public health infrastructure,
    workforce, and data modernization programs nationwide to
    improve readiness for the next public health crisis.
        I am pleased to see the support for biomedical research and
    innovation to develop better diagnostics, improve treatments,
    and precision care for patients, including targeted investments
    for research on women's health, and in support of the goal to
    cut the cancer death rate by at least 50 over the next 25
    years.
        I am also happy to see investments to improve access to
    reproductive healthcare, including expanding the Title X Family
    Planning Program, which helps so many patients, particularly
    women of color, get birth control, cancer screenings, STD
    screenings, and other essential healthcare.
        I believe that we need to do more in these areas to truly
    meet the need. But Mr. Secretary, I appreciate this budget
    request prioritizing funding under the tight budget
    constraints. And look forward to working with you on them.
        To that end, Mr. Secretary, I want to hear more about how
    HHS (Health and Human Services) is working within its agency to
    address our Nation's mental health and substance use disorder
    crises. Tragically, overdose deaths remain stubbornly high, and
    continue to break records year after year. In 2022, nearly
    108,000 Americans died of an overdose. In my State of
    Wisconsin, there were 18,828 drug overdose deaths in 2022,
    surpassing the record set in 2021.
        Of these deaths, 1,464 involved opioids. I know my
    colleagues are seeing similar grim statistics in their States.
    Of particular interest, I will want to know how the
    administration is specifically addressing poisonings due to
    fentanyl. This drug is wreaking havoc across the country and we
    must partner to take an all-of-government approach to prevent
    it from coming into our communities, reduce use and misuse, and
    make accessible treatment programs and overdose reversal
    medications available.
        Finally, Mr. Secretary, women's health and reproductive
    rights are under attack in this country. Draconian laws are
    being put in place that deny Americans their rights to control
    their bodies, their families, and their futures, and that put
    women's health and well-being at risk. Just last week, we saw
    Arizona reinstate an 1800s-era abortion ban not dissimilar to
    my home State of Wisconsin's 1849 era criminal abortion ban
    that had devastating consequences.
        Everyone deserves the freedom to make their own healthcare
    decisions without interference from politicians and judges. I
    want to hear more about what HHS is doing to protect women's
    health and ensure women can access the reproductive healthcare
    that they need.
        I look forward to your testimony and appreciate your being
    here today.
        In a moment, I will turn it over to Ranking Member Capito
    for her opening remarks. Following Senator Capito's opening
    statement, we will hear from you, Secretary Becerra, and after
    that, Senators will each have 5 minutes for their rounds of
    questions.
        Senator Capito.

                    statement of senator shelly moore capito

        Senator Capito. Thank you, Chair Baldwin. Thank you,
    Secretary Becerra, for coming, and thank you for sharing our
    thoughts a bit, yesterday, over the phone; I appreciate that.
        As Chair Baldwin noted, last year the Senate Appropriations
    Committee marked up all 12 bills for the first time in 5 years.
    I hope we can do it again, and this budget hearing is necessary
    to be a first step in that process. And so I look forward to
    hearing more about HHS budget proposals and the priorities for
    fiscal year 2025.
        I want to thank Chair Baldwin for working together,
    bipartisan, and the success of our process depends on finding
    common ground, as we did for fiscal year 2024, albeit 6 months
    late, we finally reached that.
        This budget proposes more realistic funding levels in some
    areas to align with that Bipartisan Fiscal Responsibility Act,
    and I commend you for that. However, unfortunately, the budget
    also continues proposals for new partisan mandatory programs
    that would spend too much money that we--in this day and age,
    we just do not have.
        Instead of focusing on our common goals to improve the
    health of Americans, the budget yet wades into polarizing
    issues, such as repealing the Hyde Amendment, increasing
    funding for Title X family planning, and gun violence research,
    and funding new climate change initiatives. These are all sort
    of recycled budget policies that the Congress has rejected over
    the last 3 years.
        Also, I want to note my disappointment, this is a personal
    thing for me, that the budget did not prioritize any new
    resources, specifically for Alzheimer's research. I acknowledge
    we are facing a very difficult spending climate, and we hope we
    can focus on bipartisan areas of need, including a continued
    focus on biomedical research, supporting rural healthcare,
    growing our health workforce, a huge problem across the
    country, and continuing to combat the devastating effects of
    substance abuse, as Chair Baldwin noted.
        I was pleased to see a focus on biomedical research related
    to the Cancer Moonshot across HHS agencies, including NIH
    (National Institutes of Health) and CDC (Centers for Disease
    Control and Prevention). West Virginia, my home State,
    continues to rank above the national average in both new cancer
    diagnosis and deaths.
        Substance abuse challenges also continue to be a real
    problem facing the country, but particularly my State. We have
    some of the highest statistics here.
        Concerning to me too is a proposed $10 million for new
    discretionary group program for funding harm reduction grants.
    This is the Partisan American Rescue Plan Program that,
    famously, attempted to fund crack pipes with taxpayer dollars,
    as my colleagues may recall, in the name of harm reduction. You
    did walk away from that ill-conceived policy, you walked it
    back, and I continue to have some serious concerns. And I would
    encourage a greater focus on primary prevention.
        Secretary Becerra, this is your fourth budget hearing
    before the subcommittee, so it should not be a surprise to you
    that rural healthcare is a priority for this body. I was a bit
    disappointed that the budget lacked new resources for rural
    health programs. In fact, it is $12 million below the recently
    enacted funding level.
        CDC data shows that rural Americans are more likely to
    suffer from higher rates of diabetes, are more likely to die
    from cancer, heart disease, and stroke, than urban Americans.
    This is, unfortunately, true in my home State, which also leads
    the nation in rates of diabetes and heart disease. Improving
    rural health outcomes goes hand-in-hand with investing in the
    healthcare workforce.
        Your budget proposes timely investments, $63 million above
    fiscal year 2024, across behavioral health, nursing, and other
    health professional workforce training. So thank you for that.
    The mental health and behavioral health crisis highlights the
    importance of trained professionals in every healthcare sector
    working to meet the physical and mental health needs of
    Americans.
        Workforce shortages and rural health challenges should push
    all of us to think differently about how and where care is
    delivered. Telehealth should be a part of the equation, we
    learned that during COVID, and we have seen that used quite
    effectively, yet the budget proposes an effective cut of $4
    million to the Office of Advancement of Telehealth.
        The healthcare landscape is complex and ever changing. I
    hope we hear from you today about these challenges and the
    other emerging challenges. Our jobs will be difficult, again,
    for 2025, given the economic realities that face our Nation.
    Just as we did for fiscal year 2024, it is my hope that we will
    come together in a responsible way to find areas of
    efficiencies and focus on the many areas of agreement I have
    just discussed.
        Thank you, Secretary Becerra, for coming. And I look
    forward to your testimony.
        Senator Baldwin. Thank you, Senator Capito.
        Our witness today is Xavier Becerra, the Secretary of the
    Department of Health and Human Services.
        Secretary Becerra, thank you for joining us today. You will
    have 5 minutes for your opening remarks. And you may begin.

                    summary statement of hon. xavier becerra

        Secretary Becerra. Chair Baldwin, Ranking Member Capito,
    and Members of the Subcommittee, thank you for inviting me to
    testify on the 2025 budget.
        When President Biden took office, I think it is important
    to note, back in January 2021, COVID was ravaging our families,
    and our economy, and thousands of Americans were dying every
    day, thousands of Americans were dying every day. About 4,000
    died the day that President Biden took office. In January 2021
    the number of Americans with health insurance was like our jobs
    and the economy, down and on the canvas. Prescription drug
    prices were skyrocketing, with patients and their pocketbooks
    at the mercy of Big Pharma and its profits.
        We changed that. Today, 3 years later, nearly 700 million
    shots of COVID vaccines have gone into the arms of Americans.
    COVID is still around, but we can now manage it like the flu.
    Today, more than 300 million Americans, a record number, can go
    to the doctor or hospital and not go bankrupt, because they
    have their own health insurance. More than 21 million of those
    Americans count on the Affordable Care Act Marketplace for
    their insurance. That is another record.
        Today, while Big Pharma is still big, the President's New
    Prescription Drug Law has brought down the price of insulin to
    $35 per month for Americans on Medicare. And as we speak, we
    are negotiating with drug companies to lower the price of even
    more prescription drugs, even as they sue us to stop us. The
    President's budget doubles down on the investments that made
    the comeback of our jobs, our economy, and our health possible.
    It doesn't just protect Medicare; this budget strengthens it
    beyond Medicare's life, and beyond our lifetime.
        This budget lays out a vision for a nation that invests in
    its most vulnerable, it fosters innovation, and protects every
    American's access to the care that she needs. Perhaps most
    importantly, it continues our shift from a health system that
    treats illness to one that sustains wellness.
        All told, the fiscal year 2025 budget proposes more than
    $130 billion in discretionary, and about $1.7 trillion in
    mandatory funding to advance our mission and invest in key
    priorities.
        Let me share a few of those highlights. The budget provides
    Medicaid-like coverage to low-income individuals in the outlier
    States that have not expanded Medicaid under the Affordable
    Care Act. When that happens, another 1.5 million of our fellow
    Americans will have healthcare coverage and the peace of mind
    that comes with it.
        This budget builds on the largest investment in behavioral
    health in a generation. It bolsters a 988 Suicide and Crisis
    Lifeline. It gives young people support at home and at school.
    The President's investments in Behavioral Health Workforce
    would add 12,000 new psychiatrists, psychologists, clinical
    social workers, marriage and family therapists, counselors, and
    peer support specialists, at a time when their services are
    desperately needed. Across HHS, the budget tackles the maternal
    health crisis by improving access to pre- and post-natal care,
    supporting emergency care services, and expanding maternal care
    in rural and underserved communities. We are also making child
    care more affordable for working families and more available
    where families live and work.
        This budget would provide increased wages for early
    childhood education workers. It would fund more than 750,000
    slots for children in Head Start, and it provides universal
    preschool for our Nation's four million 4-year-old children,
    and eventually would include our 3-year-olds as well.
        Our budget grows and strengthens our cybersecurity
    initiatives to ensure patient safety and privacy, and to keep
    our hospitals and providers, especially smaller ones, and those
    in rural communities, running and secure.
        Finally, this administration has made tremendous strides in
    preparedness capabilities since the pandemic, and we keep
    building. This budget invests in countermeasures to combat
    antimicrobial-resistant drugs. It expands our monitoring of
    supply chains, and it integrates 200 data sources across
    Federal, State, and local governments to improve information
    sharing.
        We can't reduce the health and well-being of Americans to
    align on a budget spreadsheet, but we can transform the numbers
    on the balance sheet into real investments and services that
    sustain health and promote wellness for all Americans.
        With that, I thank you for this opportunity. And I look
    forward to your questions.
        [The statement follows:]
                      Prepared Statement of Xavier Becerra
        Chair Baldwin, Ranking Member Capito, and distinguished Members of
    the Subcommittee, thank you for the opportunity to discuss the
    President's Fiscal Year (FY) 2025 Budget for the Department of Health
    and Human Services (HHS). I am pleased to appear before you today, and
    I look forward to continuing to work with you to serve the American
    people.
        When President Biden took office, the number of Americans with
    health insurance was declining. We changed that. Over 300 million
    Americans now have health insurance--the most under any other
    Administration.
        Until now, Americans paying far too much for prescription drugs
    haven't had any relief. We changed that. The Inflation Reduction Act,
    signed into law by President Biden in 2022, caps the price of insulin
    at $35 per month per insulin prescription for people with Medicare, and
    certain important vaccines, like the Shingles vaccine, are available
    for free. And now, for the first time, HHS is negotiating directly with
    drug companies to lower prescription drug costs for people with
    Medicare, and we're working to make healthcare markets more competitive
    across the board.
        The Biden-Harris Administration has taken decisive action to
    protect access to reproductive healthcare, including abortion and
    contraception care. We are also fighting tooth and nail to stop the
    dismantling of the remaining rights and freedoms available to women
    across the country.
        In 3 years, the Biden-Harris Administration has made the largest
    investment in behavioral health, which includes both substance use and
    mental health, in a generation. We are on the path to increasing the
    number of mental health counselors in schools, have improved support
    services for high-risk and underserved populations, and trained
    healthcare providers, families and school personnel on best practices
    for supporting young people with behavioral health needs, including
    those taking medications to treat opioid use disorder.
        There are many, many more accomplishments that I could highlight--
    but, there is more work to be done. It is critical that we look forward
    to the challenges that lie ahead and take the actions that will ensure
    that we can continue to improve the health and wellbeing of all
    Americans.
        This budget lays out a vision for a nation that fosters innovation,
    invests in health, and supports its most vulnerable.
        HHS remains at the center of some of the most important issues for
    American families--including expanding access to care and lowering
    healthcare costs; protecting and strengthening Medicare, Medicaid, and
    the Marketplace; helping ensure access to reproductive healthcare;
    improving maternal healthcare; transforming the way we deliver
    behavioral healthcare, particularly for substance use disorders;
    improving care for older adults and people with disabilities; preparing
    for future public health threats; ending cancer as we know it; and
    ensuring access to high-quality education and support for children.
        We also must continue to advance cutting-edge research, and meet
    the health needs of Tribal Nations and Native communities. And none of
    this would be possible without the resources to support our operations.
        All told, the FY 2025 budget proposes $130.7 billion in
    discretionary and $1.7 trillion dollars in mandatory funding to advance
    our mission and invest in key priorities that will impact the lives of
    all Americans. We remain steadfast in our commitment to be good
    stewards of taxpayer dollars, and to continually improving the
    experience of the people whom our programs serve.
               expanding coverage and lowering health care costs
        Once again, a record-breaking number of Americans enrolled in the
    Health Insurance Marketplace in 2024--over 21.3 million people. That
    means more Americans are getting the healthcare coverage they need at
    an affordable cost. This is a testament to the success of the
    Affordable Care Act.
        The FY 2025 budget continues to build on this success by making
    permanent the expanded premium tax credits that the Inflation Reduction
    Act extended and providing Medicaid-like coverage to low-income
    individuals in states that have not expanded Medicaid under the
    Affordable Care Act, along with financial incentives to ensure states
    maintain their existing expansions. For Medicaid and CHIP, the Budget
    allows states to extend the existing 12-month continuous eligibility
    for all children to 36 months, and allows states to provide continuous
    eligibility for children from birth until they turn age 6. Further, the
    budget prohibits enrollment fees and premiums in CHIP. It extends
    consumer surprise billing protections to ground ambulances, building on
    the No Surprises Act. The budget also advances the steps taken in the
    Inflation Reduction Act to improve access to affordable prescription
    drugs by further expanding
        Medicare's ability to negotiate prices directly with drug
    manufacturers, and expanding inflation rebates and the $2,000 out-of-
    pocket prescription drug cost cap beyond Medicare and into the
    commercial market.
        Fundamental to our vision of affordable, accessible healthcare is
    ensuring Americans can rely on Medicare for generations to come. The FY
    2025 budget proposes changes that indefinitely extends the solvency of
    the Medicare Hospital Insurance Trust Fund.
        In addition, the budget continues on the path to doubling Health
    Center Program funding, which provides healthcare services to millions
    of Americans, particularly those in underserved communities. The budget
    provides $8.2 billion for Health Centers in 2025, allowing the program
    to serve approximately 3.9 million additional patients. This investment
    also supports the expansion of behavioral health services at Health
    Centers.
                         transforming behavioral health
        The FY 2025 budget proposes over $20.8 billion in investments to
    improve behavioral health across the Department. This includes $602
    million, an additional $82 million, to the 988 Suicide and Crisis
    Lifeline for an expanded awareness campaign and increased technical
    assistance support and infrastructure. This investment in 988 also
    maintains specialized services for LGBTQI+ youth, Spanish speakers, and
    the Deaf and Hard of Hearing Community.
        The budget seeks to expand access to high-quality mental
    healthcare, including through a $1 billion investment in the Community
    Mental Health Services Block Grant. The budget also improves behavioral
    health benefits for people with Medicare and Medicaid and in the
    private insurance market, with an emphasis on improving access,
    promoting equity, and fostering innovation. In addition, the budget
    invests $1 billion in health information technology adoption for
    inpatient psychiatric facilities, as well as certain outpatient and
    residential behavioral health facilities. If we are serious about
    integrating behavioral health providers into the rest of the healthcare
    system, we must close the technology gap and advance better information
    exchange with other healthcare, public health, and community partners.
        The budget also addresses the sobering impact of the behavioral
    health crisis on our nation's youth. National surveys of youth have
    shown significant increases in certain mental health symptoms,
    including depressive symptoms and suicidal ideation, compounded by the
    effects of the COVID-19 pandemic. The surveys underscore the urgency
    and importance of our commitment to equip our youth with the tools they
    desperately need to address these unique challenges. The budget expands
    mental health services in schools and bolsters youth mental health
    programs by investing an additional $50 million in Project AWARE
    (Advancing Wellness and Resiliency in Education) and an additional $50
    million in Children's Mental Health Services. These programs provide
    services to states, tribes, and communities to support children with
    serious emotional challenges and their families. The budget also
    includes $30 million for the Centers for Disease Control and
    Prevention's (CDC) Essentials for Childhood: Preventing Adverse
    Childhood Experiences (ACEs) through Data to Action Program, which will
    increase the number of states, territories, localities, and tribes
    implementing ACEs prevention strategies and approaches in their
    communities.
        In addition, the budget increases funding to states for overdose
    prevention and substance use disorders treatment. In January 2021, the
    overdose death rate was increasing 31% year-over-year. Today, the rate
    of increase has dropped to about 2% year-over-year. We're making great
    progress, but in the face of an increasingly dangerous drug supply, we
    need to do more. The budget provides an additional $20 million for the
    State Opioid Response program, which has provided treatment services to
    over 1.2 million people and has helped states to reverse more than
    500,000 overdoses. It also includes a $5 million increase for the
    Tribal Opioid Response program to address the disproportionate impact
    of the overdose crisis on American Indian and Alaska Native people.
        The FY 2025 budget also continues to invest in growing and
    diversifying the behavioral health workforce. The budget includes $254
    million for the Health Resources and Services Administration (HRSA) for
    Behavioral Health Workforce Development Programs, including expanding
    the substance use disorder provider workforce. The budget also
    continues to expand key HRSA programs by providing $916 million for the
    National Health Service Corps and $320 million for Teaching Health
    Centers Graduate Medical Education programs in 2025 to ensure the
    continued growth of healthcare services and expand workforce capacity
    across the country, including for behavioral health. The budget also
    includes $20 million for the Substance Abuse and Mental Health Services
    Administration's (SAMHSA's) Minority Fellowship Programs to reduce
    health disparities and improve behavioral healthcare outcomes for
    underserved populations.
        improving the well-being of children, families, and older adults
        The FY 2025 budget invests in the future of our nation's children
    through high-quality early childhood education. The budget proposes to
    guarantee affordable child care to low- and middle-income working
    families from birth until kindergarten and offer preschool to all four-
    year-olds, making early care and education programs affordable and
    available where families live and work, and increasing wages for early
    childhood education workers. Under this proposal, preschool would be
    free and the average family would pay no more than $10 per day for
    child care until their child starts kindergarten, saving them over $600
    per child, per month. This proposal will go a long way to support our
    most vulnerable children and their families.
        The budget continues to bolster Head Start for children from birth
    to age five and requests a $544 million increase for the Head Start
    workforce, allowing wages to keep pace with inflation and for us to
    maintain a high-quality child care workforce. As child care continues
    to be unaffordable or unavailable for millions of Americans, the budget
    provides funding to Americans that desperately need it to continue to
    work and support their families. It also requests a $500 million
    increase for the Child Care and Development Block Grant to continue our
    progress in stabilizing the child care sector and helping more
    Americans afford child care.
        The budget also invests in child welfare, with a package totaling
    $11.4 billion over 10 years. This funding expands services and supports
    to families at risk of child maltreatment or involvement with the child
    welfare system, increases funding for prevention services and kinship
    placements and supports for older youth, and increases and streamlines
    funding to tribes.
        Finally, we are also investing in supports for older adults and
    people with disabilities to ensure they can participate fully in our
    communities. The FY 2025 budget provides $2.7 billion for
    Administration for Community Living programs--a $84 million increase
    above the 2024 Enacted level. This includes additional funds for
    nutrition programs, as well as funding for suicide prevention for older
    adults.
                    enhancing long-term care in all settings
        HHS programs support the health and well-being of people with
    disabilities and older adults. The FY 2025 budget includes a 10-year,
    $150 billion proposal to expand Medicaid home and community-based
    services to allow more older adults and people with disabilities to
    receive care at home and in their communities. Recognizing that a
    strong, well-trained workforce is essential to delivering high-quality
    services, the budget initiative is designed to enhance the quality of
    these jobs. When older adults' support needs become so great that they
    must enter nursing homes, they deserve safe, high-quality long-term
    care. At the 2024 Enacted level, state survey agencies would complete
    just 65% of statutorily required nursing home surveys in FY 2024, down
    from 100% in FY 2022 and 75% in FY 2023. To address the increasing
    workloads and align with the Administration's commitments to improve
    the safety and quality of nursing home care, the budget requests an
    increase in funding to allow CMS to conduct 85% of the mandatory
    surveys, as well as legislative proposals that strengthen quality and
    care in long term care facilities for FY 2025. In addition, the
    Administration's proposal to shift survey and certification funding for
    nursing home facilities from discretionary to mandatory and increase
    that funding to conduct 100% of mandatory surveys, effective in FY
    2026, would allow for sustained and reliable oversight and enforcement
    in the nation's nursing homes and ensure that Americans receive high
    quality, safe services within these facilities.
      strengthening maternal health outcomes and reproductive healthcare
                                     access
        The budget reflects the Administration's commitment to address the
    U.S. maternal mortality rate, which is higher than all other developed
    nations and on the rise. The majority of these deaths are preventable,
    and Black and American Indian and Alaska Native women are
    disproportionately affected. Across HHS, the budget invests in tackling
    this maternal health crisis, including $376 million focused on
    addressing maternal mortality and maternal health equity. This includes
    targeted funding within the Indian Health Service (IHS) to provide
    culturally-relevant maternal healthcare in Indian Country, additional
    funding for CDC to expand maternal mortality prevention, and continued
    support for the Implementing a Maternal Health and Pregnancy Outcomes
    Vision for Everyone (IMPROVE) initiative in the National Institutes of
    Health (NIH). It also includes $215 million in HRSA specifically for
    reducing maternal mortality and morbidity. This funding will improve
    access to pre- and post-natal care, including for behavioral health,
    provide access to emergency care services, expand maternal care in
    rural and underserved communities, and more.
        To help improve maternal health coverage and prioritize person-
    centered care, the budget also includes an optional Medicaid benefit
    that expands coverage of maternal health support services across the
    prenatal, labor and delivery, and postpartum periods, with enhanced
    Federal funding available for the first 5 years in which states take up
    the State Medicaid option. This includes coverage for a range of
    maternal health support workers, including doulas. With this benefit,
    we aim to bolster maternal health supports throughout the entire
    continuum of care and to demonstrate our dedication to supporting women
    at every stage of pregnancy and beyond.
        Access to reproductive healthcare, including contraception, is a
    more urgent issue now than it has been in decades. The budget provides
    $390 million, a 36 percent increase, to the Title X family planning
    program to meet the increased need for family planning services, which
    are essential to ensuring women have control over personal decisions
    about their own health, lives, and families. Title X remains the only
    Federal grant program dedicated solely to providing individuals with
    comprehensive family planning services in communities across the United
    States.
                   preparing for future public health threats
        While this Administration has made tremendous strides in
    preparedness capabilities since the pandemic, there are many public
    health threats beyond COVID-19. The budget therefore includes over
    $28.9 billion in total resources across the Department to support
    preparedness, including efforts to prevent future pandemics, in
    addition to response capabilities, consistent with the President's plan
    to prepare for and respond to biological threats, as outlined in the
    2022 National Biodefense Strategy and Implementation Plan.
        This includes $8.9 billion in discretionary funding for
    preparedness across the Department. The budget invests an additional
    $55 million for CDC for the Center for Forecasting and Outbreak
    Analytics as well as to manage the Response Ready Enterprise Data
    Integration platform.
        Our nation continues to face emerging public health threats and it
    is important that we are well positioned to adequately respond. The
    budget continues to strengthen our domestic supply chain by investing
    $95 million to accelerate development and domestic production of
    medical countermeasures, and onshore production of active
    pharmaceutical ingredients and essential medicines through the
    Administration for Strategic Preparedness and Response. It also
    includes $12 million to support the Food and Drug Administration (FDA)
    in addressing medical and food shortages and $10 million for a new
    supply chain coordination office within HHS.
        As a continuation of our work to treat and prevent infectious
    diseases, the budget also includes a new HHS-wide proposal to eliminate
    hepatitis C infections in the United States. This five-year program
    focuses on high-risk populations and will increase access to curative
    medications, and expand implementation of complementary efforts such as
    screening, testing, and provider capacity.
                       advancing health in indian country
        HHS remains committed to addressing the significant health
    disparities faced by Tribal Nations and Native communities, and the
    chronic underinvestment in the Indian Health Service. The budget
    proposes $8.2 billion for IHS, a $1.1 billion increase above the 2024
    Enacted Level. This includes the proposed reauthorization of the
    Special Diabetes Program for Indians. This will maintain direct
    healthcare service levels, address targeted public health issues, and
    advance critical operational efforts like Health Information Technology
    modernization.
        Beginning in FY 2026, the budget proposes full mandatory funding
    for all IHS accounts, and automatically grows funding each year to
    account for factors like inflation and pay. This approach will address
    chronic underinvestment by ensuring funding grows along with IHS's
    needs. The budget also includes a dedicated funding stream for public
    health capacity and infrastructure needs in Indian Country, a key
    lesson learned from the pandemic.
        This budget also addresses healthcare workforce needs across the
    Indian Health Service by providing hiring authorities to improve the
    recruitment and retention of providers in our system. Workforce
    challenges--including significant staffing needs in behavioral health
    fields, such as substance use disorder care--are one of the top
    concerns raised by tribes to HHS. Addressing these challenges is
    critical to providing better-quality healthcare to the people IHS
    serves and to continuing to fight the concurrent substance use and
    suicide crises tribes are currently facing.
        The Department will continue to partner with Tribes and Congress to
    realize mandatory funding, and to ensure we can continue to provide
    advance discretionary appropriations so IHS can maintain critical
    healthcare services if there is a lapse in appropriations.
                      advancing science to improve health
        Cancer impacts Americans of all ages and from all walks of life.
    Decreasing the cancer death rate and the number of loved ones we lose
    to the disease remains a top priority for the Administration. The Biden
    Cancer Moonshot set ambitious goals to cut the cancer death rate by 50
    percent over 25 years, preventing more than 4 million cancer deaths by
    2047, and to improve the experience of people touched by cancer. The FY
    2025 budget invests $2.9 billion across the Department to make that
    possible, including $716 million in discretionary resources at the NIH
    National Cancer Institute to continue their efforts to speed delivery
    of cancer drugs and vaccines and ensure access to current and new
    standards of cancer care. An additional $100 million increase for CDC
    will support cancer prevention activities, including tobacco prevention
    and cessation. The Advanced Research Projects Agency for Health (ARPA-
    H) will also support Cancer Moonshot goals by investing in the
    development of unprecedented breakthroughs to prevent, detect, and
    treat cancer.
        Additionally, ARPA-H will maintain its role as a catalyst for
    transformation in the health ecosystem-- including through its
    recently-announced Sprint for Women's Health. With its $1.5 billion
    budget, the agency will continue finding real-world solutions for real-
    world problems, driving biomedical innovation in a variety of arenas.
        The budget continues the Administration's commitment to support
    scientific innovation. It includes $50.1 billion in total resources for
    NIH, prioritizing in particular women's health research and firearms
    and gun violence research with additional funds. The budget also
    continues to support Brain Research Through Advancing Innovative
    Neurotechnologies, All of Us, and important research on opioids and
    pain management, HIV/AIDS, and health disparities to improve American
    health outcomes.
        To keep our nation at the forefront of scientific innovation, we
    must seize the promise of artificial intelligence--while also managing
    its risks. NIH is committed to harnessing the power of artificial
    intelligence to advance research, and has already launched ambitious
    initiatives to propel the fusion of biomedicine and artificial
    intelligence and machine learning. In addition, the FY 2025 budget
    provides resources to oversee artificial intelligence within the
    Department to advance its responsible use in public health and
    healthcare.
        The FY 2025 budget also invests in scientific research that has
    resulted in significant improvements to American lives. CDC's overall
    budget--increased by $520 million--prioritizes investments in areas
    such as improving public health data, preventing and mitigating the
    impact of infectious diseases, reducing injury and violence, and
    protecting against environmental health hazards. The budget also
    provides a total of $513 million to the Agency for Healthcare Research
    and Quality to further invest in their mission to produce scientific
    evidence that makes healthcare better, more accessible, and more
    affordable.
       supporting program operations and mission-critical infrastructure
        HHS needs sufficient operational funding to fulfill our mission.
    This includes resources to allow the Office of the Secretary to oversee
    the Federal government's largest budget. The budget makes badly needed
    investments in Centers for Medicare & Medicaid Services (CMS) Program
    Management to ensure CMS can carry out its core operations, such as
    surveying hospitals and nursing homes to ensure quality care is being
    delivered to millions of Medicare and Medicaid enrollees. It also
    invests in FDA to support the agency's expert staff that ensures the
    safety of our food supply, guarantees the effectiveness of our
    medicines, and that conduct rigorous and transparent scientific
    reviews.
        The Nonrecurring Expenses Fund is a key source of funding for
    Departmental operations. The Fund permits HHS to transfer unobligated
    balances of expired discretionary funds into an account for necessary
    information technology and facilities infrastructure acquisitions.
    Since FY 2013, the fund has allocated over $6.5 billion in capital
    investment projects across the Department. HHS's proposed FY 2025
    projects will address aging systems and facilities, including at IHS,
    NIH, and CDC. These improvements are integral in improving the health
    and well-being of the American people.
        A fundamental component of HHS's infrastructure is its
    cybersecurity capabilities. We have seen a dramatic rise in large data
    breaches reported to HHS, and the healthcare information HHS protects
    is a prime target for cybercriminals. Our plan sets the direction for
    cybersecurity in healthcare, both from a policy and operational lens,
    and commits HHS to pursuing new priorities to both strengthen and
    support the sector at this critical time. The FY 2025 budget
    prioritizes investments to address cybersecurity threats and invests
    $141 million in cybersecurity initiatives in the Office of the Chief
    Information Officer to address cybersecurity mandates and allow
    deployment of cybersecurity initiatives and tools that will keep the
    Department at the forefront in battling ever-evolving cyber threats.
    The investment in cybersecurity includes $11 million for the
    Department's Health Insurance Portability and Accountability Act
    modernization to increase compliance, enhance the privacy and security
    of health information, and to improve breach prevention and response
    efforts. The budget also includes an increase of $12 million above FY
    2024 for ASPR as the agency designated to coordinate cybersecurity
    incident prevention and response in the healthcare and public health
    sector. The budget also establishes a Medicare incentive program to
    encourage hospitals to adopt essential and enhanced cybersecurity
    practices.
        The budget also invests in civil rights enforcement to ensure we do
    our part to protect the American people's fundamental rights of
    nondiscrimination and health information privacy. The budget provides
    the HHS Office for Civil Rights a $17 million increase, which includes
    a robust investment in enforcement staff to address and resolve major
    case increases that have led to a significant backlog.
        HHS also invests in program integrity and promoting competition to
    support our commitment to good stewardship of taxpayer dollars. Our
    responsibility is to ensure that every dollar entrusted to us directly
    enhances the lives of the American people. The budget invests a total
    of $4 billion over 10 years in new mandatory Health Care Fraud and
    Abuse Control funding to provide oversight of nursing homes, managed
    care, and community-based settings. This mandatory investment will
    yield a net savings of $5 billion over 10 years. Additionally, the
    budget provides increased funding to the discretionary Health Care
    Fraud and Abuse Control program and the HHS Office of Inspector General
    to support its oversight.
           improving the customer experience for the american public
        Lastly, I wanted to talk about how we are making government and
    government programs easier for American people to access and use. HHS
    is improving customer experience throughout the Department, mostly
    using current administrative funds. In FY 2025, the budget includes an
    $11 million investment for the Department to improve data services for
    benefits delivery, as well as $3 million to support the Streamlining
    Medicare-Only Enrollment project, among other efforts. These
    investments are bolstered by the HHS-wide customer experience
    initiative launched in FY 2024, one of the largest such initiatives in
    the Federal government to date. Our goal is to provide a customer
    experience that ensures the public can access and utilize the impactful
    resources within HHS. As part of the initiative, every agency within
    HHS will pursue substantial projects to improve services to the
    American people. This expands on the many customer experience
    initiatives HHS has already pursued. For example, HHS continues to
    partner with other departments and agencies through the Life
    Experiences initiative to streamline enrollment and eligibility across
    benefits programs such as Medicaid and the U.S. Department of
    Agriculture's Supplemental Nutrition Assistance Program, increase
    access to decisionmaking support for older adults, reduce burdensome
    and repetitive manual income verifications, and support states in
    innovating and improving Federal-state benefits access and delivery.
                                   conclusion
        I am honored to lead the Department of Health and Human Services,
    working alongside dedicated civil servants to enhance the health and
    well-being of the American people. Investments in this budget will
    allow us to continue fulfilling our mission, and we know you are all
    critical partners in achieving this goal. We are grateful for your
    support of the Department, and we are excited to work with you on
    funding for FY 2025.
        I want to thank the Committee for inviting me to discuss the
    President's FY 2025 Budget for HHS. I look forward to working with you
    to fulfill that vision. Thank you for your partnership in advancing our
    shared goal to improve the health, safety, and well-being of our
    nation.

        Senator Baldwin. Thank you, Mr. Secretary.
        We are now going to begin our questions. And I will start
    by recognizing myself.

                                OPIOID EPIDEMIC

        Secretary Becerra, our communities continue to struggle
    with the opioid crisis. I cited the statistics in my opening
    statement, but as a reminder, in 2022, 108,000 Americans died
    from a drug overdose, a record high. We have seen the opioid
    epidemic transform over the years. When I first was elected to
    the Senate, it was primarily an epidemic of prescribed opioids,
    and then we saw some shift to the use of heroin. But now, with
    the emergence of synthetic opioids like fentanyl, we are seeing
    an increase in deaths among individuals, particularly youth,
    who don't even know that they are taking fentanyl.
        With fentanyl, one pill can kill. How does the HHS budget
    address the devastation that we are seeing from opioid-related
    deaths in our communities?
        Secretary Becerra. Madam Chair, perhaps the most important
    thing is that we recognize, as you just mentioned, that it is a
    shifting landscape. And so some $9 billion that the President's
    budget has to address drug overdose and the opioid addiction,
    are really targeted on things like fentanyl, on trying to make
    sure that we give States the capacity to help their young
    populations avoid overdose, and it makes sure that we are
    providing the harm reduction to make sure that people don't
    accidentally kill themselves when they think they are doing
    something that is recreational.
        And so of the $9 billion, it should not surprise you that
    more than a-billion-and-a-half is going to State Opioid
    Resource Grants that will help States decide how they can best
    tackle the opioid crisis, especially among children.
        SAMHSA (Substance Abuse and Mental Health Services
    Administration), our agency that administers most of our
    substance use and mental health programs, is going to receive
    about $4.5 billion of the $9 billion, because they are the ones
    that work closely with state mental health programs throughout
    the country. And so it is letting the States have the
    flexibility and the resources to tackle this crisis.
        Senator Baldwin. I want to dig a little bit deeper here,
    because as I mentioned many times, teens will take a pill that
    they got from a friend or got online, unaware that it is laced
    with fentanyl. I have heard from so many parents in the State
    of Wisconsin who have lost a child to fentanyl poisoning. The
    budget proposes substantial funding for treatment programs,
    which is certainly incredibly important for tackling this
    crisis, but how is HHS working to prevent young adults from
    using--and children, from using drugs and making these deadly
    mistakes in the first place?
        Secretary Becerra. Madam Chair, we did something at the
    Federal level that had not been done before. We stopped relying
    on stigma to drive our Federal policy. So today, we actually
    support programs that offer fentanyl strips to individuals so
    they can find out if the drug they might be taking is laced
    with fentanyl. That way, they don't kill themselves.
        We also made naloxone far more available. So today, you
    could have access to naloxone in public places so that if you
    see someone who is overdosed, there is a great chance that you
    might save their life by administering the naloxone for them.
    And so we are also trying to make sure that local communities
    understand what they can do to make that naloxone more
    available.
        So whether it is naloxone, fentanyl strips, clean syringes,
    we are now using the evidence-based programs that have shown
    success to drive our policies.
        Maternal Health
        Senator Baldwin. Thank you. I want to shift. In 2018, I
    worked to pass legislation requiring HRSA (Health Resources and
    Services Administration) to identify areas with critical
    shortages of maternity healthcare professionals, so that we
    would have evidence to support increased investments in areas
    where women and families need providers the most.
        Unfortunately, the number of maternity care deserts
    nationwide continues to increase, and over 2 million women live
    in a county without a hospital, birth center, or obstetrics'
    provider. The decision overturning Roe has made this problem
    worse, as States with abortion bans have seen a drop in
    applicants for obstetrics and gynecology residency.
        Given our Nation's unacceptably high rates of maternal
    mortality, we must do everything we can to target investment to
    increase access to care, and support the maternal healthcare
    workforce.
        Secretary Becerra, what is HHS doing to build the
    professional--the workforce pipeline and better support our
    maternal care professionals?
        Secretary Becerra. Madam Chair, there are about $8 billion
    dollars that are dedicated in this budget to trying to address
    maternal health. Much of it is focused specifically--$400
    million is focused specifically on trying to tackle the
    maternal mortality and morbidity rates that we see in some of
    our communities, especially the Black and Native American
    communities.
        We are trying to make sure that we get to women before
    there is any chance that they would have complications in their
    pregnancy. And as you know, as a result of our efforts on
    Medicaid, and your support, we now are able to offer a woman
    and her baby not just 60 days of maternal health and child care
    after delivery, not just 60 days, but 365 days of care for mom
    and baby so they can make sure they are going to start with a
    fruitful life.
        Senator Baldwin. Thank you. Senator Capito.

                                  RURAL HEALTH

        Senator Capito. Thank you. Yes, Secretary Becerra, I want
    to talk about rural health, because I mentioned in my opening
    statement a $12 million--it appears as though it is $12 million
    lower. I understand that our bill funded it at $36--I think
    $364.6 million, which is rural outreach, rural hospital
    flexibility, and other things. The request is for $352, which
    is lower, 12.2 lower than what we actually funded this for.
        I understand also that the budget release and then the
    timing of the actual passing of the budget were almost at the
    exact same time, it might not have been ideal for you. What
    would you say about that? Healthcare delivery systems in rural
    America are still very difficult and underfunded; we have the
    lowest life expectancies in rural America. What is your
    response to that?
        Secretary Becerra. Senator, you actually touched on
    probably the most important aspect of my answer, and that is
    that our budget was being framed at a time when we had no idea
    what the 2024 budget would look like. And because of the
    constraints on where we could go, we had to make sure we tried
    to be consistent with what might come out. So we are more than
    willing to work with you on the kinds of investments we would
    make in healthcare generally, but more specifically with regard
    to rural health.
        You will find that there are specific investments in rural
    health, especially in the area of substance use disorders, in
    trying to keep hospitals afloat that we can work on to build on
    because I think you are right. There is no doubt that it is
    tougher if you are in a rural community to find a healthcare
    facility near you. And so we will do everything we can to try
    to keep not just them sustained but also have them thrive.
        Senator Capito. Well, we will work on that. And
    understanding the circumstances of when your budget came out.
        Secretary Becerra. Yes.

                              OVERDOSE PREVENTION

        Senator Capito. I did have a lot of questions on drug abuse
    and SAMHSA, prevention, and harm reduction. Here is the
    discouraging thing. These statistics are not coming down. I
    mean, the overdose statistics I heard on the radio the other
    day that the statistics in D.C. alone were up, I don't know,
    20, 30 percent deaths resulting from overdose. We don't have--I
    don't think we have the statistics quite yet for this past
    year.
        We have got a flow of fentanyl coming up through the
    southern border. We have got to do better here. I mean, we are
    really losing a generation. And I understand in your last
    answer, some of the areas, you know, fentanyl strips, and
    naloxone, but that is still just treating somebody who is
    already in heavy addiction. I mean, I think the prevention
    aspects of it have not gotten to the younger children as much
    as they should. We have got to start at kindergarten. What is
    your response to that?
        Secretary Becerra. With you, completely with you on that.
    Here is the difficulty. As you know, at the Federal level, the
    Department of Health and Human Services, we don't administer
    these programs. We work with the States. The States are the
    ones that have control over healthcare and this aspect of
    healthcare. What we do is, essentially, provide them with more
    resources, or we give them some support and flexibility in
    doing what they can with the dollars that we give them. We are
    more than willing to work with the States to increase their
    capacities. They need more capacity.
        Senator Capito. What States are doing it? Or I mean, I am
    sure you are looking at what the innovative programs of a State
    that might be able to be shared nationally, I am sure that is
    best practices that you are pursuing here on the prevention
    side.
        Secretary Becerra. Oregon, as you know, had an issue with
    increasing drug use, and what they have done, when I have been
    to visit, I have seen how they are incorporating young people
    into their programs, to try to get them to become essentially
    peer support, so that peer-to-peer kids are hearing from
    someone who can help them out, obviously getting the adult and
    professional help as well. But we need to try to reach young
    people, to your point, before they become users.
        And so there is where we have got to figure out a way to
    capture them quickly, and I think Oregon is doing a pretty good
    job of trying to use young folks to help them approach that
    cohort.
        Senator Capito. Well, coming from a State that doesn't have
    the legalization of recreational marijuana, I think that is an
    example of where some of the issues may be. I know there is a
    lot of people that believe that is a good thing to do. I
    personally am not one of them.

                               SUICIDE PREVENTION

        Quickly, on the suicide prevention line you have asked for
    a lot more money here, we have provided a four-fold increase in
    fiscal year 2023, you are requesting a $100 million more for
    2025, and I am wondering, can you give me a breakdown? You
    might not have that right now, but how is this breaking out to,
    is it going out the door to State and local crisis centers,
    versus a contractor that is administering the system? I would
    just like some more details on this request given the sensitive
    nature of the program and the critical work they do.
        Secretary Becerra. Certainly, and we can follow up with
    your staff to give you more of the details because those are
    out there. Most of the money helps sustain the State operation,
    the call centers that already existed. We essentially have
    buoyed them, because we established backup call centers,
    because a lot of the States didn't have the capacity to deal
    with all the calls that might come in. We didn't want people
    waiting on the phone, busy signal.
        Senator Capito. No. Yes.
        Secretary Becerra. So we stood up all the backup call
    centers. We also made specialty lines. So for example if you
    are a veteran there is a line that is specific for you.
        Senator Capito. Right.
        Secretary Becerra. Those are the things that the Federal
    dollars have really helped boost. We also helped create the
    text and chat feature so that if you didn't want to focus----
        Senator Capito. Is that online now, the text and chat
    feature?
        Secretary Becerra. Yes. Absolutely it is.
        Senator Capito. Okay.
        Secretary Becerra. Absolutely. It is available now for
    hearing impaired, it is available in some places in Spanish
    language, and we are trying to make sure no one feels like they
    should not call. And now you hear that we are going to finally
    get to the point where we can make the 988 Call work so that
    wherever you are, whatever your area code is you are going to
    get some--a professional where you happen to be, not based on
    your area code. It is working the $600 million that is in the
    President's budget for 988 is absolutely going to save lives.
    We know that in the first 18 months of launching national 988
    a-million-and a-half people reached out to us, and said, help,
    we were able to answer.
        Senator Capito. Thank you.
        Senator Baldwin. Thank you. Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chair.

                                    ABORTION

        Thank you, Mr. Secretary, for being here. Mr. Secretary, if
    a mother is healthy, and the baby is healthy do you really
    support abortion of the baby up to the moment of birth?
        Secretary Becerra. Senator, let me make sure, to the moment
    of birth you are saying after gestation, the 40 weeks of----
        Senator Kennedy. You know what I am saying, Mr. Secretary.
        Secretary Becerra. Well, if I----
        Senator Kennedy. Let us suppose it is a day before the day
    before the due date and the baby is fully formed, and the baby
    is healthy.
        Secretary Becerra. I think----
        Senator Kennedy. And mother is healthy, do you support
    aborting--the right to abort the baby then?
        Secretary Becerra. I have heard no one say that. I think
    everyone has said those who support Reproductive Rights have
    said----
        Senator Kennedy. You have said----
        Secretary Becerra [continuing]. Support Roe v. Wade.
        Senator Kennedy [continuing]. You have said it. In 2020 in
    a press release, this is what you say, you said, quote, ``No
    government, State or Federal, has the right to make decisions
    for a woman about her body or her healthcare'', end quote, your
    words, not mine.
        Secretary Becerra. Good words.
        Senator Kennedy. So let me ask you again, up to the moment
    of birth, if the mother is healthy, and the baby is healthy, do
    you believe that--that there should be the right to abort that
    baby up to the moment of birth?
        Secretary Becerra. And I, again, I will give you the
    answer. I have always supported Roe v. Wade, which does not do
    what you have just said. And I know of no one who is proposing
    or advocating what you have just announced, and I would hope
    that what you would recognize is that that should not stop a
    woman from having the right to decide for herself with the
    consultation of her physician what she should do.
        Senator Kennedy. Would you support making it legal --
    illegal to abort a baby if the mother is healthy and the baby
    is healthy on the day before that baby is scheduled to be born?
        Secretary Becerra. I certainly would support the
    reestablishment of Roe v. Wade.
        Senator Kennedy. So you think that there are restrictions
    that the State, Federal, or State, as the case may be, can
    place on abortion?
        Secretary Becerra. Senator, if you talk to any woman she
    will tell you that she uses common sense in making her
    decisions.
        Senator Kennedy. Do you -think that the State or the
    Federal Government, in the third trimester of a pregnancy, has
    the right to impose limitations, moral and legal right to
    impose limitations on an abortion? I think that is yes or no.
        Secretary Becerra. I would certainly say that Roe v. Wade
    answered those questions, we defend and support----
        Senator Kennedy. I want--sorry----
        Secretary Becerra [continuing]. Roe v. Wade.
        Senator Kennedy [continuing]. Roe v. Wade has been
    overturned. I want your answer, do you support restrictions by
    the Federal or the State Government on the right to an abortion
    in the third trimester.
        Secretary Becerra. And my answer is clear that if we
    establish Roe v. Wade, we get back to a system that gives women
    protection----
        Senator Kennedy. Do you support restrictions to the right
    to an abortion in the third trimester? Why are you dodging the
    question?
        Secretary Becerra. Well, no, I am just saying--I am telling
    you where I am. I am----
        Senator Kennedy. Tell me, do you support restrictions in
    the third trimester----
        Secretary Becerra. I have personally----
        Senator Kennedy [continuing]. If the mother is healthy and
    the baby is healthy?
        Secretary Becerra. And Senator, let me try to make sure I
    answer this. Personally, as you have mentioned, I have been
    quoted on a number of occasions before I became Secretary. I
    support a woman's right to make a decision about her body.
        Senator Kennedy. But do you support restrictions in the
    third trimester? I just asked--why are you embarrassed to
    answer?
        Secretary Becerra. Because I believe in Roe v. Wade, and I
    think everyone recognizes that that law----
        Senator Kennedy. You support Roe v. Wade?
        Secretary Becerra. I do.
        Senator Kennedy. Roe v. Wade allowed for restrictions in
    the third trimester.
        Secretary Becerra. Then you have your answer.
        Senator Kennedy. Do you support restrictions in the third
    trimester?
        Secretary Becerra. If Roe v. Wade is as you have described
    it----
        Senator Kennedy. Why are you scared to answer the question?
        Secretary Becerra. I am not afraid to answer, I am
    actually----
        Senator Kennedy. Are you scared you are going to get in
    trouble with people, with your--your colleagues----
        Secretary Becerra. No, no, no; not at all.
        Senator Kennedy [continuing]. To support abortion up to the
    moment of birth?
        Secretary Becerra. Not at all.
        Senator Kennedy. Then why won't she answer the question?
        Secretary Becerra. Because, Senator, I think I have given
    you the answer that makes the most sense. Roe v. Wade worked
    for some 50 years----
        Senator Kennedy. Do you support restrictions in the third
    trimester on the right to abortion? It is real simple. You are
    the Secretary of a Department of the United States of America.
    Do you support them or do you oppose them?
        Secretary Becerra. My answer is pretty simple, we will
    defend Roe v. Wade----
        Senator Kennedy. What is simple? You don't want to answer
    it, do you?
        Secretary Becerra. I have answered you----
        Senator Kennedy. Do you know why you don't want to answer,
    because you and your colleagues believe that a child has no
    rights, even a fully developed child, you know that.
        Secretary Becerra. You can say that.
        Senator Kennedy. And I know.
        Secretary Becerra. I know where I am. I will continue to
    defend women's rights.
        Senator Kennedy. Let me ask you for a final time. I think
    this is a number of times.
        Secretary Becerra. It is not going to make any difference.
    But go ahead.
        Senator Kennedy. Yes. Well, if you want to choose to not
    answer it. That is up to you.
        Secretary Becerra. I am not denying anything, Senator.
        Senator Kennedy. You--what--let me phrase it another way.
    What restrictions do you support in the third trimester to the
    right of a--to an abortion? Tell me what restrictions.
        Secretary Becerra. If you read the Roe v. Wade decision, it
    will answer your question.
        Senator Kennedy. Why don't you just answer it for me?
        Secretary Becerra. I did. Roe v. Wade established the
    protection----
        Senator Kennedy. What restriction do you support on the
    right to an abortion in the third trimester, you personally?
        Secretary Becerra. Roe v. Wade. Roe v. Wade.
        Senator Kennedy. Okay. Roe v. Wade doesn't say what
    restrictions. Roe v. Wade just says, the State and the Federal
    Government have the right to impose restrictions. I am asking
    you what restrictions you support? For example, if the mother
    and the baby are healthy, and we are week before birth, and the
    parents change their mind and say we don't want a boy, we want
    a girl, abort the baby who happens to be a girl, would you
    support that right?
        Secretary Becerra. I know no one who would go as far as
    what you are indicating.
        Senator Kennedy. Well, then why wouldn't you say you would
    oppose it?
        Secretary Becerra. Because I am telling you where I stand.
        Senator Kennedy. No, you are not.
        Secretary Becerra. And I have been very clear on that for a
    long time.
        Senator Kennedy. You are dodging, and wobbling, and
    weaving, and flip-flopping like a----
        Secretary Becerra. Let me stand as you would like. Senator,
    I won't move, and I will just move my lips----
        Senator Kennedy. Let me ask you this, if a week before--a
    week before birth baby healthy, mother healthy, would you
    support the right to an abortion because the parents dislike
    the gender of the baby. Yes or no?
        Secretary Becerra. As I said, a woman should have the right
    to----
        Senator Kennedy. But you haven't said, Mr. Secretary.
        Secretary Becerra [continuing]. Make decisions about her
    body.
        Senator Kennedy. Yes, you won't answer my question. Would
    you support that?
        Secretary Becerra. As I have said, I am going to do
    everything I can to support a women's right to make the
    decision about her body.
        Senator Kennedy. Would you support what I just described?
    You are not going to answer me are you? I don't understand why
    you are scared to answer me.
        Secretary Becerra. I am not afraid. I am not afraid to
    answer your question. I have answered it over and over.
        Senator Kennedy. You are scared to take----
        Senator Baldwin. Senator Kennedy.
        Senator Kennedy. I just find that appalling. You are the
    Secretary of the Department.
        Senator Baldwin. Thank you, Senator Kennedy.
        Senator Kennedy. Can we have a second round, Madam Chair?
        Senator Baldwin. I am just gonna start a second round right
    now.
        Senator Kennedy. (Off mic) I need some answers. If I can
    just add anything----
        Senator Baldwin. You just hang in here. We are going to
    start a second round of questioning. We will certainly
    accommodate any Senators who have not yet had their first
    round, who appear. As we know we have several competing
    subcommittee hearings at this juncture.

                               988 IMPLEMENTATION

        Secretary Becerra, I want to also address the 988
    implementation, I was proud to be the co-sponsor of the 988
    legislation along with former Senator Cory Gardner, and I
    believe that it has been a remarkable service. You know we
    always had a Suicide Prevention Hotline but nobody remembered
    the 10-digit number, especially at a time of crisis. And when
    we launched the 988 number it has, literally, been a lifeline
    for so many.
        I want to ask you specifically about a pilot program that
    has been underway regarding LGBTQ (lesbian, gay, bisexual,
    transgender and queer) youth. You mentioned already, when you
    call there is a screening for Service members, if you are a
    veteran of our Military Service you can get routed to
    appropriate and knowledgeable services.
        Last year was a record-breaking year for legislative
    efforts around the country that target LGBTQ individuals,
    including the ability to receive healthcare, inclusion and
    education, even access to public restrooms, it should not
    therefore be a shock that lesbian, gay, bisexual, and
    transgender youth are more likely to experience anxiety,
    depression, and thoughts of suicide than their peers. In fact,
    LGBTQ young people are far more--are more than four times more
    likely to attempt suicide than their peers.
        We are seeing that these attacks do not live in a vacuum,
    and that they have real world consequences. I have been glad to
    work with you and the Department in creating and now expanding
    specialized services within the larger 988 crisis and suicide
    prevention lifeline, to provide response to LGBTQ youth in
    crisis. We know that there is a need there.
        In February alone almost 40,000 contacts were answered by
    the LGBTQ sub-network of 988. Can you expand on how these
    specialized crisis services for LGBTQ youth and the pilot has
    helped support this population?
        Secretary Becerra. Madam Chair, absolutely because I think
    you are going to the heart of what makes 988 so valuable, and
    that is that you have individuals who are challenged, who are
    at a moment of crisis who turn to someone, and actually trust,
    will extend confidence in someone through a phone call, through
    a chat, and that is a tremendous thing.
        And so to begin this pilot back in September of 2022, see
    it working, expand it to some seven different call centers, and
    see more than 40,000 calls come in specifically from the LGBTQ
    community means that they are responding. We want to continue
    that, because we want anyone who is facing crisis to feel like
    they can have the confidence to make the call, have their call
    be personal and private, and also get the help they need.
        Senator Baldwin. Thank you. I was just singing the praises
    of the program but I--still there are many people who are
    unaware of this crisis service. And I understand HHS is
    planning a public awareness campaign to spread the word on 988,
    will the proposed increase for 988, included in the budget
    request, support the anticipated increase in call volume as a
    result of the awareness campaign that you are conducting?
        Secretary Becerra. We are hoping to address it. We are
    hoping States will further step up to the plate to help us,
    because at the end of the day it is their call centers that are
    the front line. So we need States to continue to grow their
    capacity, because we can only depend on the generosity of
    Congress to help sustain that national component.
        What we don't want is to have gaps. We want you to be able
    to call from whatever part of the country you are in, so we
    continue to partner with States and tell them, please make
    commitments in your own budget to sustain your operations. Some
    States have actually done that they have got a permanent flow
    of dollars; most States don't.
        Senator Baldwin. Thank you. Senator Manchin.
        Senator Manchin. Thank you, Madam Chairman.

                           JESSICA GRUBB'S LEGACY ACT

        Secretary, I was pleased to see the Department's finalized
    the rule implementing the Jessica Grubb's Legacy Act we worked
    on for so long. The law reduces barriers for treating persons
    with substance abuse disorder by aligning the privacy laws
    governing the records with HIPAA (Health Insurance Portability
    and Accountability Act), the law which governs all other health
    privacy records.
        This is a law for medical professionals to access vital
    information they need to properly coordinate the care. In 2018,
    Congress passed a separate law in honor of Jessica, Jessie
    Grubb's life, just called Jessie's Law, this requires HHS to
    develop best practices standards for hospitals, and doctors
    display a patient history of opioid disorder when the patient
    provides that information. With the implementation of the
    Legacy Act it is now time to fully implement Jessie's Law.
        So the Department has finalized the rule on confidentiality
    of substance use disorder, patient records, when will it be
    releasing best practices for displaying opioid use disorder in
    patient records?
        Secretary Becerra. Senator, first, thank you for the work
    you have done, because I don't think people recognize that in
    many cases because of this--I don't want to call it an excuse,
    because of the difficulties with privacy laws, HIPAA privacy
    laws a lot of essential information about a patient wasn't
    getting to the providers, and they were making the wrong
    decisions especially when it related to drug addiction. And so
    the work that you and your colleagues have done has really
    helped.
        Senator Manchin. Senator Capito and I worked on it, and we
    know the family very well, it was so horrifying. This young
    lady had problems in something stemmed from when she was in
    college, but then she was trying to get herself, clean she
    started running, and being competitive.
        Secretary Becerra. Yes.
        Senator Manchin. And she and her parents who--an attorney
    and her mother is an educator, both went with her to the
    hospital, and says, please, identify and mark my record showing
    it. And they forgot to do it.
        Secretary Becerra. Yes. And so what we are doing is we are
    trying to tackle that HIPAA privacy hurdle, so that it doesn't
    become the reason the information isn't fully there. But you
    can understand how important it is to maintain privacy.
        Senator Manchin. Oh. And we know that. But now that we have
    done everything, we have got through every hoop possible.
        Secretary Becerra. Yes.
        Senator Manchin. When will you all be doing--when can we
    expect it too finally----
        Secretary Becerra. We are now working with providers, we
    have developed a training module so that they understand how
    this can work, how they can be consistent with privacy laws,
    yet still include the information, so a lot of it is going to
    be, and we can use your help because we need providers to start
    understanding what the new rules are. They are going to say to
    you, oh, no, we can't do that because of HIPAA privacy. We want
    them to understand, oh, no, no, Jessie's Law----
        Senator Manchin. Well, I think this law is very clear,
    basically, it says that the patient himself and the guardians
    have to have permission, and give you permission to do it.
        Secretary Becerra. Yes.
        Senator Manchin. So we thought we crossed every hurdle,
    crossed every T and dotted every I; it is just time to
    implement it.
        Secretary Becerra. Yes.
        Senator Manchin. So I would implore you to----
        Secretary Becerra. Yes. We are doing it.
        Senator Manchin [continuing]. Get your staff moving on this
    one here. We waited a long time for it.
        Secretary Becerra. And, Senator, I just pointed out we need
    the help of the providers to make sure that they are getting
    their personnel to understand the new rule.
        Senator Manchin. Okay.
        Secretary Becerra. Yes.
        Senator Manchin. Well, I think the quicker you put them
    out, the quicker they will understand them.
        Secretary Becerra. Absolutely.

                                      HRSA

        Senator Manchin. The Health Resources and Services
    Administration, administers grants and programs that are
    critical to rural health centers, and clinics, and hospitals,
    your budget requests a $2 billion increase to this agency to
    carry out these programs. However, many areas of West Virginia
    remain unable to access these resources; West Virginia is the
    only State that lies completely within the Appalachian Mountain
    region.
        The United States Department of Agriculture, Economic
    Research Services recognized a unique topography, we are the
    most rugged, mountainous State they know east of the
    Mississippi. And a recent report on what we call Rugged
    Terrain, that has all been identified and how we have been
    classifying it. The report found that almost 81 percent of West
    Virginians live in a rugged area, that is compared to just 11.7
    percent of the entire United States population.
        The fiscal year 2024 bill included language for HRSA to
    review this report to update their rural definition to better
    capture the uniqueness of Appalachia. Can you provide an update
    on this review and a time line for when we are going to see
    some results so they can qualify for the needed funds they need
    for rural healthcare?
        Secretary Becerra. So we are not waiting. As you know,
    Senator, we are moving forward with a new classification--some
    classification for hospitals that don't meet the critical
    access care definition, so that a lot of those facilities that
    are teetering don't go under, so they can get some additional
    funding.

                               BEHAVIORAL HEALTH

        I was mentioning to Senator Capito some of the work we are
    doing to make further investments in behavioral health
    especially in substance use. But we are absolutely prepared to
    work with you as you all give us some guidance about how to get
    into these communities that are very rural to make sure we are
    being as constructive as possible. We will work with the States
    as much as we can, because they understand better what their
    State needs in terms of the rural health facilities, but we are
    trying to make sure that these new changes that you helped us
    put forward will help some of the States that have large rural
    communities, address the concerns of individuals a lot faster.
        Senator Manchin. Sir, I thank you for your service. I just
    want to say again on Jessie's Law that has been a long time in
    coming, okay, and the family they are just hanging on, needles
    and pins, just waiting for it to be completed. They want to
    save lives. They don't want anyone to go through what they have
    gone through.
        And on the rural classification, if you want to know why
    that divide is becoming bigger and bigger, rural areas have
    been left behind, the money has not gone appropriately for the
    challenges they have. And that is so important.
        Secretary Becerra. Yes.
        Senator Manchin. Thank you, sir.
        Secretary Becerra. Thank you.
        Senator Baldwin. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Madam Chairman.

                                  RURAL HEALTH

        Good to see you Mr. Secretary, thank you for being here. In
    2003, Congress established the Rural Community Hospital
    Demonstration Program to test an alternative payment model for
    rural hospitals that were facing certain financial constraints
    with the Medicare's Inpatient Prospective Patient Program, the
    IPPS. And Congress has extended the program several times, most
    recently in the Consolidated Appropriations Act of 2021.
        Mississippi ranks among the States with the highest rate of
    hospital at-risk closings. This demonstration program could
    serve as a means to keep their rural hospital doors open to
    serve their communities in need of high quality healthcare.
    However, CMS (Centers for Medicare & Medicaid Services) has not
    solicited applications since 2017, despite, as I understand it,
    there being a handful of open spots in the program. Do you
    believe this program has been helpful to rural hospitals facing
    closure, and should we extend the program when the time comes?
        Secretary Becerra. Senator, thank you for the question. The
    rural emergency hospital designation extended a lifeline to
    some of these facilities, it is absolutely essential that we
    give hospitals that are willing to stay open, a chance to
    survive if the older version definition of how they could get
    reimbursed isn't working for them. So we look forward to
    working with you, because we have got to figure out a way to
    keep some of these facilities open and operating.
        Senator Hyde-Smith. Do you know about how many spots are
    currently open right now in the program?
        Secretary Becerra. I don't have that with me, but I can
    make sure my team follows up with you.
        Senator Hyde-Smith. No problem. And can you commit to
    working with me to solicit applications for the program and
    find ways to help us keep these hospitals open?
        Secretary Becerra. Absolutely.

                                MATERNAL HEALTH

        Senator Hyde-Smith. I have talked to hospital
    administrators this morning that have been in my office, and we
    are constantly battling this in Mississippi, you know, we are
    just putting out one fire after the other.
        Mississippi has consistently seen some of the poorest
    maternal health outcomes in the Nation, made worse by high
    rates of chronic disease and limited access to specialty care
    for many mothers.
        And we have also led the Nation an infant mortality,
    something that we are not proud of at all, and very concerned
    about. It is driven largely by a very high pre-term birth rate
    stemming from lack of prenatal care. Access to maternity care
    in rural areas is a major challenge and we are seeing a rapid
    expansion of OB (Obstetric) deserts, that we refer to them as,
    across Mississippi.
        In some areas of my State women are having to drive more
    than an hour for any kind of obstetric care. How can we work
    with you to improve outcomes for our mothers and babies in
    Mississippi?
        Secretary Becerra. Senator, because everything you have
    said I agree with, with regard to maternal health and
    especially how it is impacting our Black and Native American
    communities. The most important thing is early access. And as
    you mentioned, sometimes especially because a State like
    Mississippi has a lot of rural communities it is tough to have
    access. And so that is why it is so important to not allow any
    existing health facility to go under in Rural America, because
    then the access becomes even more difficult.
        Telemedicine, telehealth is going to be very important for
    communities, families in rural America, because it means they
    can have access without having to do the physical travel, we
    will continue to support that so long as Congress gives us the
    flexibilities to offer telehealth flexibilities.
        But the most important thing is access. And I will simply
    say here, many of the women who are having bad outcomes could
    have qualified for earlier care had they been eligible for
    Medicaid. And I think if we expand Medicaid in some of the
    States that haven't yet done it, about a-million-and-a-half
    more Americans, many of them women, who want to deliver a baby,
    would have access to early care and not wait until it is a
    difficult circumstance in the delivery.
        Senator Hyde-Smith. Yes. Well, I appreciate your concern
    and your willingness to help with this, because it truly is
    crucial. Mississippi is a large State, we don't have many
    people but we are a large State.
        Secretary Becerra. Yes.
        Senator Hyde-Smith. And we are scattered, and it is truly a
    hardship on so many mothers to actually get to that care. We
    have a lot of babies born in cars, sad to say. My time is out.
    Thank you.
        Senator Baldwin. Chair Murray.
        Senator Murray. Well, thank you very much Chair Baldwin.
    Secretary Becerra, good to see you. I appreciate you joining us
    today.
        HHS really is on the front lines of some of the most
    challenging issues that our families are facing, opioids mental
    health, child care, so much more. It is crucial that we
    maintain strong investments in life-saving biomedical research,
    building a strong healthcare workforce, and public health
    system, getting families affordable care close to home, and a
    lot more.
        Not to mention the constant attacks on reproductive care.
    Women in 21 States are now living under abortion bans, and
    Arizona is under a ban that dates back to before women even had
    the right to vote, despite strong support for abortion access
    around the country, anti-abortion extremists are continuing to
    attack not only abortion care, but IVF (In vitro
    fertilization), and birth control.
        Everyone, I believe, deserves the freedom to control their
    own bodies, their own lives, and their own future, free from
    interference from politicians, which is why I strongly support
    President Biden's decision to once again remove Hyde from this
    year's budget.

                                   CHILD CARE

        I look forward to continuing to work with you to protect
    reproductive healthcare every way we can, in all 50 States. And
    I am glad we have the opportunity today to talk about how we
    can provide the resources necessary to meet all the healthcare
    challenges before us and support families in my State and
    across the country. Programs like the Child Care and
    Development Block Grant and Head Start are a lifeline for
    working parents, who need affordable high-quality child care
    and early learning opportunities for their kids. They are an
    investment, not just for our families, but in our workforce and
    in our economy.
        So I am really glad that Senator Baldwin and I were able to
    send an increase of $1 billion to the President's desk to
    invest in child care and early learning for fiscal year 2024.
        Since 2015, I and many others have increased funding for
    these programs by more than 250 percent. But it is, as you
    know, a drop in the bucket when looking at the child care
    crisis that exists in this country.
        We need to protect and strengthen the investments we have
    made to make sure families can find and afford child care,
    however possible. That means more annual funding, extending
    stabilization dollars, and hopefully passing my Child Care for
    Working Families Act.
        Can you tell us today about the current state of the child
    care sector and why investments in programs like CDBG
    (Community Development Block Grant) are critical now more than
    ever?
        Secretary Becerra. Senator, thank you. And again, thank you
    for championing child care, writ large, and your success in
    getting additional funds for so many families desperately in
    need.
        Today, getting child care is like having your infant go to
    college, the cost of child care is, essentially, tuition in a
    major university. It makes it very difficult for parents,
    especially parents who have more than one child, to really
    sustain that.
        We also know that the quality of care can sometimes be
    questionable because the pay for some of these workers is so
    low. You can sometimes make more money flipping burgers than
    caring for children. We need to change that as well. The
    President's budget, thanks to the investments that many of you
    have made possible, will continue to move an effort.
        The President's proposal would make it possible for some
    families to qualify to have child care for $10 a day which
    would ultimately save them, each, those families about oh
    $7,200 in a year in the cost of their child care when you total
    it up. That would be a proposal that would help so many of the
    families, some 16 million families would qualify for that
    support. And so it is so important to move forward, as you
    said, to continue to make the investments in child care.

                                MATERNAL HEALTH

        Senator Murray. Thank you. I really appreciate that. We
    will continue to focus on that. Mr. Secretary this week is
    Black Maternal Health Week. It is an important time to talk
    about the devastating maternal mortality crisis here in the
    United States. The U.S. is now one of the most dangerous places
    in the world to give birth. And that really is astounding to
    me. Despite most maternal deaths being preventable, it is clear
    our systems are failing mothers, especially Black, Hispanic,
    and Native mothers who experience the high highest rate of
    maternal mortality.
        And extreme State abortion bans passed since the Dobbs
    decision, have further eroded the access to maternal health
    because we don't have as many providers for maternal health
    care across our country. We were able to secure a $21 million
    increase for the Improving Maternal Health Initiative across
    HRSA, CDC, and NIH in our fiscal year 2024 bill, and building
    on increases from 2023, and I hope to continue that progress in
    this budget.
        Can you talk to us about what HHS is doing now to address
    this issue and about the additional investments in maternal
    health that you are actually proposing for next year?
        Secretary Becerra. And again because of the efforts of you
    and others that we have been able to continue to increase the
    funding of maternal health. This budget, the 2025 budget by the
    President provides close to $400 million for maternal
    mortality, morbidity, to address that, because as you
    mentioned, in too many cases a Black woman is two or three
    times more likely to die at childbirth than a White woman.
        I think I misspoke and said $8 billion, it is actually $2
    billion in this Federal budget by the President, is dedicated
    to maternal health. We are now, as I mentioned earlier, before
    you got here, Senator, making available care for a woman who
    qualifies for Medicaid, and for her baby, rather than just for
    60 days, she now qualifies for 365 days of care, and so does
    her baby. We are doing a lot. Doulas are being made available
    to families.
        We are trying to do what we can upfront before the
    delivery, so the woman gets good care before delivery, gets
    good care during delivery, and good care after delivery.

                               YOUTH HOMELESSNESS

        Senator Murray. Okay. Very good. And finally, on youth
    homelessness prevention, I am laser-focused on making sure the
    Federal Government is doing everything we can to support young
    people who are experiencing homelessness and doing more to
    prevent it. I was very proud to champion new funding in our
    2024 bill for a demonstration program that will provide grants
    to State, local, and tribal governments, and local
    organizations to help prevent youth homelessness. What is HHS
    doing to address and prevent youth homelessness?
        Secretary Becerra. Senator, thanks for that work that you
    are doing. We are working with States. I am the Chair of our
    Interagency Council on Homelessness, working with HUD
    (Department of Housing and Urban Development) and other
    agencies to make sure that we are tackling homelessness with
    the support of the local governments, who actually have the
    day-today-to-day responsibility for it.
        I will tell you this, we are focused on getting families
    and children, first and foremost, off the streets, and we are
    trying to make sure foster kids don't fall into homelessness
    once they age out of the foster care system. And so we are
    doing what we can--and by the way, we are also focusing on
    LGBTQ young people because we know so many of them end up
    becoming homeless. And if we get to them early, we can keep
    them with a family. We can keep them healthy.
        Senator Murray. Thank you. Thank you very much. Thank you,
    Madam Chair.
        Senator Baldwin. Next, for a second round, we have Senator
    Capito.

                                     ARPA-H

        Senator Capito. Thank you. Thank you again, Mr. Secretary.
    We authorized ARPA-H (Advanced Research Projects Agency for
    Health) at 1--well, it was funded at $1.5 billion, and you are
    requesting flat funding for ARPA-H. For those who don't know
    what that is, it is intended to fund high-risk, high-reward
    research to find biomedical and health breakthroughs. It is
    fashioned after DARPA (Defense Advanced Research Projects
    Agency), which is done in the defense arena.
        And biomedical research has long enjoyed bipartisan
    support, of which mine is obviously part of that support. I
    have heard some concerns about either repetitive, or
    deflecting, or competitive, maybe, research that could be
    doing--that is conducted at NIH as opposed to ARPA-H. So ARPA-H
    reports to you and NIH is a separate entity. And I would like
    to know, can you tell me how you plan to make sure that the
    research activities of ARPA-H and NIH remain distinct? And I
    mean, I don't think they should be siloed because one can feed
    to the other, but to avoid that duplication?
        Secretary Becerra. Senator, so just to be sure we are
    clear, both NIH and ARPA-H----
        Senator Capito. Right.
        Secretary Becerra [continuing]. Report to me. But ARPA-H,
    which is very similar in its research mission, some said should
    have been housed within NIH.
        Senator Capito. Right.
        Secretary Becerra. What we did was we kept it separate,
    because it is supposed to be a much more nimble operation. The
    difference, basic research is done at NIH, it may take 10 to 15
    years before we see some novel discovery come out of the NIH
    research. ARPA-H says in 2 years, no more than perhaps 3 years,
    you are on the ground with this novel approach.
        And so ARPA-H was, as you mentioned, with DARPA, with the
    Department of Defense, to help us get those innovators who are
    having difficulty finding enough money, because it is a small
    idea actually get them off the ground. And so this is where
    that cutting-edge research will quickly get moving.
        And so ARPA-H has actually had some great successes. And as
    I mentioned to you in our conversation, love to make sure that,
    if you would like, you know, we will let you know some of the
    projects that are underway at ARPA-H.
        Senator Capito. Yes. So I understand your longest project,
    so far, is 9 months' old. I mean, that is because this is a new
    program.
        Secretary Becerra. Correct.
        Senator Capito. You had the ability to withdraw funding at
    any--and I don't know how many projects you have going, nine to
    ten, maybe going right now.
        Secretary Becerra. Right. Yes.
        Senator Capito. You have the ability to withdraw funding if
    it looks like these things are--that is some of the hardest
    things to do, as we know.
        Secretary Becerra. Yes. Yes.
        Senator Capito. We served together. Have you withdrawn any
    funding from any of your projects that are moving, so far, is
    it too early to tell?
        Secretary Becerra. We are only 9 months in, and so usually
    2 to 3 years, but you are right that these program managers are
    hired under with the understanding, 2 or 3 years. And that is
    it.
        Senator Capito. And so do you have a firm and affirmative
    oversight plan to make sure that, you know, you are redirecting
    funds if somebody has got an idea that is not going to work let
    us move on? And do you have that oversight plan already in
    place?
        Secretary Becerra. Yes, Dr. Wegrzyn who, by the way, came
    from DARPA, and Dr. Wegrzyn understands that completely. It is
    in the design of the proposals. Everyone understands this is
    not going to be something that is living for a decade, it is
    either, you hit it, you have success, or we are moving on.

                                 RETURN TO WORK

        Senator Capito. Okay. I want to ask you about your return
    to work process. COVID is over. It has been over for over a
    year now. The White House Chief of Staff, Jeff Zients, and
    excuse me if I pronounced his name incorrectly, encouraged
    agencies through an order in May 11, 2023, to bring back in-
    person work policies. What is your in-person work requirement?
        Secretary Becerra. We are complying with the OMB (Office of
    Management and Budget) Guidance that was----
        Senator Capito. Well, what is that? I don't know what that
    is.
        Secretary Becerra. It essentially says make sure that your
    work plans with all of your employees have a mix. So some are
    full-time, some have some telework ability. And so it is having
    the mix. And what you are traditionally trying to do is have at
    least half of your workforce in at all times.
        Senator Capito. Okay. So approximately what percentage
    would you say is back in the office 5 days a week?
        Secretary Becerra. Well, as I said, we are complying with
    the OMB Guidance.
        Senator Capito. I know, because actually and said that.
        Secretary Becerra. So that means we are essentially there,
    but we are 90,000. We have people throughout the country, we
    have a mix, and unlike other agencies we have folks who are
    medical----
        Senator Capito. Have you negotiated any contracts or with
    the Federal unions that say you have to be in 2 days every 2
    weeks, and a day is 6 hours?
        Secretary Becerra. We have negotiated contracts with the
    unions to make sure that we are complying with the OMB
    Guidance.
        Senator Capito. Well, I mean, are some of those like that,
    because I know that is--we are finding that in other agencies.
        Secretary Becerra. Yes, what we--for example, telework been
    around for a long time. And so there, we may have made
    adjustments to the telework plans that we have. But what we
    have to do is because they are under an employee collective
    bargaining agreement, we have to discuss that with you.
        Senator Capito. Okay. So can we have your collective
    bargaining agreements? I mean, I am sure they are public, so we
    could see what you have negotiated in certain areas, because
    quite honestly, 4 days a week, at 2-week period, 6 hours is a
    day, most of America would begin laughing at that.
        Secretary Becerra. Right. And that is not something that
    you have for the 90,000 people in the workforce. But let me see
    what I can do as far as providing you some of that information.
        Senator Capito. All right. And then in the--well, I think
    my time is up. So I will let these guys go ahead. Thank you.
        Secretary Becerra. Thank you.
        Senator Baldwin. Senator Kennedy.

                                 HHS EMPLOYEES

        Senator Kennedy. Mr. Secretary, how many employees does the
    Department of Health and Human Services have?
        Secretary Becerra. Roughly 90,000, Senator.
        Senator Kennedy. And your testimony is that half are back
    in the office full-time and half aren't?
        Secretary Becerra. The OMB Guidance essentially calls for a
    process where we have physically----
        Senator Kennedy. I understand the OMB Guidance.
        Secretary Becerra. Yes.
        Senator Kennedy. Is it your testimony that half are back,
    of those 90,000 are back in the office full-time and half
    aren't?
        Secretary Becerra. My testimony is that we are in
    compliance with the OMB Guidance on how we handle the
    workforce.
        Senator Kennedy. Is it your testimony that half of the
    90,000 are back in the office full-time and half aren't?
        Secretary Becerra. Again, my testimony is that we are
    complying with the OMB Guidance, like, we can make sure you
    know what the guidance is, so you know what we are complying--
    --
        Senator Kennedy. I do know what the guidance is, I am just
    trying to understand how you have implemented it, what
    percentage of your employees are back in the office full time?
        Secretary Becerra. I could try to get that information back
    to you, because we have a mix.
        Senator Kennedy. You don't know?
        Secretary Becerra. I came to talk about the budget, but I
    can try to get----
        Senator Kennedy. You don't have any idea of how many of
    your 90,000 people are back in the office full-time?
        Secretary Becerra. I could tell you the types of mix of
    employment that we have----
        Senator Kennedy. Yes. Well, that is what I am asking. You
    have got 90,000 employees.
        Secretary Becerra. That is right.
        Senator Kennedy. How many are back in the office full-time
    what percentage? You don't know?
        Secretary Becerra. And as I said, this is a budget hearing,
    I came to talk about the budget.
        Senator Kennedy. If you don't know. You don't know how many
    of your people are back in the office full time.
        Secretary Becerra. I can get back to you Senator, I could
    get you as best I can a response to that particular question,
    but I came here to talk about the President's budget.

                               MEDICARE ADVANTAGE

        Senator Kennedy. Why is Medicare Advantage so popular?
        Secretary Becerra. I am sorry?
        Senator Kennedy. Why is Medicare Advantage so popular?
        Secretary Becerra. Why is Medicare Advantage so popular?
    You will have to help me with what do you mean by that?
        Senator Kennedy. You don't know what Medicare Advantage is?
        Secretary Becerra. Absolutely, I know what Medicare
    Advantage, but why so popular----
        Senator Kennedy. Yes. What is it so popular?
        Secretary Becerra. Is there some survey that you are
    talking about, or what?
        Senator Kennedy. Yes about--I deal in numbers.
        Secretary Becerra. Okay.
        Senator Kennedy. About half of our seniors who qualify for
    Medicare choose Medicare Advantage, don't they?
        Secretary Becerra. That is actually more than half?
        Senator Kennedy. Okay. And why is that, that makes it
    popular, right?
        Secretary Becerra. Medicare Advantage today this is the
    first year that we have seen more individuals select plans in
    the Medicare Advantage and it is----
        Senator Kennedy. Why is it so popular?
        Secretary Becerra. Again, when you say ``popular'' I have
    heard many Medicare beneficiaries who are complaining about
    being stuck at a Medicare Advantage plan----
        Senator Kennedy. Well, is it because the average person,
    average senior on Medicare Advantage pays $2,400 less in
    premiums on Medicare Advantage as opposed to traditional
    Medicare, plus gets more services, like dental, and vision, in
    many respects, could that have something to do with; do you
    think?
        Secretary Becerra. I am assuming that you have seen some
    polling or surveys that give you some of those answers, I have
    heard many, many things that are said about----
        Senator Kennedy. No. I am seeing the facts. Are you telling
    me that people on Medicare Advantage don't save money in
    premiums and co-pays over traditional Medicare?
        Secretary Becerra. I can get you some do----
        Senator Kennedy. Is that your testimony?
        Secretary Becerra [continuing]. But I wouldn't have--no
    doubt that some pay more.
        Senator Kennedy. I am talking about the average.
        Secretary Becerra. Again, I don't know what numbers you are
    referring to, but I am more than willing to discuss those with
    you.
        Senator Kennedy. I am looking at the numbers that your
    Department puts out.
        Secretary Becerra. Okay. Then what are those numbers,
    Senator?
        Senator Kennedy. The numbers say that the average person on
    Medicare Advantage----
        Secretary Becerra. I am asking you if you can show me the
    numbers.
        Senator Kennedy [continuing]. Pays $2,400 less in premiums
    and co-pays and gets extra benefits; is that right?
        Secretary Becerra. My understanding is they are also
    restricted in the doctors they have access to, the hospitals
    they have access to.
        Senator Kennedy. You are trying to destroy Medicare
    Advantage; aren't you?
        Secretary Becerra. We have actually provided an increase in
    funding for Medicare Advantage.
        Senator Kennedy. No. You haven't you cut--you cut funding
    in 2023 by 1.1 percent----
        Secretary Becerra. That is absolutely incorrect.
        Senator Kennedy [continuing]. And you--next year you are
    proposing a 0.16 percent cut, and in fact the Medicare----
        Secretary Becerra. That is absolutely incorrect.
        Senator Kennedy. That is not incorrect.
        Secretary Becerra. That is absolutely incorrect.
        Senator Kennedy. And in fact, that the Medicare Trustee----
        Secretary Becerra. Senator, saying it doesn't make it true.
        Senator Kennedy. The Medicare Trustee said that you have
    lost your mind, my words not theirs.
        Secretary Becerra. Senator, saying something doesn't make
    it true. The dollar amount that we are giving to health
    insurance companies----
        Senator Kennedy. You have cut----
        Secretary Becerra [continuing]. To secure that has
    increased.
        Senator Kennedy [continuing]. Are you telling me today that
    you have not cut payments to insurers in Medicare Advantage
    last year by 1.1 percent?
        Secretary Becerra. We are giving Medicare Advantage----
        Senator Kennedy. Are you denying that?
        Secretary Becerra [continuing]. Health insurance
    companies----
        Senator Kennedy. Are you denying that?
        Secretary Becerra [continuing]. Under Medicare Advantage
    are receiving more money this year than they got last year for
    Medicare.
        Senator Kennedy. You cut them by 1.1 percent----
        Secretary Becerra. That is not a cut, Senator.
        Senator Kennedy [continuing]. And you are proposing another
    0.1 percent cut. In fact, I mean you and President Biden say
    you will not touch a hair on the head of Medicare, but that
    is--you are trying to destroy Medicare Advantage, and I mean--
    --
        Secretary Becerra. Actually the President's budget extends
    the life of Medicare----
        Senator Kennedy [continuing]. Look--look--look----
        Secretary Becerra [continuing]. Beyond your and my
    lifetime.
        Senator Kennedy. Look at the numbers. In 2023, under your
    watch, Medicare Advantage patients saw on average a 12 percent
    increase in deductible and a 5 percent----
        Secretary Becerra. The insurance companies did that not us,
    Senator.
        Senator Kennedy [continuing]. In premiums. And Florida, and
    Utah, and Wyoming, saw their premiums go up 50 percent----
        Secretary Becerra. Okay. Senator, blame the insurance
    companies, not us.
        Senator Kennedy [continuing]. Because you cut the
    payments----
        Secretary Becerra. Senator, we did not cut.
        Senator Kennedy [continuing]. To the insurance companies to
    drive them to traditional Medicare where you can control them
    better; isn't that the case?
        Secretary Becerra. The fiction you are propounding doesn't
    resolve the issue that we have, every year, so far under this
    administration increased the funding for health insurance
    companies who offer these Managed Care Medicare Advantage
    plans.
        Senator Kennedy. Are you----
        Senator Baldwin. Thank you, Senator Kennedy.
        Now, I will recognize Senator Hyde-Smith.
        Senator Kennedy. Thank you, Madam Chair, for your
    indulgence.

                             CARDIOVASCULAR DISEASE

        Senator Hyde-Smith. Mr. Secretary, Mississippi has one of
    the highest rates of cardiovascular disease and deaths from
    this disease, and the frequency of the disease continues to
    increase. It has been concerning for a very long time. It is
    important that Americans receive cholesterol screenings, and
    appropriate treatments to manage this cardiovascular disease to
    prevent further complications that could lead to sicker
    outcomes or even death.
        The fiscal year 2023 Labor HHS Report included language
    requesting a report, which was supposed to be completed in the
    summer of 2023, on cardiovascular disease, and the implications
    associated with postponing, delaying, or being provided sub-
    treatments. This remains a critical issue in Mississippi and a
    critical issue across the United States. I was very
    disappointed that the Department is nearly a year late in
    providing that information to this committee as it was
    instructed to do. Can you tell me the status of this report and
    how do you explain why the Department did not comply with the
    deadline?
        Secretary Becerra. Senator, I am going to confess to you, I
    don't have that information in front of me, and I apologize. So
    how about we do this? Let me huddle with the team, and I will
    do it as quickly as you would like, and we can get back to you
    on that particular answer. I don't want to give you
    misinformation. But I wish I could give you something. And I
    don't know if I have any of that in my notes. So rather than
    try to wing it, let me get back to you on that, because it is
    an important question.
        Senator Hyde-Smith. But you have no idea why it was late,
    or that it was even late?
        Secretary Becerra. I am sorry. I don't know. I can't tell
    you that I remember my team saying to me we are going to be
    late. And so rather than give you--again, rather than try to
    dance, let me get back to you as quickly as possible.
        And Madam Chair, if the Senator would like, we could put my
    response on the record.
        Senator Baldwin. Without objection.
        [The information follows:]

        HHS agrees with the appropriations committees that cardiovascular
    disease (CVD) is an important condition affecting the lives of millions
    of Americans and results in substantial costs to our healthcare system.
    This is evidenced by the fact that heart disease--which is just one
    form of CVD--is the leading cause of death in the United States. ASPE's
    original analysis of traditional Medicare claims data found spending on
    CVD-related hospitalizations alone exceeded $21 billion in 2019.
        CVD is a broad topic that requires ASPE to review the extensive
    literature on the disease and develop a research strategy to analyze
    Medicare claims data. ASPE used Medicare claims data in the report
    because the Medicare population is at high risk for poor CVD outcomes.
    ASPE is working diligently with available data and existing research
    findings in the literature to prepare a detailed report describing: (1)
    CVD in the general population and its adverse health outcomes, (2) risk
    factors for CVD, (3) prevention and treatment options, (4) disparities
    in disease burden and potential barriers to accessing optimal
    treatment, (5) economic costs associated with untreated/undertreated
    CVD, (6) the prevalence of CVD among beneficiaries in the traditional
    Medicare program, (7) utilization and costs associated with CVD-related
    care for traditional Medicare beneficiaries, and (8) a brief overview
    of some of the key program and initiatives supported by the Department
    that specifically address CVD. These topics were intended to address
    the Committee's broad interests in better understanding the growing
    prevalence of CVD and the economic burden of this disease, with an
    added focus on the traditional Medicare program. The breadth and depth
    of the analytic work undertaken by ASPE impacted HHS' ability to
    provide the report in a timeframe consistent with the committee's
    request. HHS expects to transmit the report by Summer 2024 and will
    publish the report at https://aspe.hhs.gov/reports/cvd-report-congress.

        Senator Hyde-Smith. I would like a response to that pretty
    quickly.

                                   TELEHEALTH

        As we look at what may be the most consequential year for
    telehealth policy to date, we cannot overstate the urgency for
    Congress and CMS to act on Medicare legislative and regulatory
    telehealth flexibilities.
        Our Nation's healthcare systems and providers need clarity.
    We need stability to implement and maintain the operational and
    clinical practices needed to ensure seamless quality care for
    millions of Medicare beneficiaries nationwide. I strongly
    encourage CMS to work alongside Congress by continuing to share
    relevant telehealth data with members of Congress, and staff,
    as well as continuing to engage with stakeholders through
    public calls on pertinent healthcare issues. How actively will
    CMS engage with Congress this year on telehealth policies?
        Secretary Becerra. Senator, we will be camped outside your
    door, if you would like, because this one is very important to
    us. As we discussed in our previous Q&A, telehealth is
    indispensable, especially in rural communities. It avoids the
    need for transportation. It makes it possible to have immediate
    access to a professional healthcare provider, and we don't want
    to lose that.
        And so we are at your door, ready to provide technical
    assistance as you all make decisions on what kind of
    flexibilities to continue to give us in working with the
    States.
        Senator Hyde-Smith. And as you know, many of those
    flexibilities that allow Medicare providers to offer telehealth
    expire at the end of this year.
        Secretary Becerra. Yes.
        Senator Hyde-Smith. And Congress plans to address these
    policies but may not finalize updates until the close of the
    end of the year. Will CMS be able to create a regulatory
    pathway to allow for immediate and seamless updates to policies
    when the law is updated?
        Secretary Becerra. Senator, I don't think you are going to
    like the answer here because regulatory work, as you know,
    takes more than just months to implement and actually put on
    the ground and operate. We are absolutely counting on Congress
    before the end of this calendar year to come up with some
    telehealth solutions, because we won't have the kinds of
    flexibilities that you or I would want to see if we get past
    December 2024, without Congress acting to extend those
    flexibilities.
        We will do whatever we can at the regulatory level, but
    more importantly at the executive level where we have any
    discretion, but as you know, the reason you all had to pass
    these extensions on flexibilities was because we didn't have a
    lot of executive discretion on what to do.
        Senator Hyde-Smith. Thank you. My time----
        Senator Baldwin. All right. Just to give you a quick status
    update, we are hearing that there are at least two other
    members who are desperately trying to get into this hearing to
    ask you questions. I will entertain a third round.
        Secretary Becerra. Lucky me.
        Senator Baldwin. Lucky you. And if they do not appear
    before the end of our third round, we will let you go.

                             CMS PROGRAM MANAGEMENT

        So I want to focus for a moment, on the Centers for
    Medicare and Medicaid Services, or CMS. This agency provides
    services for millions of Americans through Medicare, Medicaid,
    and CHIP (Children's Health Insurance Program), Wisconsin
    families and seniors rely on these programs, and I believe that
    we need to do everything that we can to ensure that they are
    working effectively to provide the care that our constituents
    deserve.
        Funding for program management at CMS was flat for almost a
    decade. Can you describe the negative impact that not investing
    in program management activities has on Wisconsin families and
    seniors, and American families and seniors?
        Secretary Becerra. Senator, thank you for the question. I
    know everyone always focuses on what we do on the ground to
    help families, and that is absolutely what our government's
    local, State, Federal have to do is be there for folks when
    they need us. The folks who are there when they need us, are
    the folks who often get neglected when it comes time to
    providing budgetary authority.
        So we provide money, Congress provided--and I was here for
    24 years as a member, so I remember those days, we would always
    fund the program, but we would neglect or skimp on providing
    funding for the personnel. CMS is essentially in that strait,
    for the last 13 years its budget actually has gone down, at the
    same time its population that it serves, Medicare, Medicaid,
    CHIP, ACA (Affordable Care Act), Marketplace, has gone up by
    over 40 percent.
        So it is going in totally opposite directions. Every year
    we are doing more. We are negotiating--CMS is negotiating the
    drug pricing, CMS is helping States address the Medicaid
    redetermination so people don't lose their coverage. CMS is
    having to deal with all these determinations about whether
    Alzheimer's treatments or cancer treatments will get covered
    under Medicare.
        CMS is a workhorse, but it is not getting fed. The people
    that are doing all the work, unfortunately, are stressed, so
    anything we can do to ensure that we can continue to have good
    production would help. And by the way, I haven't even mentioned
    cybersecurity CMS, when Change Health suffered that cyber
    attack, CMS, through Medicare and Medicaid, was there to make
    sure doctors and hospitals still got money even though all the
    systems, electronic systems had gone down, that was CMS.
        Senator Baldwin. You have mentioned many of the functions
    that CMS participates in. Can you speak also to nursing home
    inspections?
        Secretary Becerra. Well, it is--I hate to say it publicly,
    but I think every American who has their loved one, their mom,
    their grandfather, their disabled brother in a nursing home
    expects that there is going to be quality care. One of the ways
    we ensure quality care is to do inspections, to do the surveys
    to make sure that these facilities are providing real care to
    Americans that we love.
        Unfortunately, the resources that we have received,
    especially in the administrative side of the budget that don't
    allow us to do the surveys 100 percent, we did over two-thirds
    of the surveys that we needed to of the nursing homes
    throughout the country, but the funding has continued to go
    down. I fear that we are going to continue to drop in the
    number of surveys of nursing homes that we are doing which, one
    of these days is going to result in some nursing home being in
    the news because some tragedy happens, and it is a nursing home
    that we didn't have an opportunity to inspect. That should not
    happen. And if we had the resources, and in a small drop in the
    bucket, of all the money that you all provide CMS; that would
    help us make sure that nursing homes are safe.
        Senator Baldwin. Thank you. Senator Shaheen.

                                    INSULIN

        Senator Shaheen. Excuse me. Thank you, Madam Chair, and
    Ranking Member Capito. Secretary Becerra, thank you for being
    here today, and for all of your work on a daily basis, and I am
    sorry I missed your opening remarks, but I very much appreciate
    your mentioning insulin and the need to address insulin
    affordability.
        And despite the efforts in the last year's legislation, the
    Inflation Reduction Act to cap out-of-pocket costs for insulin
    for Medicare, at $35 a person, we still see challenges with
    affordability for insulin. Can you speak to that and what we
    are seeing on the private market compared to Medicare, now that
    we have capped the cost?
        Secretary Becerra. And Senator, I know despite many of your
    efforts to include the $35 cap on insulin for everyone in
    America, the bill ultimately had to get pared down to only
    provide it to the 66 million Americans who receive Medicare
    benefits. The President, in his budget, calls for extending
    that to everyone in America, not just those on Medicare, and
    what we are finding is that in some spaces some of the
    manufacturers of insulin have said that they would reduce the
    cost to commercial private insurance plans to $35, but not
    everyone in America is experiencing the savings that comes from
    having access to insulin at $35 a month.
        Senator Shaheen. Well, thank you. And in fact, then we have
    companies like Nova Nordisk who said that they were going to
    reduce the cost for Levemir, and then now they have taken
    Levemir totally off the market after saying they were going to
    reduce the cost. So there is some disingenuousness in what we
    are hearing from some of the providers.
        And on a similar note, I have heard from constituents about
    ongoing shortages of insulin, Humalog and NovoLog. We heard
    from Walter Chapman who is a 70-year-old constituent in Dover,
    New Hampshire, he visited three different pharmacies, he called
    several others in surrounding towns before he could finally
    find his insulin in stock. And he wasn't calling small,
    independent pharmacies, he was calling CVS, Walgreens, Walmart,
    with big footprints. So what are we going to do to address
    these shortages, and how can we make it more transparent so
    people know what they are getting?
        Secretary Becerra. And this is where work is ongoing. We
    have a proposal that we have submitted to try to have more
    transparency in the pharmaceutical industry, because it is so
    difficult to know what is going on behind the curtain.
        There is no reason why insulin should be in shortage
    anywhere, because it is so easy to produce, and so inexpensive
    to produce, but that is the game that is played, and that is
    why the President continues to want to get behind the curtain.
    That is why it is so indispensable that you gave us the
    authority, by law, to negotiate, to drive down the prices of
    some of the most expensive medicines under Medicare.
        Senator Shaheen. And in fact we have legislation in the
    Senate, Senator Collins and I do, Senators Warnock and Kennedy;
    that would cap the cost, out-of-pocket cost for insulin as well
    as dealing with availability. I hope that we will see
    leadership bring it to the floor this year, because I think we
    have the votes to pass it.

                                    TITLE X

        On another note, as you know Title X funding is critical to
    ensuring family planning providers can keep their doors open in
    States, particularly States like New Hampshire where abortion
    remains legal but where we have many small providers, and we
    have State legislators that are preventing those small
    providers from getting the funding they need.
        I appreciate Health and Human Services working with family
    planning providers in New Hampshire, but can you tell us what
    else you are thinking about in terms of helping keep those
    folks in business?
        Secretary Becerra. So most every time I travel across the
    country I will visit a family planning program, because they
    are indispensable to so many families. They do more-- some
    people think all they do is provide care to women--they provide
    care to families, family planning. The President's budget, as
    you are probably aware, tries to boost funding under Title X,
    another $100 million so we get back to where we used to be in
    some of the funding levels for these programs, to over $350
    million. That is going to be important because families are
    desperate, desperate for the kind of care that helps them have
    good outcomes in all of their family planning.
        Senator Shaheen. Well, that is right. And it is unfortunate
    that this is an issue that has become all about abortion
    because the family planning providers in New Hampshire serve
    thousands of women, they provide well check visits, they
    provide cancer screenings, they provide STD (sexually
    transmitted disease) screenings, and without them we would have
    so many people who would not be able to get care at all. So you
    are absolutely right. And I appreciate what the Department is
    doing. Thank you.
        Thank you, Madam Chair.
        Senator Baldwin. Thank you. Senator Britt.

                                    ABORTION

        Senator Britt. Thank you, Madam Chair. I appreciate it. Mr.
    Secretary, thank you for being here today; obviously, we are
    here to talk about budgets. I have heard a lot of talk about
    abortion today, and in particular, when I am looking at your
    budget, obviously, there was no mention of the Hyde Amendment
    to be in there. So I want to confirm that you believe taxpayer
    dollars should go to be able to fund abortions?
        Secretary Becerra. Senator, thanks for the question. The
    President has made it clear he wants to remove the Hyde
    Amendment from the budget proposals, and that is what he has
    done.
        Senator Britt. Okay. So when we are talking about that,
    Senator Kennedy asked you a question, and you all were talking
    about your answer kept being Roe v. Wade, and Roe v. Wade, and
    I want that to be the law of the land. So let us just stipulate
    that your hypothetical is the truth. And so if Roe v. Wade were
    the law of the land, and a woman wanted to take the life of her
    child the day before her child was due or the day after her
    child was due, then you support her ability to choose to do
    that; is that correct?
        Secretary Becerra. Senator, again, I will say what I said
    to Senator----
        Senator Britt. No, no, no, no, no, no. I have stipulated,
    Roe v. Wade is part is as law of the land, so, there are seven
    States in this country and the District of Columbia, that allow
    you to take the life of a child the moment before a child is
    born, so clearly you support--you support a woman's right to
    choose to do that?
        Secretary Becerra. Senator, the example you gave is
    fiction, as far as I know. Can you give me a particular
    example?
        Senator Britt. Well, if it actually is fiction, then why
    not say, no. That is out of the realm of possibility that no
    woman would think to be able to do that? Because the truth is,
    if you say that taxpayer dollars should go to fund abortions,
    then you are saying that my taxpayer dollar should go to fund
    something like that. And if that is unthinkable, then why don't
    you just say it is unthinkable? And in fact, then we can just
    take it off the table and not allow that to be legal.
        Because the truth is when you do that, I am going to read
    this to you, ``In particular, when these abortions occur, the
    gruesome surgical techniques involve crushing, dismembering,
    and removal of the fetal body. So, they actually deliver the
    baby breech, and then have to put scissors up the baby's neck,
    open it up, and then suck out the brain so that they are able
    to get the head through the birth canal.''
        And so, I just--then there is also the opportunity to go in
    and actually put a needle in that child's heart, and kill that
    child. If that child is then delivered alive, do you believe
    that that child on that table that we should be able to save
    that child? Or do you believe that our taxpayer dollars give
    this woman the right to say, don't save my child? I just think
    when we are talking about this and you are saying so boldly no
    taxpayer dollars go, and you actually won't answer the question
    when it comes to Roe v. Wade.
        And I am saying I will stipulate that your hypothetical is
    the case. There are still seven States in this country and the
    District of Columbia that allowed us to do that. We are one of
    like seven nations that allow that to take place on our soil.
    Two of the other nations are North Korea and China. And I just
    believe when we are talking about budgets, I want you to know
    where I am coming from, and why I believe wholeheartedly, with
    every ounce of me that we have to preserve the Hyde Amendment.

                                MATERNAL HEALTH

        And on that note, moving to maternal health, when we look
    at this, Alabama knows this issue all too well when it comes to
    maternal mortality and the crisis we have in this country.
    Nationally, the number of reported pregnancies related to
    deaths in the United States increased from 7.2 deaths per 100
    live births in 1987, to 17.6 deaths per 100,000 live births in
    2019. We are moving in the wrong direction.
        Obviously, with more resources, and technology, and
    availability, we should be able to turn this in the opposite
    direction. The resources made available by HRSA's Title V
    Maternal and Child Health Services Block Grant are essential to
    reducing maternal mortality rates and providing better access
    to quality healthcare and services. Most of this vital funding
    goes to States to help them address the priority health needs
    in their State.
        Mr. Secretary, with this happening, why does your budget
    request actually deduce and take funding away from the Title V
    Maternal and Child Health Services Grants that actually go to
    the States?
        Secretary Becerra. Senator, we actually increased funding
    for maternal health. We have some $2 billion in our budget for
    maternal health, and the----
        Senator Britt. So the actual grants, though, went down. The
    number for the grants went down?
        Secretary Becerra. We would have to take a look at that,
    because we have actually continued to provide support and for
    maternal mortality and morbidity programs. We are doing more.
    We have some $360-plus million in this budget for--to address
    the maternal mortality and morbidity rate.
        Senator Britt. Well, I would like to actually work with you
    on that, because obviously, Alabama, this is a significant
    challenge. We have the highest maternal mortality rate in the
    Nation. My reading of your budget is that that number actually
    goes down, even though your overall budget goes up. So let us
    have a conversation about that because we need that money in
    the States. It looks like you have a project-driven basis where
    a lot of that money is going. These grants help us,
    particularly in our rural communities, to make sure that we can
    get the care to these women that they need. And so, I would
    like you to commit to working with me on taking a look at that
    and making sure that States have the money they need to make an
    impact.
        Secretary Becerra. I commit to follow up with you on that.
        Senator Britt. Thank you.
        Senator Baldwin. Thank you. Should no one else arrive, I am
    going to recognize Senator Capito for her last round and then
    conclude the hearing if another member does appear. Okay,
    Senator Capito, and then I will allow both of the--since we
    have had multiple rounds, I will allow that.
        So, go ahead, Senator Capito.

                              ALZHEIMER'S DISEASE

        Senator Capito. Yes. Mr. Secretary, I will not have you
    answer these, but I am going to put these on your radar and
    maybe we can get follow-up in written. First of all, I want to
    talk about the Alzheimer's disease workforce, we know that this
    is a challenge as you have discussed in many other areas. We
    know that half of our primary care physicians do not feel like
    they are adequately prepared to care for individuals living
    with Alzheimer's and other dementia. So with joining with
    Senator Klobuchar, we have introduced the ADAPT Act which would
    help a--it would provide grants to organizations to set up
    dementia-specific project, ECHO programs that have been
    successful, in a small way, I believe emanating from New
    Mexico, to educate and support primary care providers in
    detecting, diagnosing, treating, and caring, so that is an
    issue of great importance to me, and if we could get a reaction
    there?
        And then the other thing; and this is very brief, Avian
    flu. I am a big believer in preparedness. We weren't ready for
    COVID as well as we could have been, and should have been, we
    certainly have got lessons learned here. And we have seen where
    Avian flu has been passed from a--I believe steer or beef
    cattle----
        Secretary Becerra. It is dairy----
        Senator Capito [continuing]. To a human individual.
        Secretary Becerra. Yes.
        Senator Capito. I am just putting that on your radar, so it
    is an area of concern for me.
        Thank you very much for coming.
        Secretary Becerra. Thank you.
        Senator Baldwin. Senator, Britt.

                                  RURAL HEALTH

        Senator Britt. Thank you so much, Madam Chair. And I really
    appreciate it.
        Mr. Secretary you have said by helping rural hospitals stay
    open we are helping residents of rural areas get the care they
    need close to home, having access to care nearby is not only
    more convenient but it also lends to better health outcomes and
    boost local economies. I want to say I couldn't agree with you
    more. I certainly hope that you mean that, and I assume that
    you would confirm that you do.
        Secretary Becerra. Yes. And any ideas you have because
    there are a lot of healthcare facilities in rural America that
    are on the verge of closing.
        Senator Britt. Yes.
        Secretary Becerra. Once they close it is tough to reopen.
    So we are more than willing to work with any of you who are
    interested in that.

                             PROVIDER RELIEF FUNDS

        Senator Britt. That is wonderful because that is actually
    the commitment I want from you today. As you know, there are a
    very small number of new rural hospitals that opened in 2020
    just before the country shut down, and one of these hospitals
    is actually located in Alabama. So Thomasville Regional Medical
    Center was among the unfortunate few who were deemed ineligible
    for Provider Relief funds due to the formula's reliance on the
    figures from 2019, and you are well aware of this, as you know.
        Secretary Becerra. Yes.
        Senator Britt. Throughout your tenure, you know, many of my
    colleagues, Representative Sewell there on the other side, the
    other chamber, and on the other side of the aisle has talked to
    you about this, and has asked for your commitment in budget
    hearings just like this, and received it to working with us to
    find solutions for this group of needy hospitals.
        These members received a commitment from you and their
    offices to ensure that these hospitals received proper Federal
    assistance via the Provider Relief Fund, and so my assumption
    is that you stand by that testimony. And my question would be,
    what actions did you take to ensure Thomasville Regional
    Medical Center received adequate Provider Relief funds?
        Secretary Becerra. Thomasville, like many of the facilities
    that have applied have to meet the criteria that Congress set
    forth for us to be able to fund them during the--with the
    Provider Relief dollars that were made available. Where we had
    some flexibility, some discretion, we took them to try to help
    some of the facilities that were clearly hurting and in
    desperate need, especially those that were providing services
    to folks who are in underserved areas.
        But our discretion, our flexibility is limited by what
    Congress set forth as the guidelines for distributing the
    dollars. Too many facilities, and I suspect Thomasville being
    one of them, fell within that scope where it became difficult
    to reach them because of the criteria----
        Senator Britt. So what do we do? I mean because there has
    to be a pathway to help, because just as you mentioned they are
    on the verge of closing, and if you look at some of the things
    that we have seen, they have--the Harvard School of Public
    Health put out that this congressional district has the lowest
    life expectancy in the country. And so if we are not going to
    help hospitals like this that provide people access to care
    within their communities, you know, your very first statement
    that I wholeheartedly agree with, then what are we, what are we
    doing? I mean this is what we are here for. So you are telling
    me why we can't. Tell me how we can, that is what I want to
    know.
        Secretary Becerra. Yes. And we can, if you all hadn't swept
    up close to $5 billion that we had in COVID relief dollars, we
    could have perhaps come to you and asked you for more
    flexibility to use some of that money for some of those
    providers under the Provider Relief Fund. We are out of money
    in the Provider Relief Fund, and we often----
        Senator Britt. So there was about $7 billion left, right?
    Is that right?
        Secretary Becerra. At this stage, no, that----
        Senator Britt. Right. But when that occurred?
        Secretary Becerra. It well left in the sense that it had
    not yet been obligated, but it was already destined to go to
    provide different services, it was then swept up by Congress,
    and now it is no longer available.
        Senator Britt. So what can we do?
        Secretary Becerra. Well, you can always try to re-up the
    Provider Relief----
        Senator Britt. Well, no, I mean what can you do in your
    role right now, what can you commit to me to help keep this
    hospital open? Or what resources are available, what thought
    process do you have? You obviously sit in the big chair, so
    don't tell me what you don't have, tell me what you do have and
    how we can get that to a path of success?
        Secretary Becerra. Well, the problem is if I don't have the
    resources to make things happen, there is only so much I can
    tell them we can do, because what they want is money. They are
    not interested in smiles, they are interested in money. If I
    don't have money in my pocket, you all swept it up, it makes it
    tough for me to offer----
        Senator Britt. Do you have any money that could work to go
    towards that at all?
        Secretary Becerra. Senator, as you know how the way things
    work, you tell me where I can spend the money.
        Senator Britt. Okay. So what would I need to advocate for
    right here in this budget to help move that forward?
        Secretary Becerra. There is two things you can do, pass
    legislation that gives us more flexibility in using some of the
    money you have already given us, which probably would gain some
    opposition from folks who say, wait a minute that is already
    money that we are going to use, and you are send it off to
    somebody else, so you are going to have to deal with that. But
    you could do that give us more flexibility with money we do
    have which we don't have flexibility to use, for example, with
    a program like Thomasville.
        Or you can re-up a program, like the Provider Relief Fund
    that has some resources so that when Thomasville comes to us, I
    can say we now have some resources that we can provide to you.
        Senator Britt. Will you commit to having--continuing this
    conversation with me, the two of us.
        Secretary Becerra. Absolutely.
        Senator Britt. Thank you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Baldwin. That will end our hearing today. I want to
    thank my fellow committee members for their thoughtful
    conversation.
        And thank you, to you, Secretary Becerra.
        For any Senators who wish to ask additional questions,
    questions for the record will be due on April 23 at 5 p.m. And
    the hearing record will also remain open until then for members
    who wish to submit additional materials for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                Questions Submitted to Secretary Xavier Becerra
                  Questions Submitted by Senator Tammy Baldwin
        Question. Recently, the Environmental Protection Agency took a
    significant step that will require municipal water systems to virtually
    eliminate per-and polyfluoroalkyl substances (PFAS) from U.S. drinking
    water. According to the CDC, virtually all Americans have measurable
    amounts of PFAS in their blood today, which can be linked to many
    severe health outcomes including cancer and birth complications.
    Earlier this year the CDC recommended that physicians consider offering
    more blood tests for individuals who may have had high levels of
    exposure to PFAS.
        How is HHS working with providers and public health departments to
    advise when blood testing is necessary?
        Answer. On January 18, 2024, the Centers for Disease Control and
    Prevention (CDC) and the Agency for Toxic Substances and Disease
    Registry (ATSDR) released PFAS: Information for Clinicians. This
    document provides updated information for clinicians to consider when
    seeing patients who have concerns about per- and polyfluoroalkyl
    substances (PFAS) exposure or possible health effects.
        In deciding whether to order PFAS testing, the document recommends
    clinicians consider an individual's exposure history, including results
    of PFAS testing from the patient's water supply, food sources, or other
    exposure routes, and whether results from PFAS blood tests can inform
    exposure reduction and health promotion.
        CDC has shared the updated guidance with medical and healthcare
    provider associations, health departments, and partners. CDC/ATSDR will
    continue to review the science and periodically update this
    information.
        Question. Is HHS focusing on the most vulnerable populations, such
    as expectant mothers and babies?
        Answer. PFAS: Information for Clinicians provides information for
    providers to consider when addressing PFAS exposures in populations
    vulnerable to chemical exposures, including pregnant women and
    children. ATSDR also supports 10 regional Pediatric Environmental
    Health Specialty Units (PEHSU) that advise parents, child caregivers,
    and healthcare providers on protecting and caring for children
    potentially exposed to harmful chemicals, including PFAS. Regional
    PEHSU units respond to requests for information, offer advice on
    environmentally related health effects for pregnant women and children,
    and provide education to healthcare providers, other health
    professionals, and community members.
        The National Institute of Environmental Health Sciences (NIEHS)
    supports research to characterize and better understand the possible
    health effects of exposure to PFAS chemicals, with active support
    toward studies related to pregnancy and perfluoroalkyl substances.
    NIEHS grantees are exploring how exposure to PFAS during pregnancy and
    through midlife may alter cardiovascular disease risk. Other studies
    are exploring the effects of environmental exposure to PFAS/PFOS on
    children who may have been exposed prenatally. In one example,
    researchers are studying bone development in children, who may have
    been exposed to PFAS during gestation, and assessing how vitamin D and
    calcium status may impact those exposures.
        Question. If someone is found to have high levels of exposure to
    PFAS through a blood test, what kind of treatments or therapies are
    available to mitigate the potential negative health outcomes of that
    exposure?
        Answer. When patients have concerns about PFAS or other
    environmental exposures, clinicians can help address these concerns by
    actively listening and providing practical advice. Clinicians play an
    important role in helping patients identify and reduce exposures and in
    promoting standard age-appropriate preventive care measures for
    physical health, mental health, and wellness (e.g., Bright Futures and
    U.S. Preventive Services Task Force recommendations).
        No approved medical treatments are available to remove PFAS from
    the body. Based on information from both a patient's PFAS exposure
    history and the patient's health history, clinicians can collaborate
    with patients to develop individualized care plans. Usual standards of
    care are appropriate to apply to any signs or symptoms of disease a
    patient might exhibit.
        Question. A few weeks ago a dairy worker in Texas tested positive
    for H5N1, or Avian flu, which has been devastating to wild birds and
    poultry around the world. Eight states have now detected the virus in
    dairy herds, which is concerning because we have not seen this virus
    affect cattle before.
        How is HHS coordinating with USDA to monitor the spread among dairy
    cows and in particular, how is HHS providing guidance to dairy farmers
    to keep themselves safe from exposure?
        Answer. The Centers for Disease Control and Prevention (CDC) works
    closely with our Federal partners, including the Administration for
    Strategic Preparedness and Response (ASPR), the U.S. Department of
    Agriculture (USDA), the Office of Pandemic Preparedness and Response
    Policy (OPPR), and the Food and Drug Administration (FDA) to ensure a
    coordinated response to the H5N1 outbreak in cattle. CDC and USDA are
    integrated into the U.S. Government Joint Unified Coordination Group
    Response Structure. CDC has liaisons from USDA, ASPR, and FDA
    integrated into CDC's incident command structure, and CDC communicates
    on an ad-hoc basis to share technical information across relevant
    agencies.
        CDC is committed to protecting the health and safety of people who
    may have a greater risk of exposure to H5N1 through contact with
    infected animals or environments contaminated by infected animals.
        Moreover, CDC continues to work closely with state health
    departments in states with infected dairy cattle. State health
    departments are working with their local health departments and other
    community partners to support monitoring for symptoms of H5N1 and
    testing workers based on CDC guidance.
        FDA has been working with deliberate speed on a wide range of
    studies looking at milk along all stages of production--on the farm,
    during processing, and on retail shelves--using well-established
    methodologies used previously to confirm pasteurization effectiveness
    for known pathogens. FDA and other U.S. Federal partners have been hard
    at work quickly setting up these first-of-their-kind studies and we're
    encouraged that initial gold-standard egg inoculation test results show
    that pasteurization is effective in inactivating HPAI virus. The Agency
    is also temporarily expanding its biosecurity and planning approach to
    inspections. We are applying this established biosecurity approach, as
    informed by previous experience with HPAI in egg and poultry
    facilities, to all farms with livestock and/or poultry (cattle, swine,
    chickens, turkeys and other less common species), egg farms, and
    produce farms with livestock.
        FDA has implemented four concrete actions to achieve our goals:
        1. Following our already established guidance that has historically
    been used to control the spread of HPAI.
        2. FDA will contact APHIS and state veterinarians to determine when
    a specific on farm visit by the agency is advisable on farms that have
    reported HPAI cases.
        3. Preannouncing on farm activities.
        4. Rescheduling on farm activities as needed to increase the time
    between investigators' contacts with different farms and decrease any
    risk of transmission between farms, based on a case-by-case review.
    Inspections will continue at premises with suspected HPAI, as
    scheduled, when the public health needs require it.
        Question. How are HHS agencies like CDC and NIH coordinating with
    USDA to monitor if and when H5N1 acquires the capacity to spread human-
    to-human?
        Answer. Because influenza viruses are constantly changing, CDC
    laboratory staff are continually analyzing viruses for genetic changes
    that could suggest H5N1 might spread more easily to people from animals
    or cause serious illness in humans. CDC labs are working to better
    characterize the virus. Our scientists have completed phenotypic
    testing of antiviral susceptibility, and our analyses confirmed that
    the virus was susceptible to commercially available, FDA-approved
    antiviral treatments. Developing Candidate Vaccine Viruses (CVVs) is a
    key early step in the vaccine development pipeline. Having an effective
    CVV in place for vaccine manufacturers can save up to eight weeks if a
    pandemic vaccine is needed.
        CDC is integrated into the US Government Joint Unified Command
    response structure, with CDC Subject Matter Experts co-leading key
    working groups around epidemiology, data and analytics, and
    communications. CDC is also participating in calls with USDA and FDA
    three times a week. Finally, CDC has liaisons from USDA, ASPR and FDA
    who are integrated into CDC's Avian Influenza incident command
    structure, and we're communicating daily on an ad-hoc basis to share
    technical information.
        The National Institute of Allergy and Infectious Diseases (NIAID),
    part of the National Institutes of Health (NIH), is assisting with
    surveillance and virus characterization activities as requested by
    state and Federal partners, including USDA. Ongoing work from the
    NIAID-supported CEIRR (Centers of Excellence for Influenza Research and
    Response) Network includes completing characterization and risk
    assessment studies on virus isolated from milk samples and generating
    reagents for further research and response efforts. Information from
    these studies is being shared with other HHS agencies, as well as USDA.
    The NIAID-supported Bacterial and Viral Bioinformatics Resource Center
    (BV-BRC) is working to enable sharing of H5N1 data in the BV-BRC data
    portal. The BV-BRC is also currently working on deploying a
    phylogenetic tree to assist efforts to assess H5N1 virus spread, using
    the most recent viral isolates available in GenBank, the publicly
    available NIH database of annotated genetic sequences. NIAID-supported
    researchers continue to help enable tracking of pathogen evolution
    through Nextstrain, a collection of open-source tools for real-time
    phylogenetic analysis of viral outbreaks.
        NIAID has led NIH efforts to help develop medical countermeasures
    for emerging infectious diseases. These efforts help to inform
    strategies to address avian and other forms of influenza. NIAID is
    currently supporting multiple avian influenza vaccines, including
    several in early-stage clinical trials, as well as therapeutics and
    diagnostics for use across multiple influenza strains. Through the
    NIAID CEIRR Network, NIAID also has supported multidisciplinary and
    collaborative research investigating the natural history, transmission,
    and pathogenesis of influenza including avian influenza. In addition,
    NIAID supports research on the immunology of influenza infections and
    vaccines, including vaccine adjuvant discovery and influenza immune
    epitope discovery related to H5 influenza viruses. NIAID also supports
    development of therapeutics and diagnostics for use across multiple
    influenza strains. These efforts include NIAID intramural research to
    characterize H5N1 isolates in existing models, including organoid and
    animal models; to develop and test potential H5N1 medical
    countermeasures; and to isolate and characterize human antibodies that
    are broadly cross-protective against different avian influenza
    subtypes. Together, these programs provide a domestic and international
    research infrastructure to support an HHS response in the event of
    human-to-human spread of H5N1.
        Question. If human-to-human transmission of H5N1 occurs, are there
    adequate supplies of vaccines and antiviral medications in the
    Strategic National Stockpile to control the spread of this disease? How
    quickly could those doses be made available?
        Answer. While the risk to humans remains low, the Administration
    for Strategic Preparedness and Response (ASPR) does have a number of
    preparedness programs that HHS could leverage if necessary. As always,
    states can request personal protective equipment (PPE) from the
    Strategic National Stockpile (SNS) if needed, supplementing what is
    already commercially available or available in state-managed
    stockpiles. This PPE is available to protect farm workers and others
    who may come in contact with infected animals and includes face
    shields, face masks, goggles, and gowns. ASPR has reminded states of
    this resource should they need it.
        In addition, ASPR has tens of millions of antivirals in the SNS,
    many of which are also available on the consumer market. The antivirals
    are available to treat anyone who may test positive for the virus, and
    as you heard from the Centers for Disease Control and Prevention (CDC),
    we are not seeing resistance to these antivirals in the current H5N1
    strain.
        And finally, we have two candidate vaccines that are well-matched
    to the circulating strain of H5N1 through ASPR's pre-pandemic influenza
    preparedness program. Hundreds of thousands of vaccine doses could be
    available in the near future. However, the use of the vaccine will
    require review of the available data and determination of the
    appropriate regulatory path by the Food and Drug Administration (FDA).
    Should additional funding be provided, over 100 million doses could be
    manufactured in the coming months. Our flu preparedness program is
    designed to be fast-moving and flexible, and we continue to look for
    ways to innovate. As such, we have requested proposals for an mRNA
    platform for influenza vaccines, which could be integrated into this
    program. We are currently in discussions with companies about these
    proposals and hope to announce more soon.
        Question. If a substantial proportion of the U.S. population needs
    to be immunized against H5N1, what is ASPR's large-scale manufacturing
    capacity for tens of millions of doses of vaccine? How long would it
    take to produce additional doses?
        Answer. ASPR's U.S. National Pre-Pandemic Influenza Vaccine
    Stockpile (NPIVS) program enables response to pre-pandemic influenza
    strains as they evolve. NPIVS works closely with industry partners to
    make and test updated vaccines that match new strains of influenza
    viruses with pandemic potential as they emerge, while at the same time
    supporting manufacturing capacity to allow for large-scale vaccine
    production if needed. Vaccine candidates (CVVs) being developed and
    tested under this preparedness program, in close coordination with
    manufacturers, are expected to match the current strain. When vaccines
    might be available depends on a number of factors, including the strain
    of the influenza virus and whether there is a well-matched CVV. If
    there is limited mutation and the current CVV can be utilized, vaccines
    could start to be available 12-14 weeks after funding is provided.
    However, if significant mutation in the virus is observed and there is
    no longer a well-matched CVV, eight weeks would be required for
    generation of a new CVV that matches a mutated strain, and then 12-14
    weeks after the development of the new CVV, a longer timeline would be
    expected before vaccines could potentially start to be available,
    pending review of all data by the FDA. Efforts to support vaccination
    of a significant proportion of the U.S. population would require
    additional funding. For the CDC Tier 1 population (https://www.cdc.gov/
    flu/pandemic-resources/national-strategy/planning-guidance/pandemic-
    severities-tier-1.html), 60 million doses of adjuvanted vaccine would
    be required (two doses per person).
        ASPR's NPIVS program stores vaccines in building blocks, including
    antigens that match historical and more recent strains of influenza and
    adjuvants that increase the immune response to vaccine antigens,
    allowing the Federal government to maintain flexibility and quickly
    respond to an avian flu outbreak. Initial reserves can rapidly support
    the vaccination of priority population(s) while large-scale
    manufacturing is ramped up. If needed, ASPR would work with
    manufacturers to ramp up production to make additional vaccine doses
    available.
        Question. The Indian Child Welfare Act was firmly upheld by the
    Supreme Court last year and continues to be a vitally important piece
    of keeping tribal families together. Unfortunately, Native children
    continue to be removed from their homes at disproportionate rates. The
    final fiscal year 2024 bill includes $3 million within the
    Administration for Children and Families to provide assistance to
    states in developing strong partnerships with tribes to better serve
    Native children who come into contact with the child welfare system.
        How is HHS helping State and County child welfare agencies carry
    out their responsibilities under the Indian Child Welfare Act?
        Answer. HHS recognizes that effective implementation of the Indian
    Child Welfare Act (ICWA) is critical to honoring Tribal sovereignty and
    ensuring that American Indian/Alaska Native (AI/AN) children can remain
    connected to their families, cultures, and Tribal communities. We are
    committed to working with our Federal partners at the Department of the
    Interior and the Department of Justice to ensure effective
    implementation of ICWA. At HHS, we provide funding to support state and
    Tribal child welfare programs, as well as grants to strengthen the
    capacity of both state and Tribal courts to oversee child welfare
    cases. We also fund Capacity Building Centers for states, courts, and
    Tribes that offer resources, trainings, and other technical assistance
    relating to ICWA.
        The Children's Bureau Capacity Building Collaborative is comprised
    of the Capacity Building Center for States (CBCS), the Capacity
    Building Center for Tribes (CBCT), and the Capacity Building Center for
    Courts (CBCC). Each individual Center, as well as the Collaborative,
    offers technical assistance around tribal-state relationships. Requests
    for technical assistance can come through the State, the Tribe, or the
    Courts, or jointly in some combination of these Centers. These requests
    for technical assistance have included a variety of topics such as
    ICWA, legal/judicial and court issues, the Child and Family Service
    Reviews (CFSRs), title IV-E agreements, and general improvement of
    tribal-state relationships as well as resource and information sharing.
    The Center for Courts helped facilitate the ICWA Partnership Grantee
    Meeting on January 16-17, 2024, to kick off the new round of ICWA
    partnership grantees and teach selected project management techniques,
    including presentations by JBA evaluators. The Center for Courts and
    Children's Bureau facilitated this event and collaborated with the CIP
    Directors/Coordinators and tribes (grantees) in planning this event.
        One key to ensuring effective implementation of ICWA is to promote
    strong partnerships among state child welfare agencies, Tribes, and
    Courts. In fiscal year (FY) 2023, the Children's Bureau funded five
    State-Tribal Partnership grants for projects in Alaska, Minnesota,
    Nebraska, North Dakota, and Oregon. With the support of the additional
    $3 million provided in the FY 2024 Appropriations bill, the Children's
    Bureau in HHS will fund a cluster of grants for State-Tribal
    Partnerships to Implement Best Practices in Indian Child Welfare. These
    grants will support intergovernmental partnership models to improve
    implementation of child welfare best practices that are culturally
    appropriate for AI/AN children to prevent maltreatment and the removal
    from families and communities, and improve safety, permanency, and
    well-being. Recipients will serve as demonstration sites to design and
    implement projects to effectively implement culturally appropriate best
    practices in Indian child welfare, including measuring improvements in
    child welfare practice, Indian child welfare codes, legal and judicial
    processes, case monitoring, case planning, data collection, in-home
    family preservation services, infrastructure, and systems change. The
    Children's Bureau expects to award six grants, with an award ceiling of
    $500,000 per year for 4 years.
        Question. Almost 7 percent of American adults have been impacted by
    Long COVID. Many have struggled to find the support and services they
    need, in part because our understanding of this condition and what
    works for patients remains limited. The final fiscal year 2024 bill
    includes a $3.5 million increase for the Long COVID Care Network at
    AHRQ, which is working with grantees across the country to expand
    access to care, implement new care delivery models, and support
    providers with Long COVID education and management.
        What is HHS doing to ensure that Americans living with long COVID,
    especially those in rural and underserved communities, have access to
    the care and treatment they need?
        Answer.
      --The Agency for Healthcare Research and Quality (AHRQ) is funding
            the AHRQ Long COVID Care Network to expand access to
            comprehensive, coordinated, and person-centered care for people
            with Long COVID, particularly underserved populations that are
            disproportionately impacted by the effects of Long COVID. This
            initiative funds nine multidisciplinary Long COVID clinics
            located in different states across the nation to (1) develop
            and implement new or improved care delivery models, (2) provide
            services to more people with Long COVID, (3) expand services
            offered, (4) strengthen care coordination, (5) implement and
            share best practices for Long COVID management, (6) support the
            primary care community in Long COVID education and management,
            (7) evaluate project success, and (8) disseminate project
            findings. The initiative reaches several underserved and
            vulnerable communities, including rural, inner-city, low-
            income, and minority populations, and children and adolescents
            (both normally developing and those with intellectual and
            developmental disability). In addition to expanded care and
            services delivered through the multidisciplinary Long COVID
            clinics, the initiative will expand access to care through
            primary care education and support activities. Through outreach
            and dissemination activities, the initiative will increase
            knowledge and awareness of Long COVID across clinicians, people
            with Long COVID, and communities nationwide. The $3.5 million
            increase in FY 2024 will enable AHRQ to add three centers to
            its Long COVID Care Network.
      --The Indian Health Service (IHS) is working with healthcare
            providers to support Long COVID care for American Indian and
            Alaska Native communities by using telehealth and providing
            technical assistance to tribes. The IHS expanded telehealth by
            using technology and providing specialists as resources for
            primary care clinicians in rural and underserved American
            Indian and Alaska Native populations. Training and support on
            using the technology and resources are provided to help treat
            patients with complex conditions, including Long COVID, in
            their communities.
      --The Health Resources and Services Administration (HRSA) is working
            with community health centers across the country to improve
            Long COVID care for underserved communities, using telehealth
            and technical assistance. The Telehealth Technology-Enabled
            Learning Program connects specialists at academic medical
            centers with primary care clinicians in rural, frontier, and
            underserved populations, providing evidence-based training and
            support to help them treat patients with complex conditions in
            their communities, including Long COVID.
      --The Centers for Disease Control and Prevention (CDC) maintains an
            Information for Healthcare Providers webpage on Long COVID. CDC
            is working with the American Academy of Physical Medicine and
            Rehabilitation to improve coordination and dissemination of
            clinical knowledge of recovery and symptom management of Long
            COVID. CDC also supports continuous learning through Clinician
            Outreach and Communication Activity (COCA) webinars on Long
            COVID and in partnership with Project ECHO.
      --The Office of Long COVID Research and Practice of the Office of the
            Assistant Secretary for Health (OASH) works across HHS
            Operating and Staff Divisions, interagency Federal partners,
            and external groups to share resources, identify gaps, and work
            to identify solutions to the longer-term impacts of COVID-19
            including Long COVID and associated conditions. OASH is in
            discussions with primary care professional associations and
            other government agencies about how to better support primary
            care clinicians to work with people with Long COVID, including
            those in rural and underserved communities. Being able to
            receive Long COVID diagnosis and care at the primary care level
            will greatly expand access, as many people do not live near
            Long COVID clinics.
        CDC has partnered with the Family Health Centers of San Diego,
    several academic institutions, and Project Extension for Community
    Healthcare Outcomes (ECHO) to improve care for people with Long COVID,
    myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and post-
    infectious fatiguing illnesses. The CDC-funded program, known as the
    ``Long COVID and Fatiguing Illness Recovery Program'', works to develop
    confidence in managing these conditions among primary care providers,
    including those in federally qualified health centers, and share
    promising practices via interactive tele-mentoring sessions and monthly
    webinars. Finally, CDC maintains an Information for Healthcare
    Providers webpage on Long COVID as well as a webpage for Patient Tips.
        Question. Over 100,000 Americans are on the organ transplant
    waitlist. For years, the organ transplant system has been plagued by
    inefficiencies and mismanagement, but Congress and the Biden
    Administration have been working to make important improvements. The
    final fiscal year 2024 bill includes a $23 million increase to
    strengthen and modernize the Organ Procurement and Transplantation
    Network because patients and families deserve to be part of a high
    functioning system.
        What does HRSA hope to accomplish this year in working to modernize
    the organ transplantation system and how will this additional funding
    be used?
        Answer. The additional $23 million provided to HRSA in FY 2024
    allows HRSA to further the goals of improved transparency, performance,
    governance and efficiency of the US transplant system. Specifically,
    HRSA is on pace to establish a new and independent Board of the OPTN,
    including the review and support of changes to the OPTN governance
    structure and by-laws to ensure transparency and accountability. HRSA
    is working to support multiple vendors to improve and strengthen the
    OPTN operations including technology. Our new contract solicitations
    for multiple vendors will be awarded by the end of the fiscal year.
    HRSA has also established a project management function to support
    multi-vendor and multi-stakeholder collaboration, is launching the
    development phase for a modernized organ matching IT system, and is
    bolstering HRSA's oversight and technology staffing to support the OPTN
    modernization.
        Question. The President's Fiscal Year 2025 budget includes an
    increase of over $100 million for the Title X Family Planning Program,
    which provides services for over 2.6 million people. In a post-Roe
    America, where women do not have the freedom to get the care that they
    need, and judges and politicians have been inserted into doctor's
    offices, the Title X Family Planning Program is more important than
    ever.
        What are the consequences of keeping Title X level-funded for
    another year, and what is HHS doing to ensure that the program provides
    the highest standard of care in this environment?
        Answer. The HHS Office of Population Affairs (OPA) will continue
    its commitment to providing, through the Title X family planning
    program, a broad range of services related to achieving pregnancy,
    preventing pregnancy, assisting clients with achieving their desired
    number and spacing of children, as well as its focus on increasing
    access to and quality of comprehensive family planning and related
    preventive healthcare services, especially in areas with low and
    limited access.
        OPA allocates 90 percent of its overall funding for direct clinical
    services, including the Title X family planning services grants. In a
    level funding environment, OPA will continue to provide access to Title
    X across the country to as many clients as possible, but it will be
    difficult to expand access beyond those currently served.
        Title X grantees provide quality, client-centered family planning
    services that are consistent with the OPA and Centers for Disease
    Control and Prevention (CDC) national Quality Family Planning (QFP)
    recommendations and other relevant nationally recognized standards of
    care. For the Title X program, quality healthcare is defined as care
    that is safe, effective, client-centered, timely, efficient, and
    equitable. Client-centered care is defined as care that is respectful
    of, and responsive to, individual client preferences, needs, and values
    and where client values guide all clinical decisions.
                                     ______

                 Questions Submitted by Senator Jeanne Shaheen
        Question. The Notice of Proposed Rulemaking (NPRM) entitled
    ``Supporting the Head Start Workforce and Consistent Quality
    Programming,'' published by the Office of Head Start on November 20,
    2023, is designed to increase the pay levels for Head Start teachers
    and staff. While the NPRM indicates that the cost to implement the
    proposed rule would be approximately $1.6 billion annually from 2024-
    2033, the President's Budget Recommendation for FY25 includes only a
    $543.7 million increase for Head Start.
        With this funding amount, how would the Department intend to
    implement the proposed rule without reducing available slots for
    students?
        Answer. The Administration for Children and Families is considering
    and reviewing public comments of the proposed rule. The Office of Head
    Start (OHS) expects that most of the costs associated with the rule,
    when fully phased in after 7 years, will be covered within the existing
    funding allocation for Head Start, assuming that a full cost-of-living
    adjustment (COLA) investment is provided each year and programs right-
    size their funded enrollment to match actual enrollment levels. Based
    on these two actions, we want to clarify that the cost of the proposed
    rule is not $1.6 billion annually. In recent years, Head Start programs
    have experienced a significant nationwide staffing shortage. This
    shortage facilitated persistent under-enrollment where the number of
    children actually served is far less than the number of children they
    are funded to serve, leaving a large number of slots unfilled.
    Increasing wages for Head Start staff is needed to stabilize the
    workforce and ensure the Head Start program can continue to fulfill its
    mission to promote strong outcomes for children and families. As Head
    Start programs work to improve their actual enrollment levels, many are
    also requesting reductions in their funded enrollment. Head Start
    programs are trying to right-size their funded enrollment to match
    their community needs, staffing realities, and fiscal constraints. OHS
    is also concerned about quality in Head Start, including child safety
    incidents and the ability to recruit and retain staff who meet the
    teacher qualification requirements in the Head Start Act and can
    support enriching interactions and early learning experiences.
        We estimate that many programs can approach full implementation of
    the policies when phased in by 2031 without additional appropriations
    (beyond COLA increases to account for inflation) by reducing their
    funded enrollment levels to align with their actual enrollment. Those
    programs would then have the ability to reinvest the resources
    associated with the reduced slots within their existing budgets to
    increase wages and compensation for staff. Based on NPRM estimates,
    reducing funded enrollment would result in about 1% fewer funded slots
    than FY 23 actual enrollment. Thus, if Head Start receives no
    additional funding from Congress beyond a full COLA each year--as
    represented by the $543.7 million included in the President's Budget
    for FY 25--a 1% reduction in currently filled slots would be needed to
    reach full implementation of the policies in the proposed rule by 2031.
    It is also important to note that these projections are based on
    standard COLA rates; the actual amount of COLA needed per year is
    subject to change based on updated measures of inflation.
        Question. Community Health Centers (CHCs) are an essential part of
    the healthcare safety net in New Hampshire. The Medicaid unwinding is
    causing some CHCs to have large numbers of patients shift from Medicaid
    to uninsured; for instance, one CHC has seen a 27 percent increase in
    uninsured patients since spring 2023. With additional funding, health
    centers could continue to provide the public health and comprehensive
    primary care services, including mental and behavioral healthcare,
    while also reducing healthcare costs.
        With this in mind, could HRSA please detail any plans to increase
    base allocations for Community Health Centers?
        Answer. We share your commitment to the work of HRSA-supported
    health centers. The President's FY 2025 Budget proposes to invest $700
    million to expand access to comprehensive services in health centers,
    $200 million to expand patient support and enabling services, $100
    million to support health centers to recruit, retain, and ``grow their
    own'' workforce, $50 million to expand health center access to high
    quality, patient-centered maternal health services, and $50 million to
    expand access to street medicine services, increasing street outreach
    and patient support services. We look forward to working with Congress
    to secure multi-year, sustainable funding for health centers.
        Question. Ensuring that Medicare beneficiaries are able to obtain
    accurate and timely diagnoses is critical to improved outcomes and
    quality of life for seniors. From a Medicare spending perspective,
    accurate and timely diagnoses are also essential to avoiding more
    expensive courses of treatment that result from delayed diagnoses and
    repeat scans. To that end, the Department of Health and Human Services
    (HHS) should ensure that Medicare's payment system for hospital
    outpatient services does not create disincentives for hospitals to use
    cutting-edge diagnostic radiopharmaceuticals, such as those used in PET
    scans, to detect diseases in early stages, including in particular
    prostate cancers and other cancers that have a disproportionate impact
    of people of color. Last year, the Centers for Medicare and Medicaid
    Services (CMS) sought information from stakeholders on Medicare payment
    approaches that could avoid payment disincentives for these innovative
    diagnostic radiopharmaceuticals. One such approach, as envisioned in
    the Facilitating Innovative Nuclear Diagnostics (FIND) Act is to retain
    separate payment for innovative diagnostic radiopharmaceuticals rather
    than packaging the payment into the payment for the imaging scan.
        Will the administration commit to working with me and my office to
    help ensure that Medicare payments provide the appropriate incentive
    for hospitals to utilize innovative diagnostic radiopharmaceuticals for
    imaging scans?
        Answer. Under the OPPS, CMS packages several categories of non-
    pass-through drugs, biologicals, and radiopharmaceuticals, regardless
    of the cost of the products. In particular, under Sec. 419.2(b)(15),
    payment for drugs, biologicals, and radiopharmaceuticals that function
    as supplies when used in a diagnostic test or procedure is packaged
    with the payment for the related procedure or service. Diagnostic
    radiopharmaceuticals, which include contrast agents, stress agents, and
    other products, are one specific type of product that is policy
    packaged.
        In the Calendar Year 2024 OPPS/ASC proposed rule, CMS solicited
    comment on a number of potential new approaches to payment for
    diagnostic radiopharmaceuticals that would enhance beneficiary access,
    while also maintaining the principles of the outpatient prospective
    payment system. Overall, commenters described clinical scenarios in
    which they believed CMS' payment policies created the most significant
    access issues, and accordingly, commenters urged CMS to reform payment
    policy for diagnostic radiopharmaceuticals to address these concerns.
    However, there was not a general consensus among commenters as to the
    most effective way for CMS to reform its OPPS diagnostic
    radiopharmaceutical payment policy.
        CMS agrees this is a complex and important issue and, given the
    wide array of information presented through the public comment process,
    we intend to further consider these points and take them into
    consideration for future notice and comment rulemaking. CMS welcomes
    ongoing dialogue and engagement from stakeholders regarding suggestions
    for potential future payment changes. We are happy to work with you on
    this issue moving forward.
        Question. The COVID-19 pandemic catalyzed significant advances in
    using wastewater to monitor a range of infectious diseases in
    communities across America. With insights learned throughout the
    pandemic, Congress can assist in building a national wastewater
    surveillance system with the capability, flexibility and Federal
    funding necessary to track multiple existing infectious diseases
    simultaneously, quickly detect new threats, and share that information
    with our communities.
        As you know, the COVID funding that has supported wastewater
    surveillance at the Centers for Disease Control and Prevention (CDC)
    lapses at the end of 2025.
        What steps is the administration taking this year to further
    strengthen our wastewater surveillance system at the CDC?
        What is the total amount of annual sustained funding that the CDC
    believes is necessary to accomplish our goals once the COVID funding
    that has supported this program has lapsed?
        Answer. From 2020-2024, CDC has invested more than $500 million in
    supplemental funding to build a robust and nimble wastewater monitoring
    system for infectious disease threats such as COVID-19, mpox, and
    influenza.
        With this support, CDC has carried out the following:
      --Established a national program of over 1,500 sampling sites,
            capturing wastewater data that represents approximately 150
            million Americans in all 50 states.
      --Established four Centers of Excellence advancing wastewater
            surveillance across the United States through partnerships
            between public health departments and academic institutions in
            the City of Houston, California, Colorado, and Wisconsin.
      --Supported wastewater testing at community sites nationwide through
            a national testing contract, and wastewater surveillance
            initiatives among tribes through both a cooperative agreement
            and contractual mechanisms.
      --Launched an updated wastewater surveillance data dashboard, with
            new visualizations of COVID-19, along with materials that make
            it easier to see national trends and for communities to take
            action.
      --Encouraged collaborative learning and peer-to-peer sharing through
            the NWSS Communities of Practice across utilities, public
            health departments, and laboratories.
      --Leveraged the wastewater surveillance program to better understand
            and implement public health response to emerging pathogens such
            as influenza A.
      --Established a CDC leadership group to guide decisions around
            prioritization of wastewater surveillance targets based on
            evolving science and to adapt to any rapidly emerging public
            health priorities.
      --Built and supported wastewater testing efforts in state, tribal,
            local, and territorial (STLT) public health agencies, Centers
            of Excellence, and commercial wastewater testing.
        The FY 2025 President's Budget request includes $20 million to
    support wastewater monitoring at CDC in the Emerging Infectious
    Diseases budget line, which provides nimble, disease agnostic funding
    for cross-cutting infectious disease needs. If funded, this would
    provide the first sustained funding for wastewater activities at CDC.
        The President's Budget request of $20 million would help ensure CDC
    can retain a smaller- scale, response-ready wastewater surveillance
    capability in the future in a limited, scalable capacity. This base
    investment would preserve some of the wastewater surveillance capacity
    that CDC has built, but CDC would not be able to retain a fully
    national wastewater program. Funding would likely support a small
    number of states to continue to conduct wastewater testing, and CDC is
    examining how best to retain response-ready capability--for example,
    focusing on states/sites that can be expanded for response needs, and
    balancing coverage for high-risk, major metropolitan, and rural areas
    and areas of high social vulnerability.
        The budget also includes $20 billion in mandatory funding,
    available over 5 years, of which $6.1 billion would be allocated to CDC
    to modernize detection infrastructure, improving early warning systems
    like wastewater surveillance and strengthening our nation's public
    health laboratory system.
                                     ______

                  Questions Submitted by Senator Brian Schatz
        Question. I am concerned we are facing a telehealth cliff in 2024.
    My bill, the CONNECT for Health Act, cosponsored by 63 of my bipartisan
    Senate colleagues, would ensure permanent expansion of Medicare
    telehealth coverage.
        Do you support permanently removing geographic site requirements
    and providing the home and other settings as originating sites for
    Medicare telehealth services?
        Do you commit to working with Congress and CBO to provide the
    timely technical assistance needed to support our legislative work this
    year?
        What are the risks to the healthcare system if Congress fails to
    extend Medicare telehealth coverage by the December 31, 2024 deadline?
        What are the risks to the healthcare system if Congress provides a
    short-term extension that will have to be reauthorized in subsequent
    years?
        How does a short-term extension of telehealth policy impact CMS's
    annual rulemakings in the Medicare Physician Fee Schedule?
        Will CMS be able to create a regulatory pathway to allow for
    immediate and seamless updates to policy when and if the law is updated
    at the end of 2024?
        Audio-only services. There are a variety of high-value, low-tech
    telehealth modalities that benefit patients' access to care, including
    audio-only services. CMS could modify the definition of ``interactive
    telecommunications systems'' in regulations and program instruction to
    ensure that providers can utilize all appropriate means and types of
    technologies to furnish telehealth services. However, CMS stated in the
    CY23 and CY24 Physician Fee Schedule (PFS) Final Rule that its
    regulatory interpretation of ``telecommunications system'' generally
    precludes audio-only services except under certain circumstances.
          What clinical guidelines and peer-reviewed evidence is CMS using
            to draw the distinction outlined in the PFS to determine when
            to cover and exclude care modalities from the Medicare
            telehealth services list?
          Since CMS has already determined that it can update its
            definition of ``interactive telecommunications systems'' in
            certain circumstances, what, if any, additional statutory
            authorities does CMS need to ensure continued coverage?
        Protecting provider privacy. The architects of Medicare systems
    never envisioned that a provider would be practicing from their home.
    However, today it is commonplace and used as a strategy to reduce
    provider burnout. I am concerned that when providers furnish care from
    their homes, CMS could require that they publicly report their home
    address as the practice location, which is why I appreciate you
    extending pandemic flexibilities in the CY 2024 Physician Fee Schedule.
          Do you commit to finding an alternative solution for providers,
            ensuring safety, privacy, and minimizing additional
            administrative burdens that might hamper telehealth access?
        Answer. HHS and CMS continually consider how to best ensure access
    to medically necessary items and services and makes changes where
    appropriate and permissible under our statutory authority. We recognize
    the vital role that telehealth can play in the delivery of care,
    particularly among populations that are underserved. We implemented
    Section 4113 of the Consolidated Appropriations Act, 2023, which
    extended many telehealth flexibilities adopted during the public health
    emergency for COVID-19 through December 31, 2024. Additionally, through
    notice- and-comment rulemaking, the CMS solicited public comment and
    implemented regulatory changes that have permanently expanded certain
    telehealth policies that are within the agency's authority to modify.
    Some changes to Medicare telehealth policy would require legislative
    action to amend the statute, and we look forward to our continued work
    with Congress on this crucial issue.
        With respect to audio-only services, historically, CMS has not
    proposed any permanent modifications to the definition of ``interactive
    telecommunications system'' to allow for use of audio-only
    communications technology due to our interpretation of the statutory
    requirements, as well as concerns over program integrity and quality of
    care. In the CY 2022 Medicare Physician Fee Schedule (PFS) final rule,
    CMS noted that we believed it was reasonable to reassess these
    concerns, given the widespread utilization during the Public Health
    Emergency (PHE) for COVID-19 of Medicare telehealth services furnished
    using audio-only communications technology. Based upon an initial
    review of claims data collected during the PHE for COVID-19, which
    describe audio-only telephone E/M services, we observed that the audio-
    only E/M visits were some of the most commonly performed telehealth
    services during the PHE, and that most of the beneficiaries receiving
    these services were receiving them for treatment of a mental health
    condition. We also believed that mental health services are different
    from most other services on the Medicare telehealth services list in
    that many of the services primarily involve verbal conversation where
    visualization between the patient and furnishing physician or
    practitioner may be less critical to provision of the service.
        Given these considerations, we believed that it was be appropriate
    to revisit our regulatory definition of ``interactive
    telecommunications system'' beyond the circumstances of the PHE to
    allow for the inclusion of audio-only services under certain
    circumstances. Therefore, we finalized amendments to our regulation at
    42 CFR 410.78(a)(3) to define interactive telecommunications system to
    include audio-only communications technology when used for telehealth
    services for the diagnosis, evaluation, or treatment of mental health
    disorders furnished to established patients when the originating site
    is the patient's home.
        CMS recognizes that telehealth plays a growing role in supporting
    beneficiary access to the care they need. Additionally, CMS
    acknowledges concerns about privacy and safety related to provider's
    home addresses being shared. In the Calendar Year (CY) 2024 Medicare
    Physician Fee Schedule (PFS) final rule, CMS finalized a policy to
    continue to permit the distant site practitioner to use their currently
    enrolled practice location instead of their home address when providing
    telehealth services from their home until the end of 2024. In that
    final rule, we also requested further information from interested
    parties to better understand the scope of considerations involved with
    including a practitioner's home address as an enrolled practice
    location when that address is the distant site location where they
    furnish Medicare telehealth services. The requested information will
    inform future enrollment and payment policy development as we consider
    this issue further for future rulemaking.
        Question. Eight months on from the devastating fires on Maui, the
    needs remain enormous. Thousands of people are still living out of
    hotels and vacation rentals. Congress needs to step up and help. In its
    FY24 domestic supplemental appropriations request, HHS requested over
    $400 million to support the health and social services needs for the
    people of Maui.
        What services are survivors missing out on if Congress fails to
    deliver supplemental funding?
        Answer. Failure to enact supplemental funding would result in
    delays or gaps in service delivery to families during a critical period
    of their post-disaster recovery. These services provide an essential
    lifeline--bridging the gap in survivor needs by providing human
    services that traditional disaster programs cannot fulfill. Human and
    social services includes programs with a focus on harm reduction for
    vulnerable persons and communities (e.g., families involved in the
    child welfare system, domestic and intimate partner violence survivors,
    individuals who have experienced or are at risk of human trafficking,
    tribal nations, recent immigrants, older adults, and individuals with
    disabilities or behavioral support needs); continuity and coordination
    of essential services (e.g., child care, crisis sheltering, nutrition
    assistance, financial, energy, and water assistance); and providing
    psychosocial case management and trauma-informed approaches for
    coordinated human and social service delivery.
        Without these funds, disaster survivors would not receive
    coordinated, holistic, and responsive services consistent with the
    standards and processes of traditional human service programs. This
    would result in disjointed delivery of already constrained disaster
    services; missed opportunities to provide targeted resources for
    particularly vulnerable populations; and further delay the
    stabilization and recovery of disaster survivors.
        The Hawai'i Department of Human Services (HDHS) has indicated on
    multiple occasions a streamlined approach to supplemental disaster
    human service funding is needed, as it would afford them flexibility
    to: respond over time to evolving and emerging human service needs for
    disaster survivors; assist HDHS in providing timely and responsive
    services through sub-grant awards to community based organizations;
    enable them to provide direct services to persons whose living
    conditions and circumstances were fundamentally and substantively
    changed by the wildfire; ensure the ongoing provision of culturally and
    linguistically appropriate human services; and enhance their
    administrative capabilities for state level emergency program
    management and crisis grant execution. Additional supplemental funding
    would also enable the coordinated delivery of ongoing case management
    services, beyond the immediate period of traditional disaster programs.
        ACF's Office of Human Services Emergency Preparedness and Response
    (OHSEPR) has requested to authorize and provide $150 million for a
    Human Services Emergency Fund and $12 million for disaster human
    services case management. ACF's Office of Head Start (OHS) has
    requested an additional $19 million to support critical Head Start
    program infrastructure and services in Lahaina. If Maui does not
    receive supplemental funding, disaster survivors may be denied services
    and supports including:
      --comprehensive and holistic case management support for Hawaii for
            service coordination and support of survivors.
      --historical and cultural preservation (including the provision of
            training, education, and language preservation).
      --Family Violence and Prevention Services for additional, direct
            outreach and to augment the Strong Hearts and domestic violence
            hotlines to respond to any spikes in call volume.
      --funding for Community Action Agencies to provide community-based
            supports.
      --funding for construction or major renovation of destroyed or
            damaged child care facilities, services for additional families
            to receive child care subsidies to continue activities and
            efforts to rebuild their lives, start-up grants to incentivize
            new child care providers to address the gap in available
            services, and mental health services for children and their
            caregivers that experienced trauma because of the fires.
      --funding for the reconstruction of two Head Start facilities,
            repairs to several other centers, replacement of necessary
            furnishings and equipment, and support for interim providers to
            ensure continuity of services for children and families during
            rebuilding.
        This would also limit the capacity and ability of organizations to
    provide services to survivors as they would lack:
      --support for staff wellbeing and mitigating workforce trauma and
            compassion fatigue to provide additional culturally appropriate
            mental health services.
      --funding for emergency and incentive hiring for state human services
            officials that can be surged into Lahaina.
      --ongoing training and technical assistance, research, and evaluation
            to inform and enhance service delivery.
      --ongoing strategic planning and needs assessments over time, to
            project and adjust to emerging needs or develop solutions to
            address recurrent issues.
        If additional funding was provided via annual or supplemental
    funding for the Maui wildfires, ASPR would use the funding to replace
    and preposition medical caches, improve infrastructure and information
    technology for response and recovery activities, and support the
    Medical Reserve Corps.
        Specific to the medical caches, the Hawaii wildfire response
    activated ASPR's NDMS Disaster Mortuary Operations Response Team
    (DMORT) and Victim Identification Team, the only civilian mortuary
    response capability in the U.S. Government. This unique asset, however,
    has lacked sustained funding to keep critical staff and capabilities
    up-to-date. Therefore, they have urgent funding needs in order to
    modernize aging Disaster Portable Mortuary Unit (DPMU) equipment and
    supporting IT systems.
        The Maui wildfires severely disrupted the aging and disability
    networks' ability to provide vital services and programs to older
    adults, people with disabilities, and their family caregivers. At the
    same time, the aging and disability networks have and continue to face
    increased demand for their services, including nutrition services,
    personal care assistance, legal advocacy, transportation, assistance
    with identifying accessible housing, and more. Without supplemental
    funding for these services, older adults and people with disabilities
    will be unable to live independently in their own communities. For
    example, without assistance to find accessible housing and replace
    assistive technology and other support devices, people with
    disabilities and older adults are at risk of institutional placement
    and those institutions may be far from their community-based support
    network that includes direct care professionals, family, and friends,
    leading to more trauma.
        The Administration for Community Living has no authorities that
    allow for supplemental disaster funding to the disability networks with
    annual appropriations. A small amount ($1.1M) of funding under the
    Older Americans Act authorities was provided to the aging network last
    fall that was grossly insufficient for the scope of the disaster in
    Hawaii. As a result, programs redirected funds intended for other
    activities to address the immediate need, impacting their ability to
    provide ongoing services.
        In addition to the ongoing service needs, the infrastructure to
    provide services was lost or damaged. The area's senior center,
    nutrition sites, and an adult day center were destroyed, making service
    delivery even more challenging. The disability networks lost an
    accessible building and its contents (furniture, IT, etc.) plus an
    accessible van. The assistive technology (AT) program's inventory was
    destroyed and significantly damaged, greatly impacting the program's
    ability to loan equipment to support people with disabilities of all
    ages and their families while their AT is being replaced or fixed. Many
    individuals with intellectual and developmental disabilities face
    difficulty comprehending, processing, and coping with the disaster.
    Assistive technology and other support devices are critical to their
    health, safety, and well-being. The equipment can be costly and may not
    be covered by insurance. Without supplemental funding for services,
    supports, and the networks' infrastructure, older adults, people with
    disabilities, and their families are struggling, and the health, well-
    being, and independence of these populations are in jeopardy.
        CDC/ATSDR would support local residents by enabling 1) adequate
    public health surveillance, (2) poison center accessibility, (3)
    geospatial environmental sampling and contamination tracking, (4)
    health equity assessments, (5) community-targeted health education
    outreach, and (6) community clinical needs assessments with resultant
    clinician education aligned to the identified needs.
        Question. Maui residents have experienced so much loss, trauma, and
    grief, and addressing the mental health toll is just as important as
    dealing with the physical damage. Your domestic supplemental request
    included $144 million for behavioral health. Can you please describe
    the services included in this request?
        Answer. SAMHSA funding would be used to:
      --support grants for the 19 K-12 schools on Maui to provide trauma
            informed supports and services to children and staff.
      --support grant programs to support to preschool age children and
            support parenting training and supports for talking with
            children about stress and trauma.
      --examine the distinctive needs of underserved populations, including
            each racial and ethnic minority community, especially Hispanic/
            Latino, Asian, Native Hawaiian, and Pacific Islander
            populations.
      --focus on training and education services for peers, first
            responders, and other key community sectors, on recognition of
            the signs and symptoms of mental and substance use disorders in
            adults. support individuals in Maui with possible alcohol use
            disorder or drug use disorder; provide enhanced screening,
            brief intervention, and referral to treatment as needed.
            enhance and expand comprehensive treatment, early intervention,
            and recovery support services for adolescents (ages 12-18) and
            transitional aged youth (ages 16-25) with substance use
            disorders (SUD) and/or co-occurring substance use and mental
            disorders (COD), and their families/primary caregivers.
      --develop a low-threshold model within the harm reduction continuum
            to provide portable substance use disorder services.
      --provide training and TA in culturally-valued practices that can be
            integrated to address the immediate need for interpreters for
            the monolingual, non-English speaking communities in Maui (e.g.
            Native Hawaiian, Spanish-speaking, Filipino, Tongan, and other
            Pacific Islander communities) and to provide additional staff/
            project manager support.
        Question. The Hawaii Department of Health found elevated levels of
    toxins in Lahaina wildfire ash, including more than twelve times the
    action level of arsenic and elevated levels of antimony, cobalt,
    copper, and lead. If supplemental funding were appropriated, how could
    the National Center for Environmental Health support local public
    health officials?
        Answer. Supplemental funding to CDC/ATSDR for the Hawaii Wildfire
    Recovery would support access to timely and appropriate healthcare to
    local residents by enabling (1) adequate public health surveillance,
    (2) poison center accessibility, (3) geospatial environmental sampling
    and contamination tracking, (4) health equity assessments, (5)
    community-targeted health education outreach, and (6) community
    clinical needs assessments with resultant clinician education aligned.
        Question. Multiple healthcare, aging and disability network
    providers, Head Start, and child care facilities were destroyed in
    Lahaina. How does HHS's domestic supplemental request help to alleviate
    the strains on families and fill gaps in healthcare and social services
    left by the fires?
        Answer. The proposed supplemental language would provide human
    services and social services to the most vulnerable survivors of the
    August 2023 wildfires. To provide this assistance, the Department has
    requested Congress provide $150 million for the ACF to provide grants
    and other assistance to the Hawai'i Department of Human Services
    through a single funding stream. To provide Hawai'i with maximum
    flexibility in responding to needs, the Department recommends that
    Congress authorize a fund known as the ``Human Services Emergency
    Fund'' (Fund). An additional $12 million is requested for case
    management support to Hawaii for ongoing service coordination and
    support of survivors of the wildfires.
          The Fund would allow ACF to fulfill the request from the Hawai'i
            Department of Human Services to streamline the manner in which
            ACF provides supplemental funds. Typically, supplemental funds
            are distributed through each of ACF's program offices with
            separate requirements for eligibility, timing, delivery, and
            reporting. These varying requirements create unnecessary
            administrative burden and costs on states in need.
          To reduce the administrative burden, Hawai'i requested ACF
            provide supplemental funds through a single funding stream. The
            request from Hawai'i is based on lessons learned from the
            administrative burden Hawai'i encountered in administering
            COVID funds from many different streams. The reduced
            administrative burden would allow Hawai'i to direct the money
            in a more efficient and timely manner to local agencies and
            community service agencies in Maui. This would result in
            survivors and their families receiving services expediently.
          In addition, the single funding stream would allow Hawai'i to
            meet not only the immediate needs of survivors, but also allow
            local agencies and community service organizations to meet the
            needs of survivors that evolve as they recover from the
            wildfire. These funds are essential for meeting the evolving
            needs of the most vulnerable survivors, who require
            interventions long after the majority of the population has
            resumed their normal activities. The Fund would enable local
            agencies to provide the necessary services to these vulnerable
            populations.
        The request for $12 million to support case management would be to
    deploy an existing ACF/OHSEPR contractor currently funded in ``warm
    status'' to coordinate access to the direct services to significantly
    augment the state capabilities. This need was identified by the state
    of Hawai'i as a critical requirement to provide this support to augment
    the limited human services case management they currently have and
    enable Hawai'i's human services department to stabilize. The contract
    vehicle that DHSCM would allow these services to be provided within
    weeks after funding is received.
        These activities may include: conducting disaster survivor outreach
    and assessments; delivering case management services to disaster
    survivors including direct linkage to community-based supports;
    analyzing ongoing data to identify trends on current, emerging, and
    unmet community needs to the State of Hawai'i requiring additional
    resourcing; and providing technical assistance to the state to enable
    their successful implementation of disaster case management operations
    and transition as needed to steady-state or ongoing case management
    delivery.
        Question. Without supplemental funding for ASPR, what medical
    caches will be available in Hawaii and the Pacific territories in a
    future emergency?
        Answer. At current funding levels appropriated for FY 2024, ASPR
    will continue to support two Disaster Medical Assistance Team (DMAT)
    caches currently positioned in Hawaii. For background, a DMAT cache is
    a scalable field medical resource that can support up to a 38-person
    DMAT medical team. A DMAT cache is comprised of medical equipment and
    supplies, large tents, generators, military rations, water, and other
    support materiel necessary to support the DMAT medical team in a field
    base of operations for up to 72 hours before requiring resupply. The
    footprint of the DMAT cache is approximately 60 pallets and is
    transportable on two commercial refrigerated trucks, one 53-foot
    tractor-trailer, and one flatbed tractor-trailer to haul a forklift.
        With supplemental funding, ASPR would replace and preposition
    medical caches, improve infrastructure and information technology for
    response and recovery activities, and support the Medical Reserve
    Corps.
        Question. What are the Disaster Mortuary Operational Resource
    team's lessons learned from the Maui fires response? What priority
    funding would ensure the team is able to respond to a future event in
    which there are more fatalities than local resources can manage?
        Answer. The Hawaii wildfire response activated ASPR's NDMS Disaster
    Mortuary Operations Response Team (DMORT) and Victim Identification
    Team, the only civilian mortuary response capability in the U.S.
    Government. This unique asset, however, has lacked sustained funding to
    keep critical staff and capabilities up-to-date. Therefore, they have
    urgent funding needs in order to modernize aging Disaster Portable
    Mortuary Unit (DPMU) equipment and IT systems, expand the NDMS
    intermittent workforce with experienced mortuary and victim
    identification expertise, increase readiness of the existing workforce,
    and improve communications gear. As noted in an earlier response,
    supplemental funding would enhance this capability.
        Specifically related to after-action review, Congress should be
    aware that HHS utilizes an after-action process to identify areas for
    corrective action and ensure future response operations account for
    gaps and challenges. Specific to the response in Maui, ASPR noted there
    was inadequate communications devices for monitoring information flow
    and performing essential duties in an austere outside the continental
    United States (OCONUS) environment. Cellular communication is a known
    issue in OCONUS states and territories in Region IX. The wildfires
    caused significant damage to communication infrastructure in Maui,
    which further exacerbated difficulties in obtaining reliable telephone
    and Internet connectivity. Personnel, such as Incident Management Team
    members as well as agency representatives and liaisons, were eventually
    able to obtain more reliable connectivity after being provided access
    to Starlink via the Federal Emergency Management Agency (FEMA).
        Question. The Hawaii congressional delegation secured $4 million in
    new funding to launch a Native Hawaiian and Pacific Islander Health
    Research Office at the National Institutes of Minority Health and
    Health Disparities.
        When does NIMHD plan to launch this new office?
        What will be the focus and mission of this new office?
        How does NIMHD plan to work with NHPI communities to prioritize
    research topics?
        How will this new office help to support the development of future
    biomedical researchers from NHPI communities?
        Answer. The launch of the NIH Native Hawaiian and Pacific Islander
    Health Research Office at the National Institute on Minority Health and
    Health Disparities (NIHMD) is currently underway and will officially
    launch by September 2024. The focus and mission of the Native Hawaiian
    and Pacific Islander Health Research Office is to advance NIH efforts
    in supporting research, training, community engagement, and academic-
    community partnerships to promote and improve health in Native Hawaiian
    and Pacific Islander (NHPI) communities in the U.S. and its
    territories. The NHPI Health Research Office will engage NHPI
    communities to prioritize research topics by conducting listening
    sessions with NHPI community leaders and workshops with investigators
    with experience in NHPI research. The NHPI Health Research Office will
    coordinate with established research initiatives such as the NIH
    Community Engagement Alliance, the Research Centers in Minority
    Institutions program, and other research projects focused on NHPI
    populations. Moreover, the NHPI Health Research Office will support
    efforts promoting career development-related outreach that fosters
    greater participation of NHPI individuals in NIH educational and
    training programs that target researchers who are in various stages of
    their careers.
        NIMHD looks forward to providing updates on the activities led by
    the NHPI Health Research Office that will strengthen NIH-supported
    research on improving the health and well-being of NHPI communities.
        Question. My bipartisan STOP Pain Act was enacted as part of the
    Comprehensive Addiction and Recovery Act (CARA) of 2016. The bill
    strengthened NIH research for treatment of chronic pain. Since
    enactment of CARA and the SUPPORT Act, NIH's HEAL initiative has funded
    1,800 projects in 50 states.
        How much NIH funding has gone to pain management research since
    passage of the STOP Pain Act ?
        CDC's April 2023 report in the Morbidity and Mortality Weekly
    Report ``Chronic Pain Among Adults--United States, 2019-2021''
    estimates that 21% of U.S. adults experienced chronic pain. What are
    the estimated annual direct healthcare costs (e.g., diagnostic,
    management and treatment) and indirect costs (e.g., missed work, loss
    of productivity, disability) incurred for individuals living with
    chronic pain? If this analysis is unavailable, what funding would be
    needed to complete this assessment?
        Answer. The NIH reports categorical spending on hundreds of topics
    through the Research, Condition, and Disease Categorization (RCDC)
    system. The reported funding under the RCDC category for Pain Research
    has increased since the passage of the STOP Pain Act. In FY 2016, the
    RCDC amount for Pain Research was $483 million. The most recent RCDC
    total is for FY 2023, which is $1 billion. The average from FY 2017 to
    FY 2023 is $835 million. CDC is committed to addressing and assessing
    the challenges that patients living with chronic pain face. CDC has
    undertaken research efforts to qualify the economic costs of chronic
    pain in the United States and plans to release a publication in the
    coming year to share this information broadly with members of the
    public. CDC will share the final publication upon its release with this
    committee and is happy to answer any questions.
        Question. How are HHS OpDivs translating the millions of dollars in
    NIH funding to incentivize evidence-based, integrated care delivery
    models for treatment of chronic pain so that individuals have robust
    alternatives to highly addictive opioids?
        Answer. The NIH HEAL Initiative supports pragmatic clinical trials
    to evaluate and embed evidence-based multidisciplinary pain care in a
    variety of healthcare settings. The program goals are to develop and
    implement models of care for a variety of pain conditions for diverse
    populations with a focus on health equity. The Pragmatic Studies for
    Pain Management Without Opioids \1\ supports studies in large
    healthcare systems, whereas the Prevention and Management of Chronic
    Pain in Rural Populations \2\ focuses on care in non-traditional
    healthcare settings such as community centers, and the Advancing Health
    Equity in Pain Management \3\ focuses on culturally based care in a
    broad range of settings.
    ---------------------------------------------------------------------------
        \1\ heal.nih.gov/research/clinical-research/prism.
        \2\ heal.nih.gov/research/clinical-research/chronic-pain-rural-
    populations.
        \3\ heal.nih.gov/research/clinical-research/health-equity-pain-
    management.
    ---------------------------------------------------------------------------
        To help promote evidence-based, non-opioid based integrated care
    delivery models for treatment of chronic pain SAMHSA funded ten (10)
    grantees under the Emergency Department Alternatives to Opioids Program
    (ED-ALT) grant program (No. TI-20-005) authorized under section 7091 of
    the Substance Use Prevention that Promotes Opioid Recovery and
    Treatment for Patients and Communities Act (SUPPORT Act) (42 U.S.C.
    294i note; 132 Stat. 4035) in October 2018 which was to be used to
    ``...carry out a demonstration program for purposes of awarding grants
    to hospitals and emergency department, including freestanding emergency
    departments, to develop, implement, enhance, or study alternatives to
    opioid for pain management in such settings.'' The grantees were
    awarded beginning in FY 2020; since that time, grantees have been
    implementing alternatives to opioids for pain management in hospitals
    and emergency department (ED) settings.
        Question. The President's FY2025 Budget includes a proposal to
    provide access to recommended vaccines for adults who do not have
    insurance coverage.
        How does the proposal seek to leverage and build on the state and
    local relationships established in response to COVID to improve access
    to routine vaccinations?
        Answer. The Vaccines for Adults (VFA) program proposal seeks to
    leverage and build on the long-standing infrastructure and
    relationships between CDC and state and local immunization programs),
    which were strengthened during the COVID-19 response. The longstanding
    infrastructure and relationships were successfully leveraged during the
    COVID-19 response, along with the newer retail and community-based
    partnerships established during the COVID-19 response and the Bridge
    Access Program. The VFA proposal would create a permanent program to
    cover Advisory Committee on Immunization Practices (ACIP)-recommended
    adult vaccinations for uninsured adults with a major goal of increasing
    routine adult immunization access points and adult vaccination coverage
    for all recommended vaccines and that could be used to deliver vaccines
    quickly during outbreaks or emergency responses.
        Question. How would this proposed program increase routine
    vaccinations for adults in rural and underserved areas?
        Answer. Lack of access to and confidence in vaccines
    disproportionately impact groups at higher risk of disease, including
    adults in rural communities. Similar to the Vaccines for Children
    program, the VFA program would allow a wide range of healthcare
    providers to participate and receive reimbursement for providing all
    ACIP-recommended adult vaccinations to people living in rural areas.
    According to a 2022 National Health Statistics Report, adults aged 18-
    64 living in rural communities are more likely to be uninsured and less
    likely to have private insurance compared to those in metropolitan
    communities.\4\ For many small healthcare providers and clinicians,
    particularly in rural areas, the upfront cost of vaccine purchases and
    lack of reimbursement are major challenges to keeping all adult
    vaccines available to their patients. VFA would allow and support
    providers in rural areas to carry all ACIP-recommended vaccines for
    their uninsured patients. Making vaccines easy to get and convenient
    (through many access points) are two of the biggest building blocks in
    creating strong vaccine confidence and demand.
    ---------------------------------------------------------------------------
        \4\ National Health Statistics Reports, Number 176, November 3,
    2022 (cdc.gov).
    ---------------------------------------------------------------------------
        Through the Bridge Access Program, we have demonstrated the ability
    to improve access in all parts of the country, including rural areas.
    For example, the Bridge Access Program includes traditional healthcare
    providers, HRSA-supported health centers, health departments, large
    chain pharmacies, and independent pharmacies, providing access to
    approximately one third of zip codes where adults without insurance
    live. The Bridge Access Program has a specific focus on reaching rural
    areas and areas of low vaccine uptake. eTrueNorth, one of the three
    retail partners, serves as an aggregator of small and independent
    pharmacies. There are at least 24,000 pharmacy locations and 6,000
    safety net health providers actively participating in the Bridge Access
    Program. About 83 percent of people living in the United States (76
    percent of uninsured adults) live within a 5-mile driving distance from
    a participating pharmacy location.
        Question. What steps is CDC taking to support states in
    establishing and/or maintaining adult immunization programming? Have
    there been efforts to understand gaps in adult immunization, or to
    review states current capabilities to offer vaccines to uninsured
    adults?
        Answer. Outside of the Bridge Access Program (which is slated to
    end in August 2024) and in the absence of a statutorily authorized VFA
    program, CDC continues to support states and local public health
    partners in implementing some adult immunization programming. CDC
    provides limited support for adult programming and infrastructure
    through annual funding, which goes out to 64 immunization awardees.
    With current appropriations levels, CDC provides approximately $70
    million annually for purchase of ACIP-recommended vaccines for
    uninsured adults and for purchase of adult vaccines during outbreaks.
    This amount of funding must cover all 64 jurisdictional awardees and a
    growing adult immunization schedule (growing from six ACIP-recommended
    adult vaccines in 2004 to 17 in 2024) as well as newer, more advanced
    vaccines being added to each schedule, increasing the total cost of
    vaccine purchase. This means that jurisdictions must make increasingly
    challenging choices on which vaccines to purchase for uninsured adults.
        CDC is working to understand adult immunization trends and provide
    our jurisdictional partners with as much support as possible. This
    includes the following activities:
      --Establishing adult vaccine teams and units across the Immunization
            Services Division that support data and coverage studies,
            vaccine confidence efforts, adult-focused partnerships, and
            health equity initiatives.
      --Conducting a formal analysis of section 317 and other funding
            sources to support routine adult immunization activities among
            the 64 state and local immunization programs, which included a
            survey and key informant interviews of immunization awardees
            (findings published in Public Health Reports, March 2024). This
            analysis found that awardees reported limited funding outside
            of section 317 funding to support vaccine purchase and adult
            immunization operations and outreach activities, and limited
            support for staff focused on adult immunization activities,
            impacting their capacity to serve all eligible adults and offer
            all ACIP-recommended vaccines. Many awardees reported decreased
            level of state funding for adult vaccines, as well. This
            analysis also showed that awardees reported significant
            challenges, even with respect to maintaining current levels of
            support for eligible adults, including underinsured adults,
            despite stable discretionary funding, due to increases in the
            number and costs of adult vaccinations and competing priorities
            for these funds, which are also used to support an increasing
            number of outbreak responses (e.g., measles, Hepatitis A).
      --Developing, piloting, and launching the Success Framework for Adult
            Immunization Partner Networks (cdc.gov), a maturity model
            planning tool and resource for jurisdictions to build the
            robust partnership networks needed to support adult
            immunization in the community.
      --Based on implementation of the Success Framework, noted above,
            working with awardees to develop and pilot a more comprehensive
            Adult Immunization Program Framework, a planning tool to help
            awardees to move beyond partnerships to build and expand their
            operational capacity, improve routine adult vaccination
            coverage, and reduce longstanding disparities in adult
            vaccination rates.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. The Health Resources and Services Administration,
    administers grants and programs that are critical to rural health
    centers, clinics, and hospitals. Your budget requests a $2 billion
    increase over FY23 to this agency to carry out these programs. However,
    many areas of West Virginia remain unable to access these resources.
        West Virginia is the only state that lies completely within the
    Appalachian Mountain region. The United States Department of
    Agriculture (USDA) Economic Research Service (ERS) recognized the
    unique topography of our state in their recent report on ``rugged
    terrain''.
        The report found that almost 81% of West Virginians live in a
    rugged area. That's compared to just 11.7% of the entire United States
    population. The Fiscal Year 2024 bill included language for HRSA to
    review this report to update their rural definition to better capture
    the uniqueness of Appalachia.
        Can you provide an update on this review and a timeline for when we
    will see the results?
        Answer. On April 26th, HRSA announced a proposed modification to
    the definition of `rural' used to designate eligible areas for rural
    health grants. Because access to needed healthcare is likely to be
    impacted when roads are most difficult to traverse, HRSA proposes to
    modify the definition of rural areas by integrating the new Road
    Ruggedness Scale (RRS) released in 2023 by the Economic Research
    Service (ERS) of the U.S. Department of Agriculture. All areas included
    in the current definition of rural would remain included. Public
    comments on the proposal are due May 28, 2024. After the comment period
    closes, HRSA will analyze the public comments received and issue an
    updated Federal Register Notice.
        Question. We have seen significant growth in the Medicare Advantage
    program, with enrollment tripling in the last decade. Many seniors
    appreciate the benefits offered, including $0 premium plans, and
    expanded treatment options, however we can not turn a blind eye on
    spending.
        MedPAC estimates that there will be an $88 billion spending
    difference between traditional Medicare and Medicare Advantage plans in
    2024 alone. And in 2022, Medicare payments to Medicare Advantage plans
    averaged roughly 104% of Traditional Medicare spending, with roughly
    $12 billion of that attributed to incorrect billing practices.
        With the Congressional Budget Office projecting depletion of the
    Medicare Trust Fund by 2033, we must prioritize solutions to both
    improve quality and ensure long-term solvency.
        What is your Department doing to correct over spending in this
    program, while insuring we are still incentivizing quality health
    plans?
        Answer. CMS agrees it is imperative to protect Medicare coverage
    for beneficiaries. The President's FY 2025 budget includes proposals
    that, if enacted, would extend Medicare solvency indefinitely without
    cutting benefits. CMS is required to annually update Medicare Advantage
    (MA) payment rates and regularly implements technical updates to make
    improvements needed to keep MA payments up-to-date and accurate. On
    April 1, 2024, CMS released the Calendar Year (CY) 2025 Medicare
    Advantage Rate Notice, which continues to build on our actions to
    improve MA payment accuracy while being good stewards of the Medicare
    program and improving the program's long-term sustainability.
        CMS finalized an updated MA Risk Adjustment Model in the CY 2024
    Rate Announcement and began an expected three-year phase-in of the use
    of that model, referred to as the 2024 CMS-HCC model, starting with CY
    2024. The updated model includes important technical updates to improve
    its predictive accuracy, including restructured condition categories
    using the International Classification of Diseases (ICD)-10
    classification system (instead of the ICD-9 classification system),
    updated underlying FFS data years (from 2014 diagnoses and 2015
    expenditures to 2018 diagnoses and 2019 expenditures), an updated
    ``denominator year'' in determining the average per capita predicted
    expenditures to create relative factors in the model, as well as
    applying our longstanding principles to make revisions focused on
    conditions that are subject to more coding variation.
        For CY 2025, CMS will continue to phase in the updated risk
    adjustment model as proposed by blending 67% of the risk score
    calculated using the updated 2024 MA risk adjustment model with 33% of
    the risk score calculated using the 2020 MA risk adjustment model. CMS
    is also applying a coding pattern adjustment set at the statutory
    minimum of 5.9%. By continuing to phase in the routine updates, CMS's
    work is ongoing to improve MA payment accuracy, with more money being
    paid to care for sicker and more costly Medicare enrollees, so that
    people in MA can continue to access to the care that they need.
    Additionally, CMS will adopt a more sophisticated methodology for how
    it normalizes risk scores to more accurately address the impacts of the
    COVID-19 pandemic without excluding data years.
        In addition, through the MA Value-Based Insurance Design (VBID)
    Model, CMS is testing a broad array of complementary MA plan
    innovations designed to reduce Medicare program expenditures, enhance
    the quality of care for Medicare beneficiaries, including those with
    low incomes such as dual-eligibles, and improve the coordination and
    efficiency of healthcare service delivery. Overall, the MA VBID Model
    contributes to the modernization of MA and tests whether these model
    components improve health outcomes and lower costs for MA enrollees.
        For plan year 2024, the MA VBID Model has 69 participating Medicare
    Advantage Organizations (MAOs) with a total of 12.4 million enrollees
    projected to be enrolled in participating plan benefit packages). Over
    8.7 million of these enrollees are projected to be offered additional
    Model benefits and/or rewards and incentives as part of the Model test
    in 2024. On March 13, 2024, CMS announced its decision to have a
    competitive application process for the MA VBID for plan year 2025, in
    order to ensure the success of the model test and safeguard against
    increased costs or decreases in quality of care.
        The MA risk adjustment data validation (RADV) program is CMS's
    primary audit and oversight tool of MA program payments. The Department
    of Health and Human Services' Office of Inspector General (HHS-OIG)
    also undertakes audits of MA organizations as part of its oversight
    functions, which are similar to RADV audits, and CMS can collect the
    improper payments identified during those audits.
        On February 1, 2023, CMS finalized policies for the RADV program
    and codified in regulation that, as part of the RADV audit methodology,
    CMS will extrapolate RADV audit findings for CMS and HHS-OIG audits
    beginning with payment year (PY) 2018 RADV audits (88 Fed. Reg. 6643-
    4). CMS will collect non-extrapolated overpayment amounts identified by
    RADV audits prior to PY 2018. The finalized policies will also allow
    CMS to continue to focus its audits on those MA organizations
    identified as being at the highest risk for improper payments. In 2024,
    CMS is planning to initiate overpayment collection activities related
    to RADV audit findings and hopes to announce plans for future RADV
    audits. These activities will continue into FY 2025 and beyond, and CMS
    will continue to explore ways of strengthening and accelerating RADV
    audits.
        Question. Secretary Becerra, lung cancer remains the number one
    cancer killer in our nation, yet the current budget seems to overlook
    substantial programmatic support for combating this disease.
    Specifically, the Health Resources and Services Administration's
    Accelerating Cancer Screening program does not list lung cancer as an
    eligible topic.
        Recently, the NIH Director came to West Virginia to tour the LUCAS
    mobile screening unit at WVU, which is making significant strides in
    early detection of lung cancer, particularly in rural areas underserved
    by traditional healthcare facilities.
        Could you clarify why lung cancer initiatives, especially those
    serving rural communities, are not more prominently supported in the
    budget, and what steps the Department intends to take to address this
    vital issue in cancer care and prevention?
        Answer. The President's Budget request includes a total of $11
    million to support the provision of cancer screening services in health
    centers under the Alcee L. Hastings Program for Advanced Cancer
    Screening. The program focuses on leveraging outreach specialists and
    patient navigators to conduct patient outreach in underserved
    communities served by health centers to promote early detection of
    cancer, connect patients to screening services, and provide direct
    assistance with accessing high quality cancer care and treatment as
    needed.
        NCI remains committed to advancing research on all cancers to help
    all people live longer, healthier lives across the nation, including
    those in rural areas. This commitment extends to lung cancer, as NCI
    has long supported the advancement of lung cancer prevention,
    screening, and treatment research. NCI understands that populations in
    rural areas face increased barriers to cancer screening and care, and
    NCI will continue to fund research and support efforts to improve
    access and better address the unique needs of these communities.
        NCI support for lung cancer research has led to key scientific
    advances and public health progress, which were instrumental in guiding
    the development of lung cancer screening recommendations. The NCI-
    sponsored National Lung Screening Trial (NLST) \5\ demonstrated that
    low-dose CT scans are an effective approach to screen for lung cancer
    in people at high-risk for the disease. Additionally, NCI-supported
    research continues to inform lung cancer screening guidelines issued by
    the United States Preventative Services Task Force (USPSTF), including
    USPSTF's 2021 expanded eligibility criteria for screening to age 50-80
    and to include those with 20 pack-years of smoking exposure or more.\6\
    ---------------------------------------------------------------------------
        \5\ cancer.gov/types/lung/research/nlst.
        \6\ uspreventiveservicestaskforce.org/uspstf/recommendation/lung-
    cancer-screening.
    ---------------------------------------------------------------------------
        Increasing uptake of lung cancer screening remains a priority and
    NCI supports programs, partnerships, and individual research grants
    that reduce barriers and aim to increase screening uptake across the
    nation. Community outreach and engagement (COE) has been a fundamental
    and effective activity of NCI-designated Cancer Centers over the
    years.\7\ Through COE, Cancer Centers work with community stakeholders,
    who identify specific community needs and catalyze relevant activities
    to the Cancer Center's geographic catchment area population. For
    example:
    ---------------------------------------------------------------------------
        \7\ cancercontrol.cancer.gov/research-emphasis/supplement/coe.
    ---------------------------------------------------------------------------
      --The University of Kentucky Markey Comprehensive Cancer Center, in
            partnership with community-based hospitals, continues to engage
            in statewide collaborative efforts to increase lung cancer
            screening and survivorship care, which has helped Kentucky
            achieve the second-highest lung cancer screening rate in the
            country, leading to a 19% reduction in the diagnosis of late-
            stage lung cancers in the state. This includes efforts underway
            to explore partnership opportunities with other states to
            support equitable and high-quality implementation of lung
            cancer screening.
      --The University of Virginia Cancer Center serves 87 contiguous
            counties across northwestern Virginia and West Virginia, where
            30% of the population is rural. It is conducting a Telehealth
            Lung Cancer screening program to provide radiology consults to
            rural hospitals, leading to a sustainable pathway to screening.
      --Roswell Park Cancer Institute serves rural and Appalachian counties
            in western New York state, and in 2022, it launched a mobile
            lung cancer screening unit, called EDDY (Early Detection Driven
            to You), which addresses geographic disparities in access to
            lung cancer screening. Roswell Park is partnering with
            federally Qualified Health Centers, government, and community-
            based organizations and is intensifying its lung cancer
            screening initiative in 2024.
        NCI is supporting several additional research efforts, including
    projects focused on tools to facilitate physician and patient-centered
    discussions to increase screening awareness and completion. For
    example, one study is testing the impact of a genetically informed
    intervention on physicians' ordering and patients' completion of lung
    cancer screening and tobacco treatment in primary care. It plans to
    boost lung cancer screening by motivating behavior change and
    facilitating patient-centered discussions between primary care
    physicians and medically underserved patients at risk for lung
    cancer.\8\ NCI is also supporting a study that is testing the
    effectiveness of using a social media platform to reach screening-
    eligible individuals and the effectiveness of a novel tailored
    screening tool to increase lung cancer screening awareness.\9\ Another
    study led by researchers at the University of Oklahoma aims to develop
    and implement a community-centered lung cancer screening system for
    American Indian/Alaskan Native populations.\10\
    ---------------------------------------------------------------------------
        \8\ reporter.nih.gov/search/YfStWIMZEUuJg4LtuEmKnw/project-details/
    10795109.
        \9\ reporter.nih.gov/search/xyTHM3X6BEa0h76aF1omUg/project-details/
    10712275.
        \10\ reporter.nih.gov/search/mmncCQHYZUKptCMA-rwoBQ/project-
    details/10740839.
    ---------------------------------------------------------------------------
        Question. Ransomware cyber-attacks are not a new concept, but our
    government and industry has lagged far behind cyber criminals. Just
    this past February we saw the massive attack on Change Healthcare, a
    unit of UnitedHealth Group--which resulted in billions in losses for
    hospitals, pharmacies, and health providers across our county.
        For more than a decade the government has struggled to work
    individually through agencies that are responsible for their critical
    infrastructure sector, but we have failed because industry doesn't want
    to be held to a standard they believe may cut into their bottom line.
        As we're seeing service providers in every industry consolidate,
    making it easier for cyber criminals to target thousands of business
    that rely on these service providers, how are you working with the
    White House and the Cybersecurity and Infrastructure Security Agency
    (CISA) to put actual industry standards in place that will get us ahead
    of cyber criminals?
        Answer. The HHS Cybersecurity Working Group (CWG) regularly meets
    with CISA weekly, and as needed. The HHS CWG is composed of
    cybersecurity subject matter experts from HHS Staff and Operating
    Divisions with cybersecurity equities. Recently, the HHS CWG partnered
    with CISA to create the Cybersecurity Healthcare Toolkit to provide
    tools and resources regarding implementing cybersecurity best practices
    and industry standards to help the healthcare sector be better prepared
    to detect, respond to, and recover from cyber-attacks.
        HHS Staff and Operating Divisions with cybersecurity equities also
    meet with officials from the White House, CISA, and the Department of
    Homeland Security on specific cybersecurity issues and projects--
    particularly as they relate to cybersecurity in the healthcare sector.
        Question. What type of support is being shared with smaller
    healthcare entities (such as rural hospitals) that may not have a large
    amount of cybersecurity staff and that may not be members healthcare-
    related information sharing organizations?
        Answer. CMS recognizes the impact the Change Healthcare cyberattack
    has had on providers, particularly many small providers and those in
    rural areas. We are working expeditiously to do our part to ease the
    impact of the cyberattack.
        Specifically, CMS has taken several key actions to support the
    provider community during this difficult situation. CMS announced the
    availability of accelerated and advance payments for affected Medicare
    providers of services and suppliers. Providers and suppliers should
    reach out to their Medicare Administrative Contractors for more
    information or visit CMS' website for Frequently Asked Questions and
    Answers. CMS has also provided flexibility for certain Medicare
    reporting deadlines. We encourage Medicare Advantage and Medicare Part
    D plans to offer advance funding to providers, and to remove or relax
    certain timely filing and prior authorization requirements. We have
    provided flexibility for certain Medicare reporting deadlines.
    Similarly, we strongly encourage Medicaid and CHIP managed care plans
    to remove or relax prior authorization and utilization management
    requirements, and to consider offering advance funding to providers, to
    the extent permitted by the state.
        To support states and providers who rely on Medicaid, on March 15,
    2024 CMS released guidance to help states start making interim payments
    to Medicaid providers affected by the incident. Subject to certain
    guardrails to protect program integrity, CMS is encouraging state
    Medicaid programs to request authority to make certain interim
    payments.
        CMS has maintained frequent communications with United Healthcare
    and will continue to press them to communicate with the healthcare
    sector and to offer assistance to providers and suppliers to ensure
    continuity of operations for all healthcare providers and suppliers
    impacted by the incident.
        Additionally, the FY 2025 Biden-Harris Budget proposes two
    incentive structures to encourage hospitals to upgrade their
    cybersecurity practices, steadily increasing expectations from
    ``essential'' to ``enhanced'' to elevate the level of hospital
    cybersecurity efforts stepwise over time and to evolve with the
    changing cybersecurity landscape.
        The cybersecurity initiative would leverage the structure of and
    provider familiarity with the Medicare Promoting Interoperability
    Program to efficiently collect information and make incentive payments
    to certain hospitals and assess penalties to strengthen the hospital
    cybersecurity response.
        This proposal first invests $800 million from the Medicare Hospital
    Insurance Trust Fund over FY 2027 and FY 2028 to approximately 2,000
    high-needs hospitals. Beginning in FY 2029, new penalties would apply
    within the Medicare Promoting Interoperability program as specific
    consequences of failing to adopt essential cybersecurity practices.
    Hospitals that fail to adopt essential cybersecurity standards face
    penalties of up to 100 percent of the annual market basket increase and
    beginning in FY 2031 potential additional penalties of up to 1 percent
    off the base payment. Critical Access Hospitals that fail to adopt the
    essential practices would incur an up to 1 percent payment reduction.
    But a Critical Access Hospital's total penalty is capped at a total of
    1 percent if it would otherwise incur higher total penalties due other
    elements of the Medicare Promoting Interoperability Program.
        The proposal also invests $500 million from the Medicare Hospital
    Insurance Trust Fund for all hospitals to implement enhanced
    cybersecurity practices, available for FY 2029 and FY 2030. Beginning
    in FY 2031, CMS would be able to add enhanced cybersecurity practices
    to the list of required cybersecurity practices, subject to a higher
    total maximum penalty level of 100 percent of the annual market basket
    increase and up to 1 percent off the base payment. Critical Access
    Hospitals would be subject to up to a 1 percent payment reduction. A
    Critical Access Hospital's total penalty is capped at a total of 1
    percent if it would otherwise incur higher total penalties due other
    elements of the Medicare Promoting Interoperability Program.
        The department's Health Sector Cybersecurity Coordination Center
    (HC3) releases public information publicly on cybersecurity threats
    through www.hhs.gov/HC3. This information is openly available to anyone
    with access to the Internet. The same cybersecurity threat information
    is also obtained and published by the Health ISAC, the American
    Hospital Association, and the College of Healthcare Information
    Management Executives (CHIME). Additionally, major threat intelligence
    platforms, such as Mandiant, Intel471, and CrowdStrike leverages HC3
    content to their postings.
        HC3 also directly distributes the same information to a variety of
    entities and associations such as:
      --Alaska State Hospital and Nursing Home
      --Arizona Center for Rural Health
      --Black Hills Information Security
      --BlueCross BlueShield Nebraska
      --BlueCross BlueShield of North Dakota
      --Colorado Rural Health Center
      --Commonwealth Healthcare Corp--CNMI
      --Idaho Department of Health and Welfare
      --Iowa Rural Health Association
      --Louisiana Office of Rural Health
      --Louisiana Rural Health Association
      --Midwest Surgical Hospital
      --Missouri Rural Health Association
      --Montana Office of Rural Health
      --Nebraska Rural Health Association
      --North Dakota CISO Office
      --North Mississippi Health Services
      --Oklahoma Information Fusion Center
      --Rural Health, Inc
      --Western Healthcare Alliance
      --Wyoming Information Analysis Team
        Information is readily and publicly available without any form of
    ``membership''. Size isn't a factor regarding information sharing. HC3
    directly provides information to smaller entities and rural hospitals
    by presenting at a number of healthcare conferences. Examples include:
      --National Association of County and City Health Officials (NACCHO)
      --Health ISAC conferences
      --KY ``SECRT'' on Cyber Exec Order
      --Colorado--2022 Annual Rural Health Conference
      --Arizona Rural Health--Cyber Threats to Rural Health
      --Oklahoma State Office of Rural Health Brief
      --Missouri Rural Health Association Quarterly meeting
      --HIMSS Hawaii/Alaska Presentation
      --Louisiana SORH--Rural Health Cybersecurity
      --HRSA-Region 6--Rural Health Cybersecurity
        For entities with limited cybersecurity resources, HC3 develops and
    delivers cyber threat products. These products are intended to inform
    the entire public and private health sector about current and emerging
    threats. These products focus on how entities can implement specific
    mitigations, patches, or system changes to enhance protection or detect
    malicious activities. As an example, in 2023, HC3 released 63 of these
    products. No less than 1,500 partners including rural health centers,
    state-based insurance companies, hospitals (large and small), and
    nursing home systems received this information.
        As an added level of support, HC3 also partners with the CISA to
    conduct facilitated table top exercises enabling organizations process
    to test their cyber resilience.
        HHS OCR administers and enforces the HIPAA Security Rule. Please
    see response to question 21 about the HIPAA Security Rule, and OCR's
    plans to propose modifications to the Security Rule.
        OCR also provides numerous guidance materials to assist HIPAA
    covered entities and business associates in complying with the Security
    Rule. Last year, OCR published a webinar on complying with the HIPAA
    Security Risk Analysis requirement, a foundational step in
    cybersecurity and protecting electronic protected health information
    (ePHI). This webinar explained how to prepare a risk analysis, how ePHI
    should be assessed, what it means to be ``accurate and thorough'', and
    examples of risk analysis deficiencies from OCR investigations. OCR
    also published a video on ``How the HIPAA Security Rule Can Help Defend
    Against Cyber-Attacks'', which provides information on trends in
    reported breaches, common attack vectors, and examples from OCR
    investigations. Additionally, OCR published two newsletters including
    one which explained single and multi-factor authentication, the
    Security Rule requirements, and resources for improving authentication
    requirements. The second newsletter addressed Security Rule enforcement
    policies and how they can improve HIPAA compliance.
        HHS also offers a free Security Risk Assessment Tool that is
    designed to help small and medium sized healthcare providers conduct a
    risk analysis as required by the HIPAA Security Rule. Identifying and
    assessing potential risks and vulnerabilities to ePHI is foundational
    to implementing security measures to protect ePHI.
        All of these materials are available on the HHS and OCR websites.
        ASPR, as the Sector Risk Management Agency for the Healthcare and
    Public Health Sector (HPH), is lead for certain activities related to
    engaging and informing the healthcare sector. On February 27, 2024,
    HHS, along with the Cybersecurity and Infrastructure Security Agency
    (CISA) and the Federal Bureau of Investigation (FBI), released an
    updated joint cybersecurity advisory (CSA) on ALPHV Blackcat
    ransomware, which includes recently and historically observed tactics,
    techniques, and procedures (TTPs) and indicators of compromise (IOCs)
    to help organizations protect against ransomware. ASPR facilitates
    interagency coordination engagements, including regular, sometimes
    daily, calls in support of incident response. This allowed us to
    coordinate with U.S. government (USG) partners, including the FBI,
    CISA, Department of Veterans Affairs (VA), DoD, and others.
        HHS has been sounding the alarm on the increased need for
    healthcare sector cybersecurity resiliency, and in December 2023, HHS
    released a concept paper that outlined the Department's holistic
    cybersecurity strategy for the HPH. Towards the end of January, we
    released the voluntary HPH cybersecurity performance goals (CPGs),
    aligned with the first pillar of this strategy. We also rolled out a
    new gateway website as part of our efforts to establish the one- stop-
    shop for HHS cyber and simplify how the sector can access our resources
    and tools across all HHS divisions. These HPH CPGs will help healthcare
    organizations implement high-impact cybersecurity practices and ease
    access to the many cybersecurity resources HHS and other Federal
    partners offer. In the coming weeks and months as we emerge from this
    attack, we will be focused on developing additional tools, resources,
    and guidance to help with implementing these HPH CPGs and look forward
    to working with the sector to help improve its cybersecurity posture.
    We also launched the 2.0 version of our RISC Toolkit to the sector. It
    allows a system of systems risk assessment instead of focusing on a
    specific hospital.
        It is important to note that this cyber-attack was of a private
    company, Change Healthcare, and not of HHS systems. We continue to
    engage regularly with the healthcare sector and are urging UnitedHealth
    Group (UHG), clearinghouses, insurance companies, and other payers to
    do everything they can to maintain patients' access to care and support
    providers.
        Question. Mr. Secretary, the West Virginia Prevention Research
    Center (WVPRC) based at West Virginia University, funded continuously
    since 1995, has been part of a National Network of 26 Prevention
    Centers competitively funded by the Centers for Disease Control and
    Prevention. Over the years, the Center has served as a transformative
    force that conducts and translates innovative community-engaged
    research into practical solutions to improve health in WV with emphasis
    on rural and/or child mental health and substance abuse prevention.
        I have been a long champion of funding the CDC Prevention Research
    Center. I was greatly disappointed to learn that the WVPRC was one of
    eleven currently funded Centers whose applications were approved but
    not funded for the 2024-2029 cycle. This results in the loss of a
    $5,000,000 award over the next 5 years, significantly limiting the
    WVPRC's momentum to impact public health, especially in the area of
    youth mental and substance abuse prevention in high impact areas in
    West Virginia.
        Since its inception, the WVPRC's rural Appalachian focus has helped
    to create a West Virginia where everyone is empowered with the
    knowledge and support, they need to live their healthiest lives
    possible. With guidance from a long-standing statewide Community
    Partnership Board, the WVPRC has made positive impacts across WV by
    conducting nationally and internationally recognized youth substance
    abuse prevention research, fostering local capacity for addressing
    critical health needs through training and technical support, and
    providing state and local public health and education agencies with
    evaluation services in school-based mental health and chronic disease
    that share WV's emphasis on rural and/or child mental health and
    substance abuse prevention.
        As you are aware, there are currently 26 PRCs currently funded
    under the Chronic Disease Prevention and Health Promotion account in
    the current five-year cycle. While funding for the PRC program has
    increased from $27 million in FY 2022 to $29 million in FY 2023 and
    2024, please explain why CDC reduced the number of funded PRCs from 26
    to 20 for 2024-2029?
        Answer. CDC is funding 20 recipients this cycle (FY 2024-2029) at
    $1 million per award ($20 million per year). This is six fewer than the
    26 recipients funded from FY 2019-2024, however, those awards were only
    $750,000 per award ($19.5 million per year). CDC is increasing the
    amount of funding per award due to additional expectations and
    requirements in this NOFO, which includes additional activities for
    collaboration and elevating the impact of the PRC network, as well as a
    focus on dissemination and implementation science to accelerate
    adoption of promising interventions. Increasing individual award
    amounts also aligns with long-standing recommendations from the field,
    including the National Academies of Science, Engineering, and Medicine,
    and the Association of Schools and Programs of Public Health.
        Question. The Appalachian region consistently ranks high in
    incidences of disease, injury, and poor health behaviors. Of the 20
    PRCs funded in the new FY 2024-2029 cycle, only three are rural focused
    and only one in Appalachia is located at the University of Pittsburgh,
    which is primarily urban-focused on aging issues. Can you explain why
    rural Appalachia has no representation in the new funding cycle?
        Answer. The 20 funded PRCs were ranked based on the review criteria
    described in the NOFO, and a quarter of PRC-funded projects in the new
    cycle will include rural populations. Geographic distribution was one
    of several factors considered for funding recommendations. As stated in
    the NOFO, those factors included the scientific and technical merit of
    the proposed project, as determined by scientific peer review; the
    availability of funds; the relevance of the proposed project to program
    priorities; a selection to ensure that the PRC core research projects
    address a variety of chronic disease prevention priority categories
    indicated in the NOFO; and a selection to ensure equitable geographic
    distribution of PRCs across the United States.
        Question. Are you aware of the USDA Economic Research Service March
    2024 report entitled ``The Nature of the Rural-Urban Mortality Gap''--
    https://www.ers.usda.gov/publications/pub-details/?pubid=108701--that
    finds there is a growing natural-cause mortality gaps between rural and
    urban areas of the country, with rural prime working age population
    experiencing substantial increase in NCM rates? In light of this
    report, does it make sense to scale back rural-focused PRCs? Is the
    Administration prepared to invest in rural health research to
    understand why mortality in rural America is so much higher than that
    in urban America?
        Answer. While the number of awards has been reduced overall, there
    will still be a quarter of PRC-funded projects, including rural
    populations on a variety of health priority areas. Each PRC cycle
    brings new core research proposals with new opportunities.
        Additionally, the CDC Office of Rural Health (ORH), with its
    mission to coordinate rural public health activity across the agency,
    works with CDC researchers to identify and address gaps in rural-
    focused research. The agency continues to conduct such research across
    an array of topics outside the PRC network. Moreover, ORH collaborates
    with HRSA's Federal Office of Rural Health Policy (FORHP) to conduct
    additional research into rural health disparities, which can provide
    more insight into rural-urban differences in health outcomes.
        Question. The 2024-2029 cycle includes three PRCs in Atlanta--Emory
    University, the Morehouse School of Medicine, and Georgia State
    University, all of which are in close proximity to CDC Headquarters.
    How do you justify funding three PRCs in the Atlanta region in the
    2024-2029 cycle, while the PRCs in West Virginia, Colorado, New Mexico,
    Chicago, and Maryland with emphasis on rural and/or child mental health
    and substance abuse prevention and that have broad geographical
    representation did not make the payline?
        Answer. The PRC applications were reviewed by a Special Emphasis
    Panel (SEP) consisting of external, primarily non-Federal scientists
    for initial scientific and technical merit of the proposed project.
    Additionally, selection to ensure that the PRC core research projects
    addressed a variety of chronic disease prevention program priorities
    was applied
        Question. What level of FY 2025 funding would be required for CDC
    to award the approved, but unfunded proposals?
        Answer. CDC is funding 20 PRC recipients this cycle (FY 2024-2029)
    at $1 million per award ($20 million per year). This is six fewer than
    the 26 recipients funded from FY 2019-2024, however, those awards were
    only $750,000 per award ($19.5 million per year). With additional
    funding for awardees and program support, CDC could fund the entire
    approved but unfunded list of 15 additional PRCs.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
        Question. The budget continues a focus on the Cancer Moonshot and
    continues efforts to accelerate smoking cessation.
        What is the Department doing to encourage new innovations
    surrounding smoking cessation, including new products or therapies that
    may be more successful in helping people quit than those currently on
    the market?
        Answer. Supporting innovative strategies to accelerate smoking
    cessation is an important priority for HHS, including the National
    Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA),
    and the Office of Disease Prevention (ODP) within NIH. The Department
    recently published the HHS Framework to Support and Accelerate Smoking
    Cessation,\11\ which provides a unifying vision and set of common goals
    to help drive progress towards cessation, especially in populations and
    communities that experience smoking- and cessation-related disparities.
    NCI, NIDA, and the ODP helped to develop this framework and have been
    key contributors to a whole-of-government effort through the Cancer
    Moonshot, to increase access to smoking cessation treatment, in
    coordination with the President's Cancer Cabinet and the White House's
    Office of Science and Technology Policy.
    ---------------------------------------------------------------------------
        \11\ hhs.gov/sites/default/files/hhs-framework-support-accelerate-
    smoking-cessation-2024.pdf.
    ---------------------------------------------------------------------------
        The NCI Tobacco Control Research Branch (TCRB) also funds clinical
    trials examining novel pharmacological treatment strategies to optimize
    the efficacy of FDA-approved smoking cessation medications. For
    example, TCRB currently funds a comparative effectiveness trial
    designed to evaluate whether delivering an extended course of
    varenicline treatment, versus the standard course, improves smoking
    cessation outcomes among adult African-American smokers.\12\
    Additionally, NCI and NIDA have recently developed a funding
    opportunity, ``Advancing Adolescent Tobacco Cessation Intervention
    Research,'' \13\ to support studies that develop, test, implement, and
    evaluate behavioral tobacco cessation interventions for adolescents,
    with a focus on the critical developmental risk period of mid- to late
    adolescence (approximately 14--20 years old). This funding opportunity
    aimed to address the critical need for empirically validated tobacco
    cessation interventions for adolescents. The last round of this funding
    opportunity closed in October 2023, and applications are currently
    under review.
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        \12\ reporter.nih.gov/search/01X-oLCVjUm8dE5SkbZNRw/project-
    details/10612435.
        \13\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-22-043.html.
    ---------------------------------------------------------------------------
        NIDA is funding research on novel therapeutics and behavioral
    interventions for tobacco cessation. A multi-site randomized clinical
    trial is underway testing psilocybin for smoking cessation.\14\ Another
    study is following up on promising preclinical data to examine the
    effects of a ketamine infusion on craving and tobacco cessation in
    people who smoke.\15\ NIDA-funded researchers are also conducting a
    study using transcranial magnetic stimulation to modulate brain
    circuitry in people with co-occurring tobacco use disorder and
    schizophrenia and test if this treatment helps people to decrease or
    quit smoking.\16\ To help address adolescent nicotine vaping, NIDA is
    supporting a clinical trial testing varenicline, an FDA-approved
    treatment for smoking cessation in adults, to determine if it can help
    adolescents who vape nicotine and want to quit.\17\ NIDA is also
    funding a project developing a brief behavioral activation mobile app
    for adolescents to help address nicotine vaping.\18\
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        \14\ reporter.nih.gov/search/ggAdH7ElMU-dTkJCgGg8zA/project-
    details/10491336.
        \15\  reporter.nih.gov/search/UWMVimJmYUiKO6pI49-iRQ/project-
    details/10371688.
        \16\ reporter.nih.gov/search/xxJjtoaLJkSZ7VmE4C-Ouw/project-
    details/10775767.
        \17\ reporter.nih.gov/project-details/10689064.
        \18\ reporter.nih.gov/search/7QIGg_2Dd0iXuyF_2V6s4w/project-
    details/10250714.
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        FDA's Center for Drugs Evaluation and Research has approved several
    safe and effective smoking cessation therapies including some nicotine
    replacement therapies (NRTs) that are available without the need for a
    prescription (i.e., over-the-counter). FDA considers tobacco dependence
    to be a serious, life-threatening condition and is committed to
    increasing access to and use of therapies, including NRT drug products,
    which could help more smokers quit. At the same time, FDA also
    recognizes the strong addictive characteristics of nicotine that make
    it challenging for smokers to quit, or if successful in quitting, to
    maintain abstinence. For this reason, smoking cessation drug therapies
    are all approved with adjunctive behavioral assistance, such as website
    and additional self-help guides. The reasons for low quit rate success
    include multiple factors unrelated to availability of safe and
    effective smoking cessation products, such as nicotine withdrawal,
    weight gain, and inaccessibility to effective therapies due to
    individual financial circumstances or insurance coverage. For these
    reasons, a multipronged approach to decreasing smoking in the United
    States is needed. To that end, FDA is currently collaborating with NIH
    to understand research needs in the areas of nicotine dependence,
    factors leading to smoking initiation in nonsmokers, novel targets for
    intervention, and innovative study trial designs. Methods to increase
    participation in clinical trials and smoking cessation interventions
    are also needed, particularly in patient communities that are
    disproportionately affected by smoking and its health-related
    consequences.
        As tobacco dependence results in many serious or life-threatening
    conditions (e.g., heart and lung disease and cancer), FDA recognizes
    there is an unmet need for novel therapies particularly for individuals
    who have not been able to quit despite available therapies. The Agency
    determines on a case-by-case basis whether a drug product meets the
    criteria (e.g., the drug represents a significant improvement over
    existing therapies, or addresses an unmet medical need) for inclusion
    in FDA's expedited development and review pathways. FDA encourages a
    sponsor that believes its drug product represents a significant
    improvement over approved smoking cessation drug products to consult
    FDA early in the development program to discuss whether the drug
    product may be eligible for review under one of the expedited pathways.
        In certain cases, a sponsor can rely on FDA's finding of safety and
    effectiveness for a drug product approved under section 505(c) of the
    FD&C Act to the extent the products share characteristics. An
    application submitted under the abbreviated approval pathway described
    in section 505(b)(2) of the FD&C Act may rely on published literature
    or FDA's finding of safety and effectiveness for an approved drug, when
    certain requirements are met.
        In addition to guidance in 2020 on Nonclinical Testing of Orally
    Inhaled Nicotine-Containing Drug Products,\19\ in May 2023, FDA issued
    final guidance entitled, Smoking Cessation and Related Indications:
    Developing Nicotine Replacement Therapy [NRT] Drug Products,\20\ which
    outlines a framework for new potentially clinically relevant outcomes
    for NRT products. The NRT Guidance discusses innovations in NRT drug
    development and provides a clear roadmap to help firms that are
    considering entering or expanding in the NRT drug product space. The
    guidance outlines opportunities for innovation including:
    ---------------------------------------------------------------------------
        \19\ https://www.fda.gov/media/115150/download.
        \20\ https://www.regulations.gov/document/FDA-2019-D-0297-0015.
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      --For the first time, discussing ``reduction in risk of relapse'' as
            a potential indication to assist smokers in their continuation
            of quitting. Previously, the only approved indication was
            cessation.
      --Outlining two new potential treatment regimens: (1) pretreatment
            before quit day, and (2) reduce to quit. Industry may be able
            to include information about these regimens in their labeling.
      --For the first time, outlining considerations for pediatric
            populations and NRT products.
      --For the first time, outlining pathways for developing new treatment
            regimens, including combination therapy.
      --Clearly outlining abbreviated pathways for NRT products, including
            how to use FDA's previous findings of safety and how already
            approved NRT products and published literature can be
            leveraged. This includes reliance on the Agency's previous
            findings of systemic safety for the higher nicotine exposure
            drug product and Agency's previous finding of effectiveness for
            the lower nicotine exposure drug product.
      --Explaining when simplified efficacy study requirements may be used
            (e.g., recommending a 4-week study as the minimum period of
            efficacy ascertainment).
      --Encouraging sponsors to consider expedited development and review
            pathways and providing details on how to qualify.
      --Clarifying the appropriate pathways for companies that seek
            approval for a product that alters the route of administration
            compared to approved NRT drug products (e.g., products with
            pulmonary route of administration rather than oral).
      --Describing how labeling for approved NRT products may include
            information about clinical benefits of smoking cessation such
            as lowering the risk of lung disease, heart disease and
            smoking-related cancers without generating additional data.
        Additionally, FDA's Center for Tobacco Products regulates the
    manufacturing, marketing, distribution, and sale of tobacco products.
    Educating the public, especially youth, about the risks of using
    tobacco products, is a critical part of FDA's public health mission.
    CTP prioritized research efforts throughout the past year to inform
    public education opportunities for adults who smoke, recognizing that
    adults also want and need help as they attempt to quit smoking. For
    example, CTP is conducting formative research among adults who smoke to
    assess their comprehension and perceptions of messaging that nicotine--
    while highly addictive--is delivered through products that represent a
    continuum of risk, and that combustible products such as cigarettes
    have the greatest risk. Importantly, these efforts will be accompanied
    by efforts to prevent youth tobacco product use; encourage first-line
    use of FDA-approved cessation therapies; and for adults who both smoke
    and use e-cigarettes, reinforce the importance of completely
    transitioning to e-cigarettes.
        CDC, in alignment with the HHS Framework to Support and Accelerate
    Smoking Cessation, is taking action to support and accelerate smoking
    cessation and reduce smoking- and cessation- related disparities. In FY
    2025, CDC's Tips From Former Smokers (Tips) campaign will continue to
    focus on motivating U.S. adults who smoke to try to quit. Ads will be
    placed on national broadcast, cable, and streaming video, and on
    digital and social media channels. Additional ads will be placed on a
    variety of channels to reach specific audiences, including people who
    are African American, American Indian, Alaska Native, Hispanic/Latino,
    Asian, Native Hawaiian and other Pacific Islanders, LGBTQ+, and deaf or
    hard-of-hearing. Launched in FY 2024, CDC will continue to fund a
    community-based program to increase awareness of cessation services and
    coverage options among populations experiencing health disparities.
    CDC, in partnership with the American Academy of Pediatrics, will
    continue to promote resources to assist pediatric health clinicians in
    helping youth quit tobacco use.
        Question. Opioids continue to be a major public health problem
    across the nation. It is my understanding that there are nonopioid pain
    medications in the pipeline that are close to receiving approval.
        What is the Department doing to ensure nonopioids will be covered
    once approved by the FDA in a way that will put them on a level playing
    field with generic opioids?
        Answer. Substance use disorders (SUD) impact the lives of millions
    of Americans, including individuals who are enrolled in the Medicare
    program. CMS is committed to ensuring that Medicare beneficiaries who
    have an opioid use disorder (OUD) have the necessary access to
    treatment, including medications for opioid use disorder (MOUD).
    Ensuring access to these benefits and addressing equity concerns is an
    important part of combatting the nation's opioid epidemic, and CMS has
    been actively engaged in the work necessary to meet these goals.
        CMS is pleased to note that the OIG report entitled, ``The
    Consistently Low Percentage of Medicare Enrollees Receiving Medication
    to Treat Their Opioid Use Disorder Remains a Concern, OEI-02-23-00250''
    found a 36 percent increase in the number of enrollees receiving
    naloxone through Medicare from 2021 to 2022 and found that indicators
    of misuse and diversion of prescription opioids in Part D continued to
    decline. However, CMS also recognizes there is more work to do in
    increasing access to OUD treatment and addressing health equity.
        Several recent changes have expanded Medicare beneficiaries' access
    to MOUD. First, on January 1, 2020, Medicare began paying Medicare-
    enrolled Opioid Treatment Programs (OTPs) with a bundled payment to
    deliver OUD treatment services to Medicare beneficiaries as required by
    the Substance Use Disorder Prevention that Promotes Opioid Recovery and
    Treatment for Patients and Communities (SUPPORT) Act. Medicare
    Advantage plans must also include the Medicare OTP benefit and can
    contract with OTP providers in their service area, or agree to pay an
    OTP on a non-contract basis. To further promote continuity of care, in
    addition to on-site treatment, OTPs may also provide beneficiaries with
    unsupervised take-home doses of medication in accordance with certain
    time in treatment standards.
        Second, effective December 29, 2022, providers with a current Drug
    Enforcement Administration (DEA) registration no longer need the DATA-
    Waiver (X-Waiver) from the Substance Abuse and Mental Health Services
    Administration (SAMHSA) to prescribe buprenorphine, a type of MOUD
    treatment, strengthening Medicare providers' ability to care for
    beneficiaries with OUDs.
        Finally, in March 2023, the Food and Drug Administration (FDA)
    announced that Narcan, a brand-name formulation of the opioid overdose
    reversal drug naloxone, would be available without a prescription.
    While Medicare Part D generally does not cover over-the-counter
    medications, this change will remove barriers to access by allowing
    beneficiaries to purchase the medication without first meeting with a
    provider. Other options for Medicare-covered naloxone will remain
    available, such as other formulations or dosages of naloxone that
    remain prescription drugs, as well as other overdose reversal
    medications.
        CMS will continue to monitor use of, and access to, these
    medications. CMS monitors prescription drug use in Part D (including
    over-utilization and/or under-utilization of opioids, buprenorphine,
    and MOUD) through prescription drug event (PDE) data to oversee
    sponsors' compliance with drug utilization review (DUR) requirements as
    described in 42 CFR Sec. 423.153. CMS also monitors complaints in the
    Complaints Tracking Module (CTM) in the Health Plan Management System
    to identify potential access issues. CMS may follow up with Part D plan
    sponsors that are outliers, or share information with Departmental
    partners, as appropriate.
        Combatting the opioid epidemic is a top priority for CMS, and CMS
    remains committed to ongoing examination of its payment and coverage
    policies to ensure healthcare providers are enabled to execute best
    practices with respect to pain management and treatment of OUDs. CMS
    continues to support opioid alternatives offered by Traditional
    Medicare, MA plans, and Part D plans, including the coverage of
    acupuncture to address lower back pain and educating providers on other
    non-opioid alternatives.
        Question. Medicare's seniors no longer have to worry about cost-
    sharing when they get a vaccination--regardless of whether it comes
    under their medical benefit in their plan or their pharmacy benefit.
    Now, I am hearing that some Part D plans and PBMs could be placing new
    barriers like differential pharmacy reimbursement and utilization
    management in the way of some of these vaccines. CMS issued a letter to
    plans on December 14, working to share the agency's perspective on
    issue.
        Are you aware of this issue and what is next for CMS in resolving
    any new access barriers for seniors?
        Answer. CMS is continuing to work to improve the Medicare Advantage
    and Part D prescription drug programs and maintain high-quality
    healthcare coverage choices for all Medicare enrollees.
        In a December 14, 2023 letter to pharmacy benefit managers (PBMs)
    and health plans, CMS noted concerns from pharmacies that the amount
    plan sponsors and PBMs that serve plans in Medicare and other markets
    pay pharmacies for some vaccine administrations is causing many
    pharmacies and other providers of vaccines to lose money administering
    vaccines, discouraging them from providing these vaccines. Particularly
    as we encourage people to get vaccinated against influenza, COVID-19,
    and RSV, CMS is very concerned about payment practices that may impede
    access to recommended vaccinations, and it is imperative that plans and
    PBMs take immediate steps to ensure adequate payment for and access to
    vaccines.
        CMS maintains, and will continue to maintain, a robust clinical
    formulary review process to ensure that all Medicare Part D plans meet
    applicable formulary requirements. Consistent with the requirements at
    42 C.F.R. Sec. Sec. 423.120(b)(2) and 423.272(b)(2)(i), CMS evaluates
    formularies based on the sufficiency of categories and classes, tier
    placement, and utilization management restrictions. This review process
    is based in part on section 1860D-11(e)(2)(D)(i) of the Social Security
    Act, which authorizes CMS to approve a prescription drug plan only if
    the agency ``does not find that the design of the plan and its benefits
    (including any formulary and tiered formulary structure) are likely to
    substantially discourage enrollment by certain part D eligible
    individuals under the plan.'' In addition, under Sec. 423.272(b)(2)(i),
    ``CMS does not approve a bid if it finds that the design of the plan
    and its benefits (including any formulary and tiered formulary
    structure) or its utilization management program are likely to
    substantially discourage enrollment by certain Part D eligible
    individuals under the plan.'' Furthermore, Sec. 423.120(b)(2)(iii)
    requires each Part D plan formulary to ``include adequate coverage of
    the types of drugs most commonly needed by Part D enrollees, as
    recognized in national treatment guidelines.'' In addition,
    Sec. 423.120(b)(1)(v) requires that in making decisions about formulary
    design, the entity designing the formulary must base ``clinical
    decisions on the strength of scientific evidence and standards of
    practice.''
        Specifically for vaccines, CMS reviews all Part D sponsors'
    formularies to ensure they contain all commercially available vaccines
    (unless excluded due to available reimbursement under Part B, e.g.,
    influenza or pneumococcal vaccines, or if a commercially available
    vaccine manufacturer does not participate in the coverage gap discount
    program). Part D sponsors are only allowed to use drug utilization
    management tools to:
      --Assess the necessity of vaccines that are less commonly
            administered in the Medicare population, such as anthrax and
            yellow fever vaccines;
      --Facilitate use of vaccines in line with Advisory Committee on
            Immunization Practices recommendations; and
      --Evaluate potential reimbursement of those vaccines that could be
            covered under Part B when directly related to the treatment of
            an injury or direct exposure to a disease or condition (e.g.,
            tetanus).
        Additionally, CMS requires Part D sponsors to submit utilization
    management requirements applied at point of sale, such as prior
    authorization, step therapy, and quantity limits not based upon the
    FDA's maximum daily dose limits, as part of their Health Plan
    Management System formulary submission. Sponsors must perform adequate
    oversight of their PBMs and other delegated entities to verify that
    they are complying with all CMS requirements and not causing
    beneficiary harm due to impermissible delayed or denied access to Part
    D drugs.
        Question. How important is the Building Our Largest Dementia (BOLD)
    Infrastructure for Alzheimer's Act to our healthcare system as it
    pertains to helping health agencies and departments care for people
    living with Alzheimer's and their caregivers? Considering this program
    is coming up for reauthorization this year, would you support its
    reauthorization? Why?
        Answer. NIH funds and conducts research to better understand the
    complex and varied causes of Alzheimer's and related dementias,
    identify early signs of disease, develop effective interventions to
    prevent or delay disease progression, and improve care and support for
    those living with dementia as well as their care partners.
    Workforce Readiness
        NIH remains committed to address the critical need to increase the
    number of health professionals and researchers trained to meet the
    demand for dementia diagnosis, care, and research. In addition, NIH
    maintains dementia resource pages for healthcare professionals with
    information on cognitive assessment tests, tools for diagnosis and
    management, and more.\21\
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        \21\ nia.nih.gov/health/health-care-professionals-information/
    alzheimers-and-related-dementias-resources.
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    Access to Treatments and Services
        NIH funds research to develop a robust evidence base for dementia
    treatments and services. Efforts include funding for more than 500
    ongoing clinical trials, including pharmacological and non-
    pharmacological clinical trials that test interventions that treat or
    prevent dementia, as well as care and caregiving interventions to
    provide support to people currently living with dementia and their care
    partners in a variety of settings. In addition, NIH continues to
    support the development of less expensive and less invasive biomarkers
    and diagnostics, which can help facilitate and enhance access to
    earlier and more accurate detection and diagnosis of dementia.
        BOLD is integral to helping health agencies and departments care
    for people living with Alzheimer's and their caregivers. It
    accomplishes this primarily through two BOLD-funded mechanisms:
    Alzheimer's and Related Dementias (ADRD) Public Health Centers of
    Excellence (PHCE) and Public Health Department programs.
        The three BOLD-funded ADRD PHCEs identify promising research and
    translate it into evidence-based intervention programs for health
    agencies and departments, focusing on dementia caregiving, risk
    reduction, and early detection. For example, the BOLD Public Health
    Center of Excellence on Early Detection of Dementia created an
    educational toolkit for health systems. This toolkit provides
    information on why early detection matters, the importance of preparing
    for cognitive screening, and ensuring continuity of care after
    detection.
        CDC supports 43 Public Health Department programs. These state,
    local, territorial, and tribal organizations implement the Road Map
    series, an essential resource for building public health infrastructure
    among state and local public health agencies addressing dementia and
    brain health in their communities. Thirteen focus on developing
    strategic plans and improving their ability to treat and address
    dementia. Thirty focus on implementing their strategic plans to address
    dementia in their jurisdictions. With the FY 2023 increase in
    appropriations ($8M), CDC expanded from 23 awards in the original 2020
    cohort of BOLD programs to 43 in 2023.
        There is more demand than we can currently meet from the field--
    those 43 awards were drawn from 60 applications received. As the older
    population continues to grow and the number of people living with
    dementia increases, we anticipate that the demand for BOLD funding will
    also grow, especially since state, local, and tribal public health
    departments are all grappling with the same challenges and many more
    are eligible for BOLD program funding. For this reason, reauthorization
    of BOLD is critical to CDC's efforts to continue helping health
    agencies and departments care for people living with Alzheimer's and
    their caregivers.
        Question. I am working to introduce, along with my colleague
    Senator Klobuchar, the Accelerating Access to Dementia & Alzheimer's
    Provider Training (AADAPT) Act, which will empower primary care
    providers to better diagnose Alzheimer's and other dementia and deliver
    high-quality, person-centered care in community-based settings. My bill
    provides grants to organizations to set up dementia-specific Project
    ECHO programs to educate and support primary care providers in
    detecting, diagnosing, treating, and caring for Alzheimer's and other
    related dementia. As we see the population aging and the number of
    people living with dementia increasing, how is HHS working to ensure
    workforce readiness and access to treatments and services for people
    living with dementia?
        Answer. HHS works to ensure workforce readiness and access to
    treatment and services for people living with dementia through the
    previously mentioned BOLD initiative, particularly the three BOLD-
    funded ADRD PHCEs. These PHCEs identify promising research and
    translate it into evidence-based intervention programs for health
    agencies and departments. For example, the BOLD Public Health Center of
    Excellence on Early Detection of Dementia created an educational
    toolkit for clinicians, administrators, and patients. This toolkit
    provides information on why early detection matters, the importance of
    preparing for cognitive screening, and ensuring continuity of care
    after detection. BOLD funds also support partner dissemination of
    continuing education programs for healthcare providers, such as the
    Cognition in Primary Care course. This is a three-part interactive
    module designed for primary care physicians that helps them to evaluate
    cognition, set a plan for newly diagnosed patients, and provide tips
    for managing mild cognitive impairment and dementia.
        In addition to the workforce capacity-building included in CDC's
    BOLD initiative, HHS ensures workforce readiness and access to
    treatment and services for people living with dementia through work
    under the National Healthy Brain Initiative (HBI). CDC funds the
    Alzheimer's Association to assist with the implementation and
    evaluation of the HBI's Road Map Series and with the development of
    future Road Maps. They have also created several training courses for
    current and future public health professionals on a public health
    approach to addressing dementia, dementia caregiving, and risk
    reduction.
        Public health agencies and their partners can use the Road Map
    strategically to prepare their communities to be ``dementia-ready'' by
    stimulating changes in systems and environments. The HBI Road Map
    includes sections based on four Essential Services of Public Health,
    including building a diverse and skilled workforce.
        Question. What efforts, if any, are ongoing to determine whether
    the H5N1 virus may be circulating in people asymptomatically or
    undiagnosed? To what extent is the CDC leveraging its advanced
    molecular detection program for this purpose?
        Answer. far, influenza public health or commercial laboratory data
    in the areas with H5N1-infected dairy herds, and emergency department
    visits for influenza-like illness and conjunctivitis remain in expected
    ranges. In addition to traditional surveillance systems, we are also
    exploring through CDC's National Wastewater Surveillance System the
    potential to identify and investigate trends in influenza A levels in
    wastewater.
        CDC is developing and finalizing a research study protocol to
    assess the prevalence of H5N1 among dairy workers. Analysis of data
    from a study using this protocol would inform CDC and states as to
    whether there is asymptomatic or undiagnosed spread of H5N1.
        Additionally, CDC's SPHERES SARS-CoV-2 Sequencing for Public Health
    Emergency Response, Epidemiology and Surveillance (SPHERES) consortium
    and Pathogen Genomics Centers of Excellence (PGCoE) programs allow us
    to leverage advanced molecular detection in response to H5N1.
        CDC's Advanced Molecular Detection (AMD) program has been working
    to bring sequencing into regular public health practice since 2014. In
    2020, the AMD program established the SPHERES consortium as a forum to
    facilitate knowledge sharing around SARS-CoV-2 sequencing. SPHERES
    brings together scientists from clinical and public health
    laboratories, academic institutions, and the private sector for
    discussions around interdisciplinary and innovative research and
    applied public health pathogen genomics, bioinformatics, and genomic
    epidemiology. SPHERES shares information about ongoing work across
    sectors that advances opportunities for collaboration as we respond to
    and continue to learn more about the outbreak.
        In addition, CDC's AMD program established five PGCoE in 2022 to
    foster innovation and improve technical capacity in pathogen genomics,
    molecular epidemiology, and bioinformatics to better prevent, control,
    and respond to microbial threats of public health importance. Each
    PGCoE site consists of a health department and one or more academic
    institutions, and two of these PGCoE sites are focusing on One Health
    approaches--at the interface of animals, humans, and the environment--
    to help protect human health against the risk of zoonotic pathogens.
    For example, the Washington Animal Disease Diagnostic Laboratory used
    funding awarded to the Northwest PGCoE to build genomic sequencing
    capacity for surveillance of highly pathogenic avian influenza in
    animals. As a result, Washington unified sequencing protocols across
    veterinary and human health to monitor and detect spillover events,
    assess the risk of mammal- to-mammal transmission, and stop threats
    before they spread to humans.
        Question. How are CDC and the ASPR coordinating right now and what
    preparedness steps are they taking in the event the level of risk is
    elevated with regard to H5N1? CDC, ASPR, and FDA officials have
    expressed confidence in the pandemic influenza medical countermeasures
    available in the U.S. Please provide a description of the available
    vaccines, antivirals, and diagnostics.
        Answer. As part of the current coordinated U.S. government response
    to the H5N1 outbreak in cattle, CDC is working closely with our Federal
    partners, including the Office of Pandemic Preparedness and Response
    Policy (OPPR), ASPR, USDA, and FDA. CDC has liaisons from USDA, ASPR,
    and FDA integrated into CDC's incident command structure, and CDC
    communicates on an ad-hoc basis to share technical information across
    relevant agencies.
        Since we first detected H5N1 in cattle herds, the interagency group
    has acted with urgency--working around the clock to stand up a response
    structure across HHS, the U.S. Department of Agriculture (USDA), and
    the White House. A Unified Coordination Group facilitates the
    coordination, with ASPR in the lead on human health and USDA in the
    lead on animal health.
        As the outbreak continues, this initial response structure has
    allowed us to focus on coordinated communication and decisionmaking
    across the Federal government. The focus throughout our response has
    been: protecting the health of the American people; protecting the
    safety of our food supply; acting urgently; and taking this seriously.
        ASPR, FDA, CDC, and the National Institutes of Health (NIH) each
    have important roles to play in the response, along with our USDA
    colleagues. FDA and NIH are working together on the efficacy of
    pasteurization and milk safety studies. CDC is working on surveillance
    of H5N1 and foodborne illnesses and has worked to expand those systems
    during this response. And ASPR, in addition to coordinating the
    Department's response, has provided PPE to impacted states, made
    antivirals available to those needing treatment, and is working to
    ensure well-matched vaccines are available if needed.
        Fortunately, the risk to humans remains low, but we remain watchful
    and ever ready as we work across the Federal government to respond to
    this avian flu outbreak and keep the American people safe.
        Question. The HHS Pandemic Influenza Plan was last updated in 2017.
    Based on the many challenges of the national COVID-19 response, is HHS
    confident that executing against this plan will be effective?
        Answer.
      --The FDA is actively engaged with Federal partners, as well as
            industry, in assessing the currently U.S.-approved pandemic
            influenza vaccines, as well as the evaluation of potential
            vaccine candidates, should the need for vaccines arise.
      --The FDA has approved three H5N1 vaccines for use in the U.S. The
            manufacturers of those vaccines are Sanofi Pasteur Inc., ID
            Biomedical Corporation of Quebec, and Seqirus, Inc.
      --If it is determined that the U.S. population needs to be vaccinated
            to prevent H5N1 influenza, then the anticipated regulatory
            pathway would likely be for those manufacturers who have an
            approved H5N1 influenza vaccine to submit a manufacturing
            strain change supplement to FDA, as occurs for the seasonal
            influenza vaccines.
      --FDA has provided Guidance to Industry on Clinical Data Needed to
            Support Licensure of Pandemic Influenza Vaccines.
        Additionally, the Biologics Program's Influenza Performance measure
    supports the Department's national preparedness efforts in combating
    seasonal and pandemic influenza, by increasing manufacturing diversity
    and capacity for influenza vaccine production. In FY 2023, FDA met the
    target to continue evaluation of new methods to produce high-yield
    influenza vaccine reference strains. The Agency aims to maintain this
    target in FY 2024 and FY 2025.
        Activities to meet this target included the following:
      --FDA continued efforts to develop new methods for determining
            influenza vaccine potency, an important component in the
            evaluation of high-yield influenza vaccine viruses. A new
            international collaborative study, designed to compare several
            alternative potency methods and evaluate their potential to
            quantify sub-potent vaccine using a variety of stress methods,
            was completed in FY2022.
      --An H5N8 candidate vaccine virus for a recently identified H5N8
            influenza virus with pandemic potential that was generated in
            FY2021 was further characterized and listed on the WHO website
            for interested manufacturers.
      --Demonstrated that candidate vaccine viruses for influenza viruses
            with pandemic potential (e.g., H7N9) do not acquire adaptive
            mutations when generated in egg substrates.
      --Continued efforts to evaluate neuraminidase (NA) in circulating
            viruses and the impact of including NA in candidate vaccines.
            Showed that a candidate vaccine virus engineered for higher NA
            antigen content could provide protection in animal models with
            a lower vaccine dose. Continued collaborations with the NIH
            Vaccine Research Center to assist in producing recombinant NA
            for vaccines and for measuring NA responses from individuals in
            clinical trials.
      --Continued development of new methods to purify and quantify NA in
            vaccine candidates, including a 3-step method for purifying
            soluble NA vaccine antigens produced using insect cells.
        The last update to the HHS Pandemic Influenza Plan was in 2017
    (https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-
    2017v2.pdf). Plans are developed to provide general guidance for
    response to emerging incidents. Plans are the base guidance and assist
    in organization and general understanding of roles and responsibilities
    between Federal, state, territorial, tribal, and private-sector
    partners. However, every response has specific considerations, and some
    deviations from planning documents occur if and as requirements shift.
    Plans are reviewed periodically to incorporate lessons learned from
    responses. The general concepts included in this Plan are effective to
    guide the initial response and provide a roadmap for all involved. As
    noted, deviations can and do occur from planning documents based on the
    specific requirements of the emerging incident. Plans are simply plans
    and best practices that could be utilized for the response.
        Question. In order to better understand the scope of appropriations
    and the fiscal year 2025 budget request, please provide a table of the
    fiscal year 2023 obligations, the spend plan for the fiscal year 2024
    appropriation, and the fiscal year 2025 budget request by program,
    project, or activity for the 988 Suicide and Crisis Lifeline.
        Please provide a separate list of current grants, cooperative
    agreements, contracts, and subcontracts for the 988 Suicide and Crisis
    Lifeline, including a description, funding level, and funding source
    for each.
        Answer. Per standard HHS agency protocol, SAMHSA's 988 & Behavioral
    Health Crisis Coordinating Office and Office of Financial Resources are
    actively working to finalize the FY24 988 Spend Plan, along with the
    current list of grants, cooperative agreements, contracts and
    subcontracts for the 988 Suicide Crisis Lifeline. Once cleared by the
    agency, all of the above components will be submitted through HHS and
    OMB process for clearance, then shared with the Hill.
        Each year, SAMHSA, through ASFR has shared the 988 Spend Plan with
    the hill and will continue to share the updated plan once it has been
    finalized. In the interim, if Senator Capito would also like a copy of
    the FY23 988 Spend Plan, SAMHSA, through ASFR, is happy to provide that
    information again.
        Question. The West Virginia PRC is one of eleven currently funded
    Centers whose applications were approved but not funded for the 2024-
    2029 cycle. The discontinuation of the WVPRC gives me great concern
    that the unique issues facing WV and Appalachia will be greatly
    diminished going forward. What specific criteria did the CDC use to
    determine which PRCs would receive funding for the 2024-2029 cycle, and
    how did the WVPRC fall short of meeting these criteria?
        Answer. As with all CDC research Notice of Funding Opportunities
    (NOFO), the CDC Prevention Research Center (PRC) applications were
    reviewed by a Special Emphasis Panel (SEP) consisting of external,
    primarily non-Federal scientists for initial scientific and technical
    merit. Raw scores were presented to a Secondary Review Committee (SRC)
    comprised of CDC scientists to apply the funding criteria stated in the
    NOFO for final funding recommendations.
        Question. There is a heavy concentration in the Southeast of PRCs
    in the 2024-2029 cycle. What justification is there for concentrating
    so heavily in this region while limiting geographical diversity across
    the country--in particular Appalachia?
        Answer. The 20 funded PRCs were ranked based on the review criteria
    described in the NOFO. Geographic distribution was one of several
    factors considered for funding recommendations. As stated in the NOFO,
    those factors included the scientific and technical merit of the
    proposed project, as determined by scientific peer review; the
    availability of funds; the relevance of the proposed project to program
    priorities; a selection to ensure that the PRC core research projects
    address a variety of chronic disease prevention priority categories
    indicated in the NOFO; and a selection to ensure equitable geographic
    distribution of PRCs across the United States.
        Question. A recent report by the USDA Economic Research Service
    entitled ``The Nature of the Rural-Urban Mortality Gap'' highlights a
    growing mortality gap between rural and urban areas, particularly
    affecting working Americans. Given this concerning report, I am
    dismayed by the CDC's decision to reduce the number of rural-focused
    PRCs. How is the Administration going to invest in rural health
    research to better understand and address this glaring disparity in
    mortality rates?
        Answer. While the number of awards in the most recent cycle (FY
    2024-2029) has been reduced overall, there will still be a quarter of
    PRC-funded projects that will include rural populations on a variety of
    health priority areas. Each PRC cycle brings new core research
    proposals with new opportunities.
        Additionally, the CDC Office of Rural Health (ORH), with its
    mission to coordinate rural public health activity across the agency,
    works with CDC researchers to identify and address gaps in rural-
    focused research. The agency continues to conduct such research across
    an array of topics outside the PRC network. Moreover, ORH collaborates
    with HRSA's Federal Office of Rural Health Policy (FORHP) to conduct
    additional research into rural health disparities, which can provide
    more insight into rural-urban differences in health outcomes.
                                     ______

                 Questions Submitted by Senator Lindsey Graham
        Question. During President Biden's State of the Union Address, he
    stated;
        ``Buy America'' has been the law of the land since the 1930s. Past
    administrations including my predecessor, including some Democrats as
    well in the past, failed to buy American. Not anymore. On my watch,
    Federal projects that you fund, like helping build American roads,
    bridges and highways, will be made with American products and built by
    American workers--creating good-paying American jobs.''
        Mr. Secretary, there are a number of Federal agency procurement
    officers that continue to use waivers to get around purchasing American
    made PPE, like nitrile gloves.
        Would you commit to have your procurement officials work to
    maximize American manufactures and labor at HHS?
        Answer. During the initial response to the COVID-19 pandemic in
    2020, the U.S. medical supply chain failed due to reliance on foreign
    manufacturing and production of supplies and products. Using COVID-19
    supplemental appropriations, ASPR invested over $17 billion to expand
    the country's domestic manufacturing infrastructure, to include PPE,
    vaccines and related supplies, and active pharmaceutical ingredient
    production. Because of these investments, there is now domestic
    capacity to produce over 3.9 billion gloves, 690 million N95
    respirators, and 531 million surgical masks per year. It took decades
    for these industries to leave our shores, and it will take time and
    continued investment to bring them back. Annual funding is required:
    (1) to preserve capacity investments made thus far by ensuring
    appropriate management and oversight of the existing contracts; (2) to
    evaluate and assess where the future investments should be made; (3) to
    make those investments; and (4) to ensure the overall portfolio of
    investments is balanced, productive, and sustained. ASPR is
    appreciative of the $10 million included in the FY 2024 appropriations
    bill to continue this mission.
        ASPR has made a number of awards to on-shore pharmaceutical
    manufacturing. ASPR, through the Department of Defense (DoD), has
    awarded $45 million to On-Demand Pharmaceuticals for continuous and
    distributed drug production of cisatracurium, midazolam,
    dexmedetomidine, and propofol. ASPR, through DoD, has also awarded $30
    million to DEKA Research and Development Corporation for the
    distributed production of 0.9N saline and other supportive care fluids.
    ASPR has also awarded a contract to Phlow for $491.9 million in 2020 to
    support domestic manufacturing of active pharmaceutical ingredients
    (API). This work will require continued support from Congress.
        Question. Congress passed the Make PPE in America Act as part of
    the Infrastructure Investment & Jobs Act in 2022. This law strengthens
    efforts to onshore production of personal protective equipment (PPE) in
    the United States by requiring Federal agencies to issue long-term
    contracts for American-made PPE.
        Is HHS fully complying with this law? If not, what specific
    contracts and agencies are out of compliance and what is your plan to
    bring them into compliance?
        How does your office intend to prioritize PPE manufactured in the
    U.S., but with foreign materials and components to extent such items
    are not available in the U.S.?
        If a required material for PPE is not available in the U.S. in
    sufficient quantities, should agencies then be free to procure foreign-
    made products, or should they first procure U.S.- made products even if
    they need to use foreign-sourced material or other inputs?
        Which should have a higher priority--foreign made PPE with U.S.-
    origin materials, or U.S.-made PPE with foreign materials?
        Answer. During the initial response to the COVID-19 pandemic in
    2020, the U.S. medical supply chain failed due to reliance on foreign
    manufacturing and production of supplies and products. Using COVID-19
    supplemental appropriations, ASPR invested over $17 billion to expand
    the country's domestic manufacturing infrastructure, especially for
    (PPE). Because of these investments, there is now domestic capacity to
    produce over 3.9 billion gloves, 690 million N95 respirators, and 531
    million surgical masks per year. It took decades for these industries
    to leave our shores, and it will take time and continued investment to
    bring them back. Annual funding is required: (1) to preserve capacity
    investments made thus far by ensuring appropriate management and
    oversight of the existing contracts; (2) to evaluate and assess where
    the future investments should be made; (3) to make those investments;
    and (4) to ensure the overall portfolio of investments is balanced,
    productive, and sustained. ASPR is appreciative of the $10 million
    included in the FY 2024 appropriation bill to continue this mission.
        Purchasing critical medical countermeasures (MCMs) and PPEs
    domestically reduces the risk of relying on international partners. We
    learned during the COVID-19 pandemic that the supply chain can fail;
    having an SNS that relies on foreign manufacturing and production of
    critical products is not the best choice for national security. When
    and where possible, the SNS looks to domestic sourcing for products to
    include in the stockpile. HHS is complying with the Make PPE in America
    Act. For commercially available products with multiple manufacturers,
    domestic material may be more expensive than internationally sourced
    product. However, the higher cost of domestic material is justified by
    their superior quality, which results from stringent manufacturing
    protocols, adherence to product policies and regulatory compliance.
    Moreover, relying on foreign sourcing is not the best preparedness
    posture, and we experienced this firsthand during the COVID-19
    response. SNS also holds products that are not commercially available
    and for which there is limited or no domestic manufacturing capacity.
        ASPR requested $95 million in the FY 2025 President's Budget to
    support sustained efforts in domestic manufacturing. This funding will
    support ongoing efforts to continue partnership with the private
    sector, as well as other U.S. government partners, to sustain and
    enhance domestic manufacturing. We cannot go back to pre-COVID times
    when we all experienced the failure of the domestic supply chain. We
    have learned too much and made significant investment. We cannot let
    this effort dry up. Threats to our domestic medical and pharmaceutical
    industrial base supply chain still exist and must be addressed to
    ensure the nation is prepared to respond to the next public health
    emergency.
        The President's Budget also proposes $20 billion in mandatory
    funding, available for 5 years, across HHS to strengthen the nation's
    biodefense capabilities, of which $10.5 billion would support ASPR
    activities. This funding will support development of prototype
    vaccines, therapeutics, and diagnostics that we can put on the shelf
    that we can pull down when/should that virus hit. Funds will enhance
    and strengthen investments in domestic manufacturing and will ensure we
    are as prepared as possible for the next threat that could emerge.
        U.S. domestically manufactured products should be the priority for
    agency purchases. If specific components or raw materials are not
    available from a domestic source, the Make PPE in America Act does
    provide for a waiver process to seek approval for the use of non-
    domestic materials. The waiver request will require justification to
    explain why that component is not manufactured within the United States
    and/or why the domestic supply is so limited that global sources are
    required. The waiver will be targeted and time-limited, providing
    domestic manufacturers the opportunity to increase their production.
                                     ______

                   Questions Submitted by Senator Jerry Moran
        Question. Seven of the 10 drugs selected for price setting by HHS
    are small molecule drugs. Mr. Secretary, the FDA Commissioner recently
    expressed concerns that innovation will suffer in the area of small
    molecule drugs, which can be found in virtually every American's
    medicine cabinet, because these products will be subject to price
    controls just 9 years after they are approved. The example that Dr.
    Califf used was an approved drug that took 6 years to get through
    clinical trials, leaving just 3 years before the price controls would
    take effect.
        Do you think manufacturers will spend finite resources on such
    products, knowing that simply covering the costs of bringing it to
    market will be difficult to do?
        The structure of the Inflation Reduction Act drug price
    negotiations will change the landscape for the way drugs are developed,
    especially cancer drugs. New oncology drugs usually start in smaller
    populations, allowing innovators to bring medicines to the market
    quickly while they work on application for broader patient populations.
    IRA starts the clock on negotiation with that first approval, which
    means that discovery could have a target on its back if it works really
    well. IRA starts the clock on negotiation with that first approval,
    which means that discovery could have a target on its back if it works
    really well.
        How will you make sure that new oncology discoveries are encouraged
    and not discouraged by the law you supported?
        Answer. The Inflation Reduction Act (IRA) requires Medicare to
    negotiate drug prices for certain high- expenditure, single-source
    drugs directly with drug manufacturers for the first time. This kind of
    negotiation, used successfully for decades by the U.S. Departments of
    Defense and Veterans Affairs will increase competition, expand access
    to innovative, life-saving treatments, and lower costs for enrollees
    and the Medicare program.
        CMS supports innovation and believes it is vitally important that
    beneficiaries have access to innovative new therapies. There's a
    serious issue now with millions of Americans being unable to afford the
    drugs that are currently on the market. If patients cannot afford the
    drugs they need, they cannot benefit from innovations. Negotiation will
    make drugs more affordable for people with Medicare. The United States
    pays three times more for prescription drugs than other developed
    nations. We also expect negotiation to encourage drug makers to create
    business models to stay competitive, fostering the development of new
    treatments and delivery methods.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. As CMS and Congress contemplate how to address Medicare
    telehealth policy this year, we must ensure that provider safety is a
    top priority. As you know, since the beginning of the COVID-19
    pandemic, CMS has allowed providers who render telehealth services from
    their home or other location to list a practice address on their
    Medicare enrollment and billing forms rather than their home address.
    We applaud CMS for extending this flexibility though 2024 within last
    year's Physician Fee Schedule. This has allowed all providers, but
    specifically in the mental health and behavioral space, to feel
    comfortable providing telehealth services from their homes and has
    alleviated administrative and operational barriers for healthcare
    systems and providers across the country. We cannot go back to pre-
    pandemic policy where providers are required to list their home
    address.
        Can you commit to implementing an address requirement that is not
    administratively or operationally burdensome for healthcare systems and
    ensures provider safety and privacy?
        Answer. CMS recognizes that telehealth plays a growing role in
    supporting beneficiary access to the care they need. CMS also
    acknowledges concerns about privacy and safety related to provider's
    home addresses being shared. In the Calendar Year (CY) 2024 Medicare
    Physician Fee Schedule (PFS) final rule, CMS finalized a policy to
    continue to permit the distant site practitioner to use their currently
    enrolled practice location instead of their home address when providing
    telehealth services from their home until the end of 2024. Additionally
    in the CY 2024 PFS final rule, we requested further information from
    interested parties to better understand the scope of considerations
    involved with including a practitioner's home address as an enrolled
    practice location when that address is the distant site location where
    they furnish Medicare telehealth services. The requested information
    will inform future enrollment and payment policy development as we
    continue to consider this issue for future rulemaking.
        Question. Mr. Secretary, as you may know the poultry and cattle
    industries are critical to Mississippi's economy, and in recent years
    the transmission of highly pathogenic avian influenza has decimated the
    production of eggs, which in turn drives the price up for the already
    financially stressed American consumer. Just last year we saw egg
    prices increase almost 40% at the peak of the bird flu spreading around
    my state. Now we see it spreading to cattle, which is no less alarming.
    Mr. Secretary I know cows and chickens are not in the business of HHS,
    but the fact that this deadly flu has already sickened one cattle
    worker in Texas is deeply troubling to me, and I want to make sure your
    agency is focused on ensuring we have the personal protective equipment
    to keep farm workers safe, and vaccines and therapeutics ready to go if
    HPAI begins spreading more easily between people in the future.
        Are any efforts ongoing to determine whether the virus may already
    be circulating in people asymptomatically or undiagnosed? To what
    extent is the CDC leveraging its advanced molecular detection program
    for this purpose?
        Answer. Multiple CDC surveillance systems are used year-round for
    seasonal flu and other illnesses that help the agency monitor the
    health of the U.S. public. These public health systems are routinely
    used to detect rare events, like single human infections with influenza
    viruses. In addition to traditional surveillance systems, we are also
    exploring how wastewater surveillance might be used to monitor for
    influenza A (H5N1). CDC has also developed a research study protocol to
    assess the prevalence of H5N1 among dairy workers. Analysis of this
    information will help CDC and state partners to determine whether there
    is asymptomatic or undiagnosed spread of H5N1.
        Additionally, CDC's SPHERES SARS-CoV-2 Sequencing for Public Health
    Emergency Response, Epidemiology and Surveillance (SPHERES) consortium
    and Pathogen Genomics Centers of Excellence (PGCoE) programs allow us
    to leverage advanced molecular detection in response to H5N1.
        CDC's Advanced Molecular Detection (AMD) program has been working
    to bring sequencing into regular public health practice since 2014. In
    2020, the AMD program established the SPHERES consortium as a forum to
    facilitate knowledge sharing around SARS-CoV-2 sequencing. SPHERES
    brings together scientists from clinical and public health
    laboratories, academic institutions, and the private sector for
    discussions around interdisciplinary and innovative research and
    applied public health pathogen genomics, bioinformatics, and genomic
    epidemiology. SPHERES shares information about ongoing work across
    sectors that advances opportunities for collaboration as we respond to
    and continue to learn more about the outbreak.
        In addition, CDC's AMD program established five PGCoE in 2022 to
    foster innovation and improve technical capacity in pathogen genomics,
    molecular epidemiology, and bioinformatics to better prevent, control,
    and respond to microbial threats of public health importance. Each
    PGCoE site consists of a health department and one or more academic
    institutions, and two of these PGCoE sites are focusing on One Health
    approaches--at the interface of animals, humans, and the environment--
    to help protect human health against the risk of zoonotic pathogens.
    For example, the Washington Animal Disease Diagnostic Laboratory used
    funding awarded to the Northwest PGCoE to build genomic sequencing
    capacity for surveillance of highly pathogenic avian influenza in
    animals. As a result, Washington unified sequencing protocols across
    veterinary and human health to monitor and detect spillover events,
    assess the risk of mammal-to-mammal transmission, and stop threats
    before they spread to humans.
        Question. What would have to happen to trigger the CDC to raise the
    level of its risk assessment? If the CDC does change its assessment,
    how will it communicate this to the general public? What will its
    recommendations for the public be?
        Answer. CDC continuously assesses the risk of HPAI to the public
    based on animal and human data. As new data are obtained, CDC analyzes
    the data for any indications that the virus may become more
    transmissible to humans or may impact the use of antiviral drugs,
    available candidate vaccine viruses, or diagnostics. CDC is using its
    Influenza Risk Assessment Tool (IRAT) to assess new information and
    data from the current HPAI outbreak and the potential pandemic risk
    posed by the H5N1 virus in cattle.
        CDC is currently sharing weekly updates on its website with the
    latest data, guidance, and information on H5N1. Additionally, there are
    U.S. Government Unified Coordinating Group press conferences as well as
    calls with public health national and state partners that are channels
    for communicating new information on H5N1.
        Question. The HHS Pandemic Influenza Plan was last updated in 2017.
    Based on the many challenges of the national COVID-19 response, is HHS
    confident that executing this plan will be effective?
        Answer. The last update to the HHS Pandemic Influenza Plan was in
    2017 (https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-
    2017v2.pdf). Plans are developed to provide general guidance for
    response to emerging incidents. They form the base guidance and assist
    in organization and general understanding of roles and responsibilities
    between Federal, state, territorial, tribal, and private-sector
    partners. However, every response has specific considerations, and some
    deviations from planning documents occur if and as requirements shift.
    Plans are reviewed periodically to incorporate lessons learned from
    responses. The general concepts included in this Plan are effective to
    guide the initial response and provide a roadmap for all involved. As
    noted, deviations can and do occur from planning documents based on the
    specific requirements of the emerging incident. Plans are simply plans
    and best practices that could be utilized for the response.
        Question. What are the CDC and ASPR doing right now to get ahead of
    a potential avian flu pandemic declaration? What preparedness steps are
    they taking?
        Answer. As part of the current U.S. government coordinated response
    to the H5N1 outbreak in cattle, CDC is working closely with our Federal
    partners, including the Office of Pandemic Preparedness and Response
    Policy (OPPR), ASPR, USDA, and FDA. CDC has liaisons from USDA, ASPR,
    and FDA integrated into CDC's incident command structure, and CDC
    communicates on an ad-hoc basis to share technical information across
    relevant agencies. CDC's SARS-CoV-2 Sequencing for Public Health
    Emergency Response, Epidemiology and Surveillance (SPHERES) consortium
    and Pathogen Genomics Centers of Excellence (PGCoE) programs allow us
    to leverage advanced molecular detection in response to H5N1.
        CDC's Advanced Molecular Detection (AMD) program has been working
    to bring sequencing into regular public health practice since 2014. In
    2020, the AMD program established the SPHERES consortium as a forum to
    facilitate knowledge sharing around SARS-CoV-2 sequencing. SPHERES
    brings together scientists from clinical and public health
    laboratories, academic institutions, and the private sector for
    discussions around interdisciplinary and innovative research and
    applied public health pathogen genomics, bioinformatics, and genomic
    epidemiology. SPHERES is hosting presentations and discussions about
    the highly pathogenic avian influenza H5N1 outbreak to share
    information about ongoing work across sectors that advances
    opportunities for collaboration as we respond to and continue to learn
    more about the outbreak.
        In addition, CDC's AMD program established five PGCOE in 2022 to
    foster innovation and improve technical capacity in pathogen genomics,
    molecular epidemiology, and bioinformatics to better prevent, control,
    and respond to microbial threats of public health importance. Each
    PGCoE site consists of a health department and one or more academic
    institutions, and two of these PGCoE sites are focusing on One Health
    approaches--at the interface of animals, humans, and the environment--
    to help protect human health against the risk of zoonotic pathogens.
    For example, the Washington Animal Disease Diagnostic Laboratory used
    funding awarded to the Northwest PGCoE to build genomic sequencing
    capacity for surveillance of highly pathogenic avian influenza in
    animals. As a result, Washington unified sequencing protocols across
    veterinary and human health to monitor and detect spillover events,
    assess the risk of mammal-to-mammal transmission, and stop threats
    before they spread to humans.
        While the risk to humans remains low, ASPR does have a number of
    preparedness programs that HHS could leverage if necessary. As always,
    states can request PPE from the SNS if needed, supplementing what is
    already commercially available or available in state-managed
    stockpiles. This PPE is available to protect farm workers and others
    who may come in contact with infected animals and includes face
    shields, face masks, goggles, and gowns. ASPR has reminded states of
    this resource should they need it.
        In addition, ASPR has tens of millions of antivirals in the SNS,
    many of which are also available on the consumer market. The antivirals
    are available to treat anyone who may test positive for the virus, and
    as you heard from CDC, we are not seeing resistance to these antivirals
    in the current H5N1 strain.
        And finally, we have two candidate vaccines that are well-matched
    to the circulating strain of H5N1 through ASPR's pre-pandemic influenza
    preparedness program. Hundreds of thousands of vaccine doses could be
    deployed quickly, potentially in a matter of weeks if needed, subject
    to appropriate FDA review and action. If additional funding is
    provided, over 100 million doses could be manufactured in the coming
    months. Our flu preparedness program is designed to be fast-moving and
    flexible, and we continue to look for ways to innovate. As such, we
    have requested proposals for an mRNA platform for influenza vaccines,
    which could be integrated into this program. We are currently in
    discussions with companies about these proposals and hope to announce
    more soon.
        Currently, ASPR's U.S. National Pre-Pandemic Influenza Vaccine
    Stockpile (NPIVS) program would be best positioned to support a rapid
    response. The NPIVS was designed to support the development and
    manufacturing of countermeasures to influenza strains as they evolve.
    NPIVS works closely with industry partners to make and test updated
    vaccines that match new strains of influenza viruses with pandemic
    potential as they emerge, while at the same time supporting
    manufacturing capacity to allow for large-scale vaccine production if
    needed. Vaccine candidates being developed and tested under this
    preparedness program, in close coordination with manufacturers, are
    expected to match the current strain.
        Question. Do we expect the pandemic influenza medical
    countermeasures (vaccines, antivirals, diagnostics) that we have
    available in the U.S. work against this strain of influenza?
        Answer. ASPR's U.S. National Pre-Pandemic Influenza Vaccine
    Stockpile (NPIVS) program would be best positioned to support a rapid
    response. The NPIVS was designed to support the development and
    manufacturing of countermeasures to influenza strains as they evolve.
    NPIVS works closely with industry partners to make and test updated
    vaccines that match new strains of influenza viruses with pandemic
    potential as they emerge, while at the same time supporting
    manufacturing capacity to allow for large-scale vaccine production if
    needed. Vaccine candidates being developed and tested under this
    preparedness program, in close coordination with manufacturers, are
    expected to match the current strain.
        Question. Mr. Secretary, the University of Mississippi Medical
    Center, the only academic medical center in Mississippi, is working to
    achieve NCI designation. As you likely know, the cancer outcomes in
    Mississippi are much worse than the national average, yet there is not
    an NCI-designated center in Arkansas, Louisiana, or Mississippi, which
    means Mississippians have to go quite far in some cases to get access
    to the cutting-edge trials and treatments that these centers can offer.
    Because of the serious healthcare challenges Mississippians face, the
    reality of our healthcare disparities, the rural nature of my state and
    our high levels of poverty, I believe there is no place that needs
    access to cutting-edge cancer care more than Mississippi.
        Please share your thoughts on how achieving this designation and
    bringing these trials and treatments to Mississippi will change lives
    in our state?
        Would you commit to helping guide UMMC as it works to establish the
    infrastructure and garner the needed resources to achieve this
    designation?
        Answer. The NCI Cancer Centers Program \22\ represents a
    substantial financial commitment to supporting breakthrough approaches
    to preventing, diagnosing, and treating all types of cancers. The
    program currently supports 72 NCI-Designated Cancer Centers, in 36
    states and the District of Columbia; there are 57 Comprehensive Cancer
    Centers, 8 Clinical Cancer Centers, and 7 Basic Laboratory Cancer
    Centers. The NCI-Designated Cancer Centers are recognized for their
    scientific leadership in laboratory and clinical research, in addition
    to serving their communities and the broader public by integrating
    training and education for biomedical researchers and healthcare
    professionals. These centers dedicate significant resources toward
    developing research programs, faculty, and facilities that will lead to
    better and innovative approaches to cancer prevention, diagnosis, and
    treatment. NCI supports the research infrastructure for designated
    cancer centers to advance scientific goals and foster cancer programs
    that draw together investigators from different disciplines.
    ---------------------------------------------------------------------------
        \22\  cancer.gov/research/infrastructure/cancer-centers.
    ---------------------------------------------------------------------------
        The NCI Office of Cancer Centers \23\ (OCC) consults on a regular
    basis with cancer centers such as the University of Mississippi Medical
    Center (UMMC) planning a first-time application for NCI designation.
    The timeline for attainment of the designation varies greatly,
    depending on the status of the center at the time of initial contact
    with OCC. If the center needs to both build the research base and
    address other essential characteristics prior to application, the
    process may easily take a decade or more, depending on resources
    available, leadership, and other factors. If it already has significant
    cancer research funding, and needs only to refine its organizational
    capabilities, the process may take only a few years. The OCC is pleased
    to continue working with UMMC on this process and recognizes the
    opportunity that UMMC has to improve services for medically
    underserved, rural populations in their catchment area.
    ---------------------------------------------------------------------------
        \23\  cancercenters.cancer.gov.
    ---------------------------------------------------------------------------
        NCI remains committed to providing access to cancer clinical trials
    to communities throughout the United States, including those with rural
    and underserved populations. In addition to the NCI-Designated Cancer
    Centers, the NCI Community Oncology Research Program (NCORP) is a
    national network that brings cancer clinical trials and care delivery
    studies to people in their own communities. NCORP is comprised of 7
    Research Bases and 46 Community Sites, two of which serve Mississippi
    by providing access to NCI-approved cancer clinical trials and research
    studies.
        Question. Mr. Secretary, in a 2016 final rule, CMS required all 50
    states to use the National Average Drug Acquisition Cost (NADAC or nay-
    dak) when calculating Medicaid prescription drug reimbursements. This
    has led to transparency in Medicaid programs and potentially saved
    Medicaid programs millions of dollars. If applied to Medicare Part D
    plans, it seems like the NADAC methodology would:
      --Increase transparency,
      --Save the Federal government and seniors money,
      --Decrease drug prices,
      --Prevent steering to certain pharmacies,
      --Promote fair reimbursements, and
      --Help avoid the closure of independent pharmacies.
        If the NADAC methodology seems to be a cost saver, why is CMS not
    requiring this methodology to be used for Medicare Part D plans?
        Answer. Section 1860D-11(i) of the Social Security Act generally
    prohibits CMS from interfering in negotiations between drug
    manufacturers, pharmacies, and prescription drug plan sponsors or from
    instituting a price structure for the reimbursement of covered Part D
    drugs. Consequently, CMS cannot require Part D sponsors to use the
    National Average Drug Acquisition Cost (NADAC) when establishing and
    making payments for Part D drugs.
        Nonetheless, we continue to encourage Part D plan sponsors to work
    with pharmacies to increase transparency, decrease drug prices, and
    address pharmacy cash flow concerns. On November 6, 2023, we published
    a memo to all Part D plan sponsors via CMS' Health Plan Management
    System (HPMS) titled ``Application of Pharmacy Price Concessions to the
    Negotiated Price at the Point of Sale Beginning January 1, 2024,''
    which reiterates and emphasizes several key points related to pharmacy
    price concessions that CMS also stated in the Medicare Program;
    Contract Year 2023 Policy and Technical Changes to the Medicare
    Advantage and Medicare Prescription Drug Benefit Programs final rule.
    Within the memo, we strongly encouraged Part D plan sponsors to
    consider options such as payment plans or alternate payment
    arrangements in advance of the January 1, 2024, implementation date of
    the policy. CMS additionally emphasized that Part D plan sponsors must
    meet the prompt payment requirements at 42 C.F.R. Sec. 423.520 and
    pharmacy access standards at Sec. 423.120.
        CMS uses existing monitoring and enforcement operations to ensure
    that Part D plan sponsors comply with the access requirements
    prescribed in Sec. 423.120 and prompt payment requirements in
    Sec. 423.520. CMS conducts quarterly analyses of all Part D plan
    sponsors' networks for the contract year to identify Part D plan
    sponsors that are not meeting the pharmacy access standards as required
    by Sec. 423.120(a)(1). Part D plan sponsors that do not meet the
    standards will receive compliance actions, where the level of the
    compliance action escalates when there is repeated noncompliance in
    consecutive quarters. Additionally, CMS monitors the status of Part D
    sponsors' complaints from beneficiaries and providers, such as
    pharmacies. Prompt payment or pharmacy access violations that come to
    CMS' attention can result in a compliance action (or, if the impact on
    beneficiary access is severe enough, an enforcement action, such as
    civil monetary penalties and suspension of enrollment).
        More recently, we reiterated these points in our December 14, 2023,
    ``CMS Letter to Plan Sponsors and Pharmacy Benefit Managers,''
    available at https://www.cms.gov/newsroom/fact-sheets/cms-letter-plans-
    and-pharmacy-benefit-managers, where we identified several concerns
    about practices by some plans and PBMs that threaten the sustainability
    of pharmacies and impede access to care. We encouraged plans and PBMs
    to work with pharmacies to alleviate these issues and safeguard access
    to care.
        We are committed to ensuring beneficiaries have access to necessary
    health services. We value the critical role pharmacies play in
    healthcare delivery and recognize that we must address the needs of
    pharmacies to serve our beneficiaries effectively. We will continue to
    engage with stakeholders and consider policies for inclusion in future
    rulemaking that would lower prescription drug costs for beneficiaries,
    address challenges that pharmacies face, and improve the quality of
    pharmacy care.
        Question. Pivoting to another issue within the pharmacy space--
    Medicare Part D Convenient Access Standards. These standards are based
    on arbitrary geographic locations. For instance, the standard says at
    least 70 percent of Medicare beneficiaries who live in rural areas
    served by a Part D sponsor, should live within 15 miles of a network
    pharmacy. Often beneficiaries, who live within that 15 miles, may only
    have two choices: a single retail pharmacy 15 miles away and maybe the
    plan-owned, PBM-affiliated mail order service. Simply put, there is no
    real choice for the beneficiary and there is no competition in the
    market.
        For the plans that meet the Part D Convenient Access Standards,
    what percentage of service areas have more than 1 pharmacy meeting the
    distance standard?
        What data is available that details how many beneficiaries in
    urban, suburban, and rural areas have access to more than one in-
    network pharmacy within those distances?
        Would tightening the distance requirements and directing plans to
    partner with more than one brick-and-mortar pharmacy and/or partner
    with a non-PBM-affiliated mail order pharmacy improve access, increase
    competition, and help promote drug adherence for beneficiaries?
        Answer. CMS is committed to ensuring that Part D sponsors establish
    a pharmacy network sufficient to ensure access to covered Part D drugs
    for their enrollees. Part D sponsors must demonstrate that they
    provide: (1) convenient access to retail pharmacies for all enrollees;
    (2) adequate access to home infusion pharmacies for all enrollees; (3)
    convenient access to LTC pharmacies for enrollees residing in LTC
    facilities; and (4) convenient access to I/T/U pharmacies for American
    Indian/Alaska Native (AI/AN) enrollees.
        The convenient access standards are applied to different types of
    Part D sponsors. Regional MA-PD and PDP sponsors must meet or exceed
    the convenient access standards across urban, suburban, and rural
    areas, respectively, in each State in which they operate. To the extent
    that a regional MA-PD or PDP sponsor operates in a multi-region or
    national service area, it will be required to meet the convenient
    access standards in each State in that multi-region or national service
    area; the sponsor may not meet the convenient access standards by
    applying those standards across the entire multi-State geographic area
    it services. Local-MA-PD sponsors must meet or exceed the convenient
    access standards across urban, suburban, and rural areas, respectively,
    in each service area (including multicounty service areas) in which
    they operate. Cost plans must meet or exceed the convenient access
    standards across urban, suburban, and rural areas, respectively, in
    each geographic area in which they operate. Part D sponsors may count
    I/T/U pharmacies and pharmacies operated by FQHCs and RHCs toward the
    standards for convenient access to retail pharmacies detailed above.
    CMS reviews Part D sponsors' pharmacy network submissions to ensure
    that inclusion of I/T/U, FQHC, and RHC pharmacies in contracted
    pharmacy networks does not substitute for the inclusion in Part D plan
    networks of retail pharmacies.
        MA-PD plans or cost plans that provide access (other than via mail
    order) to qualified prescription drug coverage through retail
    pharmacies owned and operated by the MA organization that offers the
    plan or the cost plan are not required to meet the retail pharmacy
    access standards. MA-PD plans and cost plans may receive waivers from
    meeting these standards. However, in order for the pharmacy access
    standards to be waived, the MA-PD plan or cost plan in question must
    have a pharmacy network that, per CMS' determination, provides
    comparable pharmacy access to its enrollees as provided under 42 CFR
    422.112 or 42 CFR 417.416(e), as appropriate. This waiver is
    automatically granted when the MA-PD plan or cost plan provides Part D
    drugs predominantly through plan-owned and operated retail pharmacies
    (i.e., more than 50 percent of prescriptions are provided through owned
    and operated retail pharmacies). While this waiver of the convenient
    retail access standards is automatically granted to plans that meet
    this criteria, MA-PD and cost plans using this waiver must initially
    submit information to CMS about the number of prescriptions filled at
    plan-owned retail pharmacies and at contracted pharmacies, and the
    percentage of prescriptions provided through plan-owned retail
    pharmacies during the last complete year prior to the contract year
    when the waiver applies. Part D sponsors that have been granted this
    waiver are required to provide CMS with data on an annual basis on
    prescriptions filled at plan-owned and operated retail pharmacies.
        CMS conducts quarterly analyses of all Part D plan networks for the
    contract year to identify Part D sponsors that are not meeting the
    pharmacy access standards as required by Sec. 423.120(a)(1). CMS uses
    Medicare Plan Finder data to determine whether sponsors meet pharmacy
    access requirements on a quarterly basis. Sponsors that do not meet the
    standards receive compliance actions as described in Sec. 423.505(n).
    Compliance with pharmacy access standards is generally high among the
    Part D plans and no sponsor has failed to meet access standards for
    multiple consecutive quarters.
        Question. Unfortunately, nearly three decades ago, Members of
    Congress decided that telehealth had great potential. . . but only for
    certain patients in certain settings and in certain geographic
    locations. They did not know then what the 21st century would bring and
    how telehealth and technology would evolve to be something as
    convenient as pressing a button. We now have the opportunity to fix
    mistakes and empower patients and their providers to decide when and
    where telehealth works.
        Secretary Becerra, I understand healthcare providers are regulated
    at the state level and held accountable by their licensure boards;
    state laws also dictate things like what types of telehealth modalities
    can be used (audio vs video vs message). At the Federal level, HHS's
    OIG, CMS, the FTC, and even the DEA all have policies and mechanisms in
    place to help contain fraud/waste/abuse, ensure patient safety, and
    decide the appropriateness of individual covered services.
        Do we really need Federal Medicare statute-on top of all of these
    mechanisms and guardrails -to restrict access to care based on
    something as arbitrary as the patient's location?
        Answer. HHS and CMS continually consider how to best ensure access
    to medically necessary items and services and makes changes where
    appropriate and permissible under our statutory authority. We recognize
    the vital role that telehealth can play in the delivery of care,
    particularly among populations that are underserved. We implemented
    Section 4113 of the Consolidated Appropriations Act, 2023, which
    extended many telehealth flexibilities adopted during the public health
    emergency for COVID-19 through December 31, 2024. Additionally, through
    notice-and-comment rulemaking, the CMS solicited public comment and
    implemented regulatory changes that have permanently expanded certain
    telehealth policies that are within the agency's authority to modify.
    Some changes to Medicare telehealth policy would require legislative
    action to amend the statute, and we look forward to our continued work
    with Congress on this crucial issue.
        Question. As we stated in the hearing, in 2003, Congress
    established the Rural Community Hospital Demonstration Program to test
    an alternative payment model for rural hospitals that were facing
    financial constraints with Medicare's inpatient prospective payment
    system (IPPS). Congress has extended the program several times, most
    recently in the Consolidated Appropriations Act of 2021.
        Mississippi ranks among the states with the highest rates of
    hospitals at risk of closing. This demonstration program could serve as
    a means to keeping their rural hospital doors open to serve their
    communities in need of high-quality healthcare. However, CMS has not
    solicited applications since 2017 despite, as I understand it, there
    being a handful of open spots in the program.
        Do you believe this program has been helpful to rural hospitals
    facing closure and we should extend the program when the time comes?
        The program allows for 30 hospitals to participate, how many spots
    are currently open in the program?
        Can you commit to working with me to solicit applications for the
    program and to find ways to help hospitals keep their doors open in
    rural areas?
        Answer. The Rural Community Hospital Demonstration (RCHD) was
    authorized under the Medicare Prescription Drug, Improvement, and
    Modernization Act (MMA) of 2003 ``to test the feasibility and
    advisability of the establishment of rural community hospitals to
    furnish covered inpatient hospital services to Medicare
    beneficiaries.'' The goal of the RCHD is to strengthen the financial
    condition of small, rural community hospitals and help them to meet the
    needs of Medicare beneficiaries who reside in their market areas by
    providing the potential for higher Medicare payments for covered
    inpatient hospital services.
        In an evaluation of the RCHD, CMS found that prior to joining the
    demonstration, RCHD hospitals tended to have lower Medicare inpatient
    margins than eligible non-participant hospitals. Once hospitals joined
    the RCHD, they received payments for inpatient services that were, in
    general, much higher than they would have received under either IPPS or
    SNF PPS. For the cohort of hospitals that joined in FY 2018, results
    show that, on average, participation in the RCHD resulted in large,
    positive, and statistically significant increases in their Medicare
    inpatient and combined margins, bringing hospitals closer to the break-
    even point. For continuing RCHD hospitals, results show that, on
    average, the RCHD did not result in any additional changes in their
    Medicare inpatient and combined margins relative to the changes they
    already experienced. In 2024, 22 hospitals are participating in the
    demonstration. We are happy to work with you on the important issue of
    access to hospital care in rural areas.
        Question. On February 13, 2024, HHS OIG released an audit that
    demonstrated that even during the height of the pandemic when everyone
    was using telehealth and providers were only starting to figure out how
    to bill for the services, there was no evidence of fraud and no reason
    for policies that restrict access to telehealth.
        As Congress considers permanently extending telehealth
    flexibilities for Medicare, do you agree with your OIG that fraud
    should not be a main concern? Do CMS and OIG have the appropriate
    authorities and tools to catch potential fraud--regardless of modality
    (in-person, via telehealth, etc.)?
        Answer. HHS and CMS continually consider how to best ensure access
    to medically necessary items and services and makes changes where
    appropriate and permissible under our statutory authority. We recognize
    the vital role that telehealth can play in the delivery of care,
    particularly among populations that are underserved. We implemented
    Section 4113 of the Consolidated Appropriations Act, 2023, which
    extended many telehealth flexibilities adopted during the public health
    emergency for COVID-19 through December 31, 2024. Additionally, through
    notice-and-comment rulemaking, the CMS solicited public comment and
    implemented regulatory changes that have permanently expanded certain
    telehealth policies that are within the agency's authority to modify.
    Some changes to Medicare telehealth policy would require legislative
    action to amend the statute, and we look forward to our continued work
    with Congress on this crucial issue.
        CMS recognizes the importance of analyzing the impact of these
    changes, and, as such, immediately evaluated the waivers and
    flexibilities issued by the Agency to determine the potential for
    fraud, waste, and abuse in the Medicare program. This process included
    identifying program integrity risks and vulnerabilities associated with
    the waivers and flexibilities; prioritizing those with the largest
    potential for financial loss, beneficiary harm and/or likelihood of
    occurrence; and creating mitigations that addressed these program
    integrity risks and vulnerabilities, including those related to
    telehealth.
        One such mitigation strategy was the continued use of data
    analytics to identify potential program integrity risks. During and
    after the PHE, CMS has continued to analyze claims data to monitor,
    trend, and respond to existing telehealth fraud schemes and to detect
    and respond to potential new emerging fraud schemes. CMS uses a robust
    program integrity strategy to reduce and prevent Medicare improper
    payments, which includes the use of the Fraud Prevention System (FPS).
    The FPS is a predictive analytics technology that runs sophisticated
    algorithms against Medicare Fee-For Service (FFS) claims nationwide.
    When FPS models identify aberrant activity or patterns, the system
    automatically generates and prioritizes leads for further review and
    investigation by Unified Program Integrity Contractors (UPICs). Based
    on the results of all information collected, the UPICs coordinate with
    CMS and the Medicare Administrative Contractors in taking appropriate
    administrative action to recover improper payments and prevent future
    loss of funds, or the UPICs refer the case to law enforcement.
        Additionally, CMS has supported our Federal law enforcement
    partners during and after the PHE on various fraud schemes including
    those related to telehealth. CMS continues to meet regularly with law
    enforcement to discuss new cases, fraud referrals, active UPIC and law
    enforcement cases, and paths for various administrative actions.
        CMS has also taken action to prevent improper Medicare payments by
    educating healthcare providers and suppliers on proper billing. For
    example, CMS has undertaken a number of stakeholder calls including
    open door forums and Medicare Learning Network calls, as well as
    published numerous pieces of subregulatory guidance designed to educate
    practitioners on the additional telehealth flexibilities, including how
    to appropriately bill for these services.
        Question. A bipartisan coalition of State Attorneys General raised
    serious concerns over the past several years about the incumbent grant
    recipient for the human trafficking hotline, Polaris, declining to
    forward tips about trafficking to law enforcement. The AGs note that
    proper reporting of these tips plays a vital part in achieving our
    national goals of disrupting human trafficking operations and helping
    victims recover from the trauma and abuse they suffered. They say, for
    example:
        Attorney General Rob Bonta (D-CA): ``Utilizing Polaris effectively
    and to its full potential is crucial in gathering intelligence to
    combat trafficking, which should include forwarding third-party tips as
    originally intended. Law enforcement relies on third-party tips to
    determine if a vulnerable victim is at risk from a trafficker. Even the
    smallest tip from a concerned citizen can play a significant role in an
    investigation, leading to the dismantling of a trafficking ring,
    rescuing trafficking victims from a life of violence, and providing
    critical support for victims through shelters and service providers.
    This intelligence is instrumental in ensuring the safety of those
    affected by trafficking, allowing survivors to rebuild their lives with
    assistance from dedicated organizations.''
        Attorney General Josh Kaul (D-WI) says, ``Getting information to
    law enforcement can make it possible for officers to hold traffickers
    accountable. Ensuring that law enforcement receives third-party tips
    about potential human trafficking can make communities safer.''
        The ACF FY 2025 Congressional Justification report appears to
    indicate that the Administration agrees that such reporting is
    important, agrees that it is a key function of the National Human
    Trafficking Hotline, and has taken the concerns of these Attorneys
    General and other law enforcement seriously. It notes that the
    Administration has been providing more oversight, technical assistance,
    and monitoring of the Hotline's operations. However, according to the
    Attorneys General, there is a serious disconnect between what you are
    reporting--or what Polaris is reporting to you--and what these
    Attorneys General are experiencing because they report no actual change
    in reporting, no apparent change in protocols, and no known outreach.
        Can you please provide further information on the updates in your
    justification, specifically:
        Has Polaris provided any data on its ``concerted efforts to improve
    coordination and provide tips to law enforcement about all potential
    trafficking incidents.'' For instance, can you provide the number of
    third-party tips (that is, called in by an individual who is not the
    victim), the number of those tips forwarded to law enforcement, and the
    breakdown of each by the age of the possible victim?
        Answer. The National Human Trafficking Hotline (Hotline or NHTH)
    grant recipient is making concerted efforts to improve coordination and
    provide tips to law enforcement about potential trafficking incidents.
    The Hotline grant recipient has also conducted a review and update of
    its protocols for providing tips to law enforcement, convened meetings
    with law enforcement partners in its database, developed a Public
    Service Announcement about the Hotline services and coordination with
    law enforcement for use in law enforcement training on human
    trafficking, and made efforts to clarify the types of information
    necessary to make a report law enforcement.
        Hotline data are dynamic. All data reflects a single point in time
    and figures are subject to change as the Hotline engages in continuous
    data validation and cleansing efforts. For example, multiple
    individuals, including potential victims, may contact the Hotline one
    or multiple times regarding the same potential trafficking situation,
    which complicates computation of ``tips forwarded to law enforcement''
    by contactor type. Additionally, the specific ages of potential victims
    are frequently not known or reported, particularly among third-party
    contactors.
        In calendar year (CY) 2023, the NHTH reported 2,442 likely
    situations of trafficking to law enforcement, 552 of which were
    situations in which the potential victim was the initial signaler to
    contact the NHTH.\24\ The initial signaler to contact the NHTH in the
    remaining 1,890 likely situations of trafficking reported to law
    enforcement was someone other than the potential victim.
    ---------------------------------------------------------------------------
        \24\ The initial signaler is the first person who communicates with
    the hotline about the situation and includes people directed to call on
    behalf of the potential victim, service providers with consent to
    contact, and other third parties. Some situations of trafficking may
    have more than one signaler; in some of these cases we may also have
    heard from the potential victim after the initial signaler contacted
    the Trafficking Hotline.
    ---------------------------------------------------------------------------
      --Of the 552 likely situations of trafficking reported to law
            enforcement in which the potential victim was the initial
            signaler, 172 situations involved minors. Of the 1,890 likely
            situations of trafficking reported to law enforcement where the
            initial signaler was not the potential victim, 1,439 situations
            involved minors.
        Question. Please provide the updates made to ``its protocols for
    providing tips to law enforcement.'' Is the clarification about the
    ``types of information necessary to make a report [to] law
    enforcement'' part of these updates? If not, please share that as well.
        Answer. The following updates were made to the Hotline law
    enforcement protocols: a) removals of specific officers from protocol
    contact lists in response to turnover or reassignment; b) updates of
    existing law enforcement information; c) any enhancement made; d) new
    protocols created; f) comprehensive restructuring of report recipients;
    g) specialist in human trafficking added; h) reorganized by victim
    type; i) new agency added; j) emergency contact added; and k) human
    trafficking coordinator added.
        The Hotline updates do not reflect new information about how to
    make a report to law enforcement. ACF has required that the Hotline
    grant recipient consult with law enforcement regarding the information
    needed and the appropriate format for transmitting tips from the
    Hotline. ACF plans to consult independently with law enforcement
    officials regarding the same. This information will inform requirements
    incorporated in the next Notice of Funding Opportunity (NOFO).
        Question. Has Polaris provided a list of the meetings it has
    convened with ``law enforcement partners'' or the ``16 community-based
    awareness events,'' which included law enforcement, or a list of the
    ``more than 1,000 new contacts'' made to its law enforcement points of
    contact database? Can you share what jurisdictions these cover?
        Answer. ACF maintains regular contact with the Hotline grant
    recipient, which includes discussions about meetings, community
    awareness conferences, and events it initiates or participates in. Such
    convenings include Federal, state, and local law enforcement including
    those from the Departments of Justice, FBI Prosecution Units, Human
    Trafficking Task Force representatives, and child protection services
    professionals in CA, CT, DE, FL, IL, MI, MO, NC, TX, VA, and WI.
        Question. As you noted, Polaris receives the final year of funding
    for its current grant cycle in FY 2024. Can you please share the steps
    that ACF intends to take to ensure that whatever recipient is awarded
    the Hotline grant next will operate the Hotline in a more cooperative
    manner with law enforcement? Further, please share the timeline ACF
    will pursue for awarding funds for the next five-year project.
        Answer. ACF convenes bi-weekly meetings with the Hotline grant
    recipient to monitor hotline operations. During those meetings the
    grant recipients describe ongoing efforts with law enforcement and
    provide updates about any concerns raised by law enforcement
    representatives. In addition, ACF is incorporating additional language
    in the next NOFO outlining specific coordination requirements with law
    enforcement.
        ACF is in the process of drafting the NOFO to solicit proposals to
    operate the National Human Trafficking Hotline. The award of a new
    cooperative agreement will be made in 2025. ACF anticipates issuance of
    the NOFO in December 2024, with applications anticipated to be due in
    March 2025 and grants awarded anticipated in April 2025.
        Question. How many Part D plans have a mail-order pharmacy in-
    network?
        How many of those are vertically integrated?
        How many of these plans offer more than 1 mail-order pharmacy as
    in-network options?
        Is there any data available detailing how long it takes for mail
    order pharmacies to get prescriptions to a Part D patient?
        Can you locate the ``statement of work of solicitation (#MDA906--
    03--R--0002) of the Department of Defense under the TRICARE Retail
    Pharmacy (TRRx) as of March 13, 2003'' that is the codified benchmark
    for Medicare convenient access standards?
        What is the medication adherence rate of Medicare Part D
    beneficiaries? Is there any data pointing to how many medications are
    never picked up? (first fill or refill?)
        Are there any metrics--other than geographic distance--that could
    measure adherence and true access to medications? Anything used by
    URAC? How about proportion days covered?
        Answer. HHS is committed to ensuring Medicare Advantage (MA) and
    Medicare Part D prescription drug plans best meet the needs of people
    with Medicare, and this administration has taken action to ensure MA
    and Part D prescription drug plans remain strong, stable, and
    affordable. Each Part D plan must give at least a standard level of
    coverage set by Medicare. Part D plans can vary on which pharmacies
    they use, prescription drugs they cover, and how much they charge.
        Part D sponsors must secure the participation in their pharmacy
    networks of a sufficient number of retail pharmacies that dispense
    drugs directly to patients (other than by mail order) to ensure
    convenient access to covered Part D drugs by Part D plan enrollees. The
    inclusion of mail-order pharmacies in Part D plan networks is optional.
    Network mail-order pharmacies do not count toward meeting the retail
    pharmacy access requirements. Additionally, Part D sponsors that
    include mail-order pharmacies in their networks must permit enrollees
    to receive benefits, which may include an extended supply of covered
    Part D drugs (for example, a 90-day supply), through a network retail
    pharmacy rather than a network mail-order pharmacy, if they so choose.
        CMS publishes the MA and Part D Star Ratings each year to measure
    the quality of health and drug services received by consumers enrolled
    in MA and Part D plans. The Star Ratings system includes data on
    medication adherence and are publicly available online.\25\
    ---------------------------------------------------------------------------
        \25\ https://www.cms.gov/files/document/101323-fact-sheet-2024-
    medicare-advantage-and-part-d-ratings.pdf.
    ---------------------------------------------------------------------------
        The Monthly Prescription Drug Plan Formulary and Pharmacy Network
    Information files \26\ contain formulary and pharmacy network data for
    Medicare Prescription Drug Plans and MA plans and are publicly
    available online.
    ---------------------------------------------------------------------------
        \26\ https://data.cms.gov/provider-summary-by-type-of-service/
    medicare-part-d-prescribers/monthly-prescription-drug-plan-formulary-
    and-pharmacy-network-information.
    ---------------------------------------------------------------------------
        With respect to vertical integration, we know that the increasing
    level of vertical integration that is occurring among plans, PBMs, and
    their own pharmacies has the potential to result in anticompetitive
    behavior and place independent pharmacies at a disadvantage. That is
    why, in a December 14, 2023 letter to PBMs and plans, CMS urged plans
    and PBMs to engage in sustainable and fair practices with all
    pharmacies--not just pharmacies owned by PBMs. CMS also solicited
    comment in a request for information issued on August 1, 2022 on all
    aspects of data related to the MA program, including the impact of
    mergers and acquisitions, high levels of enrollment concentration, and
    the effects of vertical integration.\27\ CMS is closely monitoring plan
    compliance with CMS network adequacy standards and other requirements.
    ---------------------------------------------------------------------------
        \27\ https://www.Federalregister.gov/documents/2024/01/30/2024-
    01832/medicare-program-request-for-information-on-medicare-advantage-
    data.
    ---------------------------------------------------------------------------
        Question. MA-PD plans are automatically waived from the convenient
    access standard requirements if they own their own retail pharmacy and
    demonstrate that 50% of prescriptions are filled there.
        Is there any data on medication adherence in these plans?
        Does disregard of the convenient access standard impact
    beneficiaries' access to medications?
        Is there any data capturing the geographic distance of these
    pharmacies to beneficiaries and if the plans --if not waived--would be
    able to meet the convenient access standards?
        Answer. CMS is committed to ensuring that Part D sponsors establish
    a pharmacy network sufficient to ensure access to covered Part D drugs
    for their enrollees. Part D sponsors must demonstrate that they
    provide: (1) convenient access to retail pharmacies for all enrollees;
    (2) adequate access to home infusion pharmacies for all enrollees; (3)
    convenient access to LTC pharmacies for enrollees residing in LTC
    facilities; and (4) convenient access to I/T/U pharmacies for American
    Indian/Alaska Native (AI/AN) enrollees.
        The convenient access standards are applied to different types of
    Part D sponsors. Regional MA-PD and PDP sponsors must meet or exceed
    the convenient access standards across urban, suburban, and rural
    areas, respectively, in each State in which they operate. To the extent
    that a regional MA-PD or PDP sponsor operates in a multi-region or
    national service area, it will be required to meet the convenient
    access standards in each State in that multi-region or national service
    area; the sponsor may not meet the convenient access standards by
    applying those standards across the entire multi-State geographic area
    it services. Local-MA-PD sponsors must meet or exceed the convenient
    access standards across urban, suburban, and rural areas, respectively,
    in each service area (including multicounty service areas) in which
    they operate.
        Cost plans must meet or exceed the convenient access standards
    across urban, suburban, and rural areas, respectively, in each
    geographic area in which they operate. Part D sponsors may count I/T/U
    pharmacies and pharmacies operated by FQHCs and RHCs toward the
    standards for convenient access to retail pharmacies detailed above.
    CMS reviews Part D sponsors' pharmacy network submissions to ensure
    that inclusion of I/T/U, FQHC, and RHC pharmacies in contracted
    pharmacy networks does not substitute for the inclusion in Part D plan
    networks of retail pharmacies.
        MA-PD plans or cost plans that provide access (other than via mail
    order) to qualified prescription drug coverage through retail
    pharmacies owned and operated by the MA organization that offers the
    plan or the cost plan are not required to meet the retail pharmacy
    access standards. MA-PD plans and cost plans may receive waivers from
    meeting these standards. However, in order for the pharmacy access
    standards to be waived, the MA-PD plan or cost plan in question must
    have a pharmacy network that, per CMS' determination, provides
    comparable pharmacy access to its enrollees as provided under 42 CFR
    422.112 or 42 CFR 417.416(e), as appropriate. This waiver is
    automatically granted when the MA-PD plan or cost plan provides Part D
    drugs predominantly through plan-owned and operated retail pharmacies
    (i.e., more than 50 percent of prescriptions are provided through owned
    and operated retail pharmacies). While this waiver of the convenient
    retail access standards is automatically granted to plans that meet
    this criteria, MA-PD and cost plans using this waiver must initially
    submit information to CMS about the number of prescriptions filled at
    plan-owned retail pharmacies and at contracted pharmacies, and the
    percentage of prescriptions provided through plan-owned retail
    pharmacies during the last complete year prior to the contract year
    when the waiver applies. Part D sponsors that have been granted this
    waiver are required to provide CMS with data on an annual basis on
    prescriptions filled at plan-owned and operated retail pharmacies.
        CMS conducts quarterly analyses of all Part D plan networks for the
    contract year to identify Part D sponsors that are not meeting the
    pharmacy access standards as required by Sec. 423.120(a)(1). CMS uses
    Medicare Plan Finder data to determine whether sponsors meet pharmacy
    access requirements on a quarterly basis. Sponsors that do not meet the
    standards receive compliance actions as described in Sec. 423.505(n).
    Compliance with pharmacy access standards is generally high among the
    Part D plans and no sponsor has failed to meet access standards for
    multiple consecutive quarters.
                                     ______

                  Questions Submitted by Senator John Boozman
        Question. In 2024 the projected number of new cancer diagnoses in
    the U.S. will top 2 million for the first time. This number is
    equivalent to about 5,480 diagnoses each day. Making decisions after
    receiving a complex medical diagnosis such as cancer is challenging for
    anyone. Patient navigation services help cancer patients and survivors
    get the care they need and provide a valuable return on investment by
    identifying diagnoses at earlier stages, reducing unnecessary resource
    utilization and increasing adherence to treatment regimens. Yet to
    date, patient navigation services are still absent or limited in many
    cancer programs and hospital settings due to cost concerns and lack of
    clinical reimbursement for some payers.
        Would you agree that these services play an important role for
    cancer patients and survivors in getting the care they need, and we
    should work to identify pathways to expand access to patient navigation
    services?
        Answer. Patient navigation services play an important role for
    cancer patients and survivors getting the care they need. It can help
    improve outcomes for cancer survivors and help prevent cancer when used
    to get people screened. Screening is an important first step in
    improving cancer outcomes; for example, precancerous lesions and polyps
    found during cervical and colorectal cancer screening tests can be
    removed before they become cancerous. CDC is supporting the use of
    patient navigation services through its National Breast and Cervical
    Cancer Early Detection Program (NBCCEDP) and National Comprehensive
    Cancer Control Program (NCCCP).
        Nearly all of the NCCCP programs are implementing patient
    navigation (PN) and/or community health worker (CHW) activities related
    to cancer screening and survivorship. For example, CDC has offered
    supplemental funding to all NCCCP awardees since 2023 to support the
    widespread adoption of practice-and evidence-based, sustainable,
    survivorship activities to increase the duration and quality of life of
    cancer survivors. Additionally, more than 20 programs are implementing
    a model, developed through a previous demonstration project, to improve
    wellness of cancer survivors in rural communities. Under the NBCCEDP,
    awardees like the New Mexico Breast and Cervical Cancer Early Detection
    Program are using patient navigators to help women get cancer
    screening, follow-up care, and treatment. Between 2016 and 2022, New
    Mexico used patient navigation services to help more than 1,300 women
    in 15 federally qualified health centers get screened for breast and/or
    cervical cancer, and all of the women diagnosed with breast cancer
    started treatment.
        CDC has hosted training webinars for NCCCP and NBCCEDP programs and
    coalitions to increase awareness and utilization of these newly covered
    treatment services. Enabling reimbursement of patient navigation
    services related to cancer screening, such as those provided by the
    NBCCEDP and other providers, would be very beneficial to helping adults
    receive recommended screenings for breast, cervical, colorectal, and
    lung cancer, especially among people who have little or no access to
    care.
        We are committed to promoting higher quality cancer care and
    improving outcomes while reducing costs. As part of that effort, the
    Biden Administration has taken a number of efforts to improve the care
    of Medicare cancer patients, most notably with the President's cancer
    agenda and the Cancer Moonshot. The Department of Health and Human
    Services (HHS) recognizes that patient navigators provide vital support
    for cancer patients and survivors. Decades of evidence, including
    studies supported through the National Cancer Institute (NCI) and other
    HHS operating divisions, that demonstrated clinical benefits--included
    higher survival rates--for patients who received patient navigation
    services.\28\
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        \28\ ncbi.nlm.nih.gov/pmc/articles/PMC4818009/.
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        As part of the CY 2024 Medicare Physician Fee Schedule final rule,
    CMS finalized coding and payment changes to better account for
    resources involved in furnishing patient-centered care involving a
    multidisciplinary team of clinical staff and other auxiliary personnel.
    These finalized services are aligned with the HHS Social Determinants
    of Health Action Plan and help implement the Biden-Harris Cancer
    Moonshot goal of every American with cancer having access to covered
    patient navigation services. Specifically, we finalized a policy to pay
    separately for Community Health Integration, Social Determinants of
    Health Risk Assessment, and Principal Illness Navigation services to
    account for resources when clinicians involve certain types of
    healthcare support staff such as community health workers, care
    navigators, and peer support specialists in furnishing medically
    necessary care. Community Health Integration and Principal Illness
    Navigation services involve a person-centered assessment to better
    understand the patient's life story, care coordination, contextualizing
    health education, building patient self-advocacy skills, health system
    navigation, facilitating behavioral change, providing social and
    emotional support, and facilitating access to community-based social
    services to address unmet social determinations of health (SDOH) needs.
        The Centers for Medicare & Medicaid Services (CMS) established
    policies in the calendar year 2024 Medicare Physician Fee Schedule
    final rule to make separate payment to healthcare providers for patient
    navigation services related to cancer treatment for Medicare, including
    for patients diagnosed with cancer. Additionally, in March 2024,
    President Biden's Cancer Moonshot announced commitments from seven
    leading health insurance companies, as well as 40 comprehensive cancer
    centers and community oncology practices nationwide, who are expanding
    access to navigation services to help patients and their families
    navigate treatments for cancer. This also includes the Administrations
    work to collaborate with the American Medical Association (AMA), which
    issued updated guidance on the appropriate use of CPT codes, which are
    used by all insurers in reporting clinical navigation services.
        Question. In your FY2025 budget, there is a proposal that would
    penalize hospitals and health systems for not meeting certain
    cybersecurity requirements. However, a review of the top data breaches
    in 2023 shows that over 95% of the most significant health sector
    breaches were related to ``business associates'' and other non-hospital
    healthcare entities. Reducing reimbursements when Medicare already
    underpays providers seems counterproductive to securing the
    cybersecurity the healthcare system as a whole. The recent Change
    Healthcare attack taught us that the system is highly interconnected.
        Are you considering how to address third-party cybersecurity risk
    for other entities such as insurers, medical device manufacturers,
    clearinghouses, and others?
        Answer. In 2023, the U.S. Department of Health and Human Services
    (HHS) released a concept paper that outlines the Department's
    cybersecurity strategy for the healthcare sector. The concept paper
    builds on the National Cybersecurity Strategy that President Biden
    released last year, focusing specifically on strengthening resilience
    for hospitals, patients, and communities threatened by cyber-attacks.
    The paper details four pillars for action, including publishing new
    voluntary healthcare-specific cybersecurity performance goals, working
    with Congress to develop supports and incentives for domestic hospitals
    to improve cybersecurity, and increasing accountability and
    coordination within the healthcare sector.
        Hospitals are specifically at risk for ransomware and other types
    of cyber-attacks because of their scale of operations and the critical
    nature of their services. However, hospitals have many competing
    priorities, and investments in cybersecurity do not necessarily result
    in visible differences to patients or yield financial benefits unless a
    cyber incident occurs, meaning some hospitals have limited incentive to
    prioritize cybersecurity efforts at pace with escalating threats.
        The FY 2025 President's Budget includes a $1.3 billion hospital
    cybersecurity support proposal to ensure care and advance resilience.
    The proposal would establish two incentive structures leveraging the
    Medicare Promoting Interoperability Program structure to encourage
    hospitals to upgrade their cybersecurity practices, steadily increasing
    expectations from ``essential'' to ``enhanced'' to elevate the level of
    hospital cybersecurity efforts stepwise over time and to evolve with
    the changing cybersecurity landscape.
        The first incentive structure would provide $800 million total
    investment payments from the Medicare Hospital Insurance Trust Fund to
    incentivize approximately 2,000 high-needs hospitals (including CAHs)
    to adopt essential foundational cybersecurity practices in FY 2027 and
    FY 2028. The second structure would invest another $500 million from
    the Medicare Hospital Insurance Trust Fund to incentivize all Medicare-
    certified hospitals and CAHs to adopt enhanced cybersecurity practices
    in FY 2029 and FY 2030. The cybersecurity initiative would leverage the
    structure of, and provider familiarity with, the Medicare Promoting
    Interoperability Program to efficiently collect information, make
    incentive payments to certain hospitals, and increase standards to
    strengthen the hospital cybersecurity response.
        Yes. In the Fall 2023 Unified Agenda, the Department announced
    plans for OCR to propose modifications to the HIPAA Security Rule.
    These modifications will improve cybersecurity in the healthcare sector
    by strengthening requirements for HIPAA regulated entities to safeguard
    ePHI; and prevent, detect, contain, mitigate, and recover from
    cybersecurity threats.
        The Health Insurance Portability and Accountability Act of 1996
    (HIPAA) Security Rule applies to covered entities (CEs), including
    health plans, healthcare clearinghouses, and most healthcare providers;
    and business associates, which are persons or entities that generally
    on behalf of a covered entity create, receive, maintain, or transmit
    protected health information (PHI) for a covered function; or provide
    certain services to or for such CE, where the provision of the services
    includes the disclosure of PHI.
        The HIPAA Security Rule establishes national standards to protect
    electronic PHI (ePHI) created, received, maintained, or transmitted by
    covered entities and their business associates. The Security Rule
    requires appropriate administrative, physical, and technical safeguards
    to ensure the confidentiality, integrity, and availability of ePHI.
        The HHS Office for Civil Rights (OCR) initiates investigations of
    covered entities' and business associates' compliance with the HIPAA
    Privacy, Security, and Breach Notification Rules based upon a complaint
    or breach report filed with OCR. Additionally, OCR may open compliance
    review investigations based on an event or incident brought to OCR's
    attention, such as through the media, referrals from other agencies, or
    based upon patterns identified through multiple complaints alleging the
    same or similar violations against the same entity.
        The HHS OCIO Cybersecurity Program includes the Health Sector
    Cybersecurity Coordination Center (HC3) to aid in the protection of
    vital, controlled, healthcare-related information and to ensure that
    cybersecurity information sharing is coordinated across the health and
    public health sector. HC3 does this through the development and
    distribution of comprehensive health and public health sector-specific
    cybersecurity threat briefs, alerts, on specific threats to the sector,
    and white papers.
        Question. Providers are struggling in the aftermath of the
    ChangeHealth cybersecurity attack, as many are faced with a staggering
    financial backlog. I understand many providers had to access private
    loans to continue providing care to their communities, threatening the
    viability of our nation's provider network.
        Are there additional flexibilities needed from Congress to ensure
    HHS can make resources available to providers earlier for future
    incidents?
        How can you assure that companies that are breached hold providers
    and vendors harmless for the impact of the breach?
        How will you ensure that patients are informed about how their
    information was shared?
        Answer. OCR enforces the HIPAA Breach Notification Rule, which
    requires HIPAA covered entities and their business associates to notify
    individuals affected by a breach of unsecured PHI within 60 calendar
    days from the date of the discovery of a breach. This breach
    notification requires important information be provided to affected
    individuals including: (a) a brief description of what happened,
    including the date of the breach and the date of the discovery of the
    breach, if known; (b) a description of the types of unsecured PHI that
    were involved in the breach (such as whether full name, social security
    number, date of birth, home address, account number, diagnosis,
    disability code, or other types of information were involved); (c) any
    steps individuals should take to protect themselves from potential harm
    resulting from the breach; (d) a brief description of what the covered
    entity involved is doing to investigate the breach, to mitigate harm to
    individuals, and to protect against any further breaches; and (e)
    contact procedures for individuals to ask questions or learn additional
    information, which shall include a toll-free telephone number, an e-
    mail address, web site, or postal address.
        However, the Health Information Technology for Economic and
    Clinical Health (HITECH) Act and the HIPAA Breach Notification Rule do
    not authorize OCR to compel a covered entity to perform the breach
    notification requirements. OCR's available remedies for a potential
    breach notification violation include securing a settlement agreement
    with a corrective action plan that would include performance of breach
    notification, or proposing a civil money penalty. OCR may choose to
    propose a civil money penalty for a violation of the HIPAA Rules when a
    regulated entity does not resolve a potential violation with a
    settlement agreement and corrective action plan. When OCR proposes a
    civil money penalty, the HIPAA covered entity might choose to pay a
    penalty instead of taking corrective action, or it might proceed to an
    administrative hearing to adjudicate the violations and related civil
    money penalties.
        Additionally, HIPAA does not authorize HHS OCR to seek injunctive
    relief, such as going to court to request an order requiring a breach
    notification. HHS OCR's FY 2025 Congressional Justification to Congress
    includes a proposed law entitled, Enhancing HIPAA Protections by
    Increasing Civil Monetary Penalty Caps and Authorizing Injunctive
    Relief as a means of improving compliance with the HIPAA Rules.
    Authorizing HHS OCR to seek injunctive relief would significantly
    improve HHS OCR's ability to prevent additional or future harm to
    individuals resulting from entities' noncompliance with the HIPAA
    Rules.
                                     ______

                   Questions Submitted by Senator Katie Britt
        Question. Secretary Becerra, the United States' manufacturing
    capacity for essential medical devices is at serious risk due to
    organized efforts by Chinese manufacturers to enter the U.S. market in
    response to inflationary pressures faced by U.S.-based manufacturers,
    distributors, and providers. Further, many of the devices currently
    entering the U.S. from China are substandard, with the Food and Drug
    Administration issuing safety communications in November 2023 and March
    and April of 2024 warning consumers, healthcare providers, and
    healthcare facilities to avoid syringes manufactured in China. These
    products are being widely used throughout the U.S. healthcare system
    despite the serious risks to patients and the resulting erosion of the
    domestic manufacturing base. As we have seen with personal protective
    equipment, the domestic industry for medical products is declining, in
    certain cases at a rapid pace, with only one domestic manufacturer of
    needles and syringes remaining.
        What steps will CMS take to advance payment policies to support
    provider procurement of domestic sources of essential medical supplies,
    expanding on the precedent set with new payment adjustments to
    hospitals for their share of additional cost incurred for domestically
    made N95 respirators?
        Answer. The COVID-19 pandemic has illustrated how overseas
    production shutdowns, foreign export restrictions, or ocean shipping
    delays can jeopardize availability of raw materials and components
    needed to make critical public health supplies. In the CY 2023 Hospital
    Outpatient Prospective Payment System (OPPS) final rule, CMS finalized
    payment adjustments to help sustain a level of domestic supply
    resilience for surgical N95 respirators that's critical to protect the
    health and safety of personnel and patients in case of a future
    pandemic or increase in transmissions of COVID-19. This policy goal--
    ensuring that quality personal protective equipment is available to
    healthcare personnel when needed by maintaining production levels of
    wholly domestically made personal protective equipment--is emphasized
    in the National Strategy for a Resilient Public Health Supply Chain,
    published in July 2021 as a deliverable of President Biden's Executive
    Order 14001 on ``A Sustainable Public Health Supply Chain.'' We
    received many comments urging CMS to expand this policy to cover other
    forms of personal protective equipment and critical medical supplies
    beyond surgical N95 respirators, and will consider these comments for
    future rulemaking, if appropriate.
        Question. On March 29th last year, the FDA Commissioner testified
    before the House Appropriations subcommittee on Agriculture and was
    asked about the rise in illegal vapor products imported from China, a
    problem which has only worsened dramatically since last year. Today,
    the U.S. nicotine vapor market is dominated by these illegal products,
    predominately from China and with zero regulation from the FDA. Last
    year, during that hearing, FDA to a summit with the Justice Department
    on this issue.
        Did the summit with FDA, and hopefully HHS as well, with DOJ to
    discuss increased enforcement options ever take place?
      --If yes, what was the date (or dates) of the summit meetings?
      --If yes, what HHS and FDA employees were in attendance?
      --If yes, what DOJ employees were in attendance?
      --If yes, what enforcement strategies or actions were agreed upon?
      --If yes, what enforcement strategies or actions, of those agreed
            upon, have been acted on?
      --If yes, what impact have those actions had on the total illicit
            market supply chain?
      --If yes, what products no longer exist on the U.S. market because of
            those actions?
      --If yes, what reduction or percentage of the illicit market has
            occurred? Is the illicit market larger today than it was a year
            ago?
        Answer. In response to the recommendations set forth in the Reagan-
    Udall Foundation evaluation of the FDA's Center for Tobacco Products
    (CTP), the Center announced plans to convene a summit related to
    tobacco product enforcement. Senior officials from the U.S. Department
    of Health and Human Services (HHS) FDA, and the Department of Justice
    (DOJ) met in July 2023 to continue ongoing discussions and close
    collaboration on issues related to enforcement.
        Looking forward, FDA continues to engage in a comprehensive effort
    to take action across the supply chain to address unauthorized e-
    cigarettes, particularly those that are popular among youth, in the
    United States. CTP monitors for unauthorized tobacco products and takes
    enforcement action, as appropriate and based on available evidence,
    across the supply chain-- including manufacturers, importers,
    distributors, and retailers. This work has included many ``first of
    their kind'' actions over the past 2 years in particular, including the
    first injunctions against e-cigarette manufacturers, the first civil
    money penalties (CMPs) against manufacturers for manufacturing and
    selling unauthorized e-cigarettes, and the first seizure of e-cigarette
    products. In particular, FDA has issued approximately 670 warning
    letters to firms and issued 57 CMP complaints for manufacturing,
    selling, and/or distributing new tobacco products without marketing
    authorization from FDA. FDA has also issued more than 550 warning
    letters and 130 CMP complaints to retailers for selling unauthorized
    tobacco products. Further, FDA has established 2 import alerts to
    detain without physical examination new tobacco products that do not
    have marketing authorization at the time of import, and FDA has
    participated in a joint operation with U.S. Customs and Border
    Protection (CBP) that resulted in the administrative seizure of more
    than $18 million worth of illegal e-cigarettes.
        FDA continues to work with DOJ and our other Federal enforcement
    partners. For example, DOJ, on behalf of FDA, has filed seven
    complaints for permanent injunction in Federal district courts against
    e-cigarette manufacturers for continued violations relating to the
    manufacture, sale, and distribution of unauthorized new tobacco
    products. In April 2024, FDA and DOJ seized tobacco products for the
    first time in coordination with the U.S. Marshals Service. In total,
    the joint effort resulted in the seizure of more than 45,000
    unauthorized e-cigarettes.
        Question. Regarding the Maternal and Child Health Services Block
    Grants, while I realize that funding has been designated elsewhere
    towards addressing maternal health and mortality (Special Projects of
    Regional and National Significance (SPRANS)), the fact remains that
    funding for the grants to states has been cut in your budget request.
    In total, States would receive $10,276,000 less in grant funding to
    address maternal health and mortality if the President's FY25 budget
    request were enacted.
        Would you clarify how this budget maneuver will help states among
    worst maternal mortality rates in the country, like Alabama?
        Answer. HRSA's FY 2025 Budget includes an increase of $50.9 million
    over FY 2024 enacted for investments aimed at reducing maternal
    mortality and morbidity before, during, and after pregnancy. This
    includes investments in the Alliance for Innovation on Maternal Health
    (AIM) program, which will continue to improve maternal health outcomes
    by promoting safety and quality of care during pregnancy, delivery, and
    in the postpartum period, increases in the Screening and Treatment for
    Maternal Mental Health program, and investments in the Advanced Nursing
    Education and Nurse Education, Practice, Quality and Retention programs
    to continue efforts to grow and diversify the maternal and perinatal
    health nursing workforce through the Maternity Care Nursing Workforce
    Expansion Program and grow the maternal health nursing workforce in
    rural and underserved community settings, as well as increases in
    SPRANS.
        The FY 2025 President's Budget Request for the Title V Maternal and
    Child Health (MCH) Block Grant Program is $831.7 million--which is an
    increase of $18 million over FY 2024 Enacted. To clarify, there is no
    cut in State Grants funding and it remains flat with FY 2024 Enacted.
    Activities authorized as part of the program include:
      --State MCH Block Grant ($593.3 million; flat with FY 2023 Enacted
            and FY 2024 Enacted): The FY 2025 President's Budget requests
            $593.3 million to support formula awards to states. HRSA will
            continue to provide formula awards to states and jurisdictions
            to meet their most pressing public health challenges.
      --Community Integrated Service Systems (CISS) ($10.3 million; flat
            with FY 2023 Enacted and FY 2024 Enacted): The FY 2025
            President's Budget requests $10.3 million for CISS to help
            states and communities build a comprehensive, integrated system
            of care to improve access and outcomes for all children.
      --SPRANS ($228.1 million; +$16 million above FY 2023 Enacted; +$18
            million above FY 2024 Enacted): The FY 2025 President's Budget
            requests $228.1 million for SPRANS, an increase of $18 million
            above FY 2024 Enacted, and $16 million above FY 2023 Enacted
            amount (after accounting for the shift of the Maternal Mental
            Health Hotline moving out of SPRANS funding to its own
            authority in FY 2024). Importantly, this additional funding
            request supports new and expanded investments in maternal
            health, including support for the workforce and furthering
            state maternal health efforts.
                                     ______

                   Questions Submitted by Senator Marco Rubio
        Question. New data from the American Society of Health-System
    Pharmacists shows there is currently a record number of active drug
    shortages in the United States-- 323 drugs in the first 3 months of
    2024. Issues with quality have consistently contributed to a majority
    of drug shortages for the most basic and lifesaving drugs, including
    medicines that treat cancer, pain medications, and ADHD medications.
    Many of the drugs in shortage are due to quality concerns and are
    sourced from foreign nations, particularly China, who have extensive
    histories of shameful quality standards. However, FDA data clearly
    shows that the agency has used its resources to prioritize domestic
    facility inspections, instead of evaluating sites in countries with
    concerning quality records. Though agency officials justified the
    agency's output as based on a ``risk-based schedule,'' it is concerning
    that the metric does not result in a higher number of foreign
    inspections as proportionate to the high amount of quality issues
    reported.
        What steps has the agency taken to address the high number of drug
    shortages in the United States? How will the President's proposed
    budget add to these efforts?
        Answer. HHS has taken steps toward building a better system to
    respond to drug shortages by proactively monitoring and assessing the
    risks and vulnerabilities to the supply chain to help protect patients
    and mitigate the impacts of shortages. These activities include
    implementing immediate term solutions to improve HHS' ability to
    respond and working to strengthen supply chain resilience. Building on
    the Administration's supply chain efforts, on April 2, 2024, the U.S.
    Department of Health and Human Services (HHS) released a white paper
    highlighting steps HHS has taken to prevent and mitigate drug shortages
    and proposing additional solutions for policymakers to consider. In
    addition to the release of the HHS White Paper, recent steps HHS has
    taken that are described therein include: using all available tools to
    the Food and Drug Administration (FDA) to oversee the safety,
    effectiveness and quality of FDA-regulated products; identifying and
    securing critical life-saving treatments through tools available to the
    Administration for Strategic Preparedness and Response (ASPR); and
    examining the tools available to CMS to curtail shortages and promote
    adoption of supply chain resilient practices in hospitals. Also, as
    announced in the November 2023 White House Fact Sheet, HHS has
    designated a new Supply Chain Resilience and Shortage Coordinator to
    strengthen the resilience of medical product supply chains and to
    address related medical product shortages.
        The FY 2025 President's Budget includes requests from HHS to
    address the high number of drug shortages in the US and strengthen
    medical product supply chains. The FY 2025 President's Budget proposed
    $12.3 million to advance FDA's capabilities to help prepare for, build
    resilience to, and respond to shortages that are supply-driven,
    demand--driven, or both through improved analytics to identify shortage
    threats and vulnerabilities, as well as regulatory approaches to assess
    disruptions and shortages. Through this agency-wide crosscutting
    initiative, FDA will hire additional investigators to fulfill
    inspectional needs associated with increased supply chain disruptions
    and consequent human food and medical product shortages seen in recent
    years. It will also continue to engage in efforts to promote
    manufacturing quality across the pharmaceutical industry and develop
    and implement modernized systems to allow for faster response time to
    shortages.
        Drug shortages remain a significant public health issue in the
    United States and a top priority for HHS. Through important changes in
    FDA authorities, and through ongoing FDA actions, progress has been
    made in preventing many drug shortages from occurring even while FDA
    works to quickly help resolve shortages when they happen. FDA helps
    prevent and resolve drug shortages in various ways such as: expediting
    reviews of new production lines or material sources to increase
    production; reviewing requests for extensions of product expiration
    dating; and exercising temporary regulatory flexibility and discretion
    as appropriate. FDA also works with other stakeholders, including
    healthcare groups and patient organizations to get information about
    specific shortages and identify opportunities to resolve them as
    quickly as possible.
        As a result of presidential, congressional, and FDA actions, drug
    manufacturers are notifying FDA earlier than in the past about certain
    manufacturing interruptions and discontinuances. These early
    notifications give FDA additional time to work with manufacturers and
    other stakeholders to identify ways to maintain treatment options and
    prevent or mitigate a shortage.
        Going forward, FDA is working to identify opportunities to reduce
    the risks of drug shortages. Examples of these include:
      --Gaining fuller insight into the supply chain. Interruptions or
            problems in the drug supply chain can create or worsen drug
            shortages. The Coronavirus Aid, Relief, and Economic Security
            Act amended the Federal Food, Drug, and Cosmetic (FD&C) Act to
            require manufacturers to notify FDA of discontinuances or
            interruptions in manufacturing of active pharmaceutical
            ingredient (API) for certain drugs and also to require firms to
            report annually the amount of drugs they manufacture. However,
            reporting when there is an increase in demand that
            manufacturers likely will be unable to meet without meaningful
            shortfall or delay would better position FDA to help prevent
            and mitigate shortages caused by an increase in demand (in
            addition to those caused by a disruption in supply).
      --Increasing the resilience of the drug supply chain. Drug
            manufacturing in more than one facility and more than one
            geographic region can provide flexibility that reduces the risk
            of drug shortages and helps with resolution of shortages when
            they occur. For example, if a manufacturing facility needs to
            temporarily close, or its operations are curtailed by factors
            such as travel restrictions, quarantines, or natural disasters,
            it is important to have alternative facilities available to
            manufacture the drug or its API. FDA is ready to work with
            manufacturers to address these needs. Furthermore, addition of
            an express requirement to annual ``amount reporting'' under
            section 510(j)(3) of the FD&C Act, such that drug manufacturers
            provide data identifying the suppliers they relied on to
            manufacture a listed drug and the extent of such reliance,
            would help FDA identify vulnerabilities in the supply chain
            that may be hidden.
        Overall, important progress has been made in preventing drug
    shortages from occurring, and FDA continues to work to ensure that
    patients in the United States have access to the medicines they need.
    FDA has put forth several legislative proposals \29\ in its fiscal year
    (FY) 2025
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        President's Budget that would address barriers to drug shortage
    mitigation tactics. If enacted, these proposals would greatly enhance
    the FDA's ongoing work to prevent and mitigate drug shortages. The FY
    2025 President's Budget also proposes $12.3 million for Shortages and
    Supply Chain, including $4.8 million for the Human Drugs Program and
    $2.0 million for the Biologics Program to advance FDA's capabilities to
    help prepare for, build resilience to, and respond to shortages that
    are supply-, and demand-driven through improved analytics to identify
    shortage threats and vulnerabilities as well as regulatory approaches
    to address disruptions and shortages. CDER requests funding for key
    areas that maintain and advance efforts to combat drug shortages. These
    include Drug Shortage Data and Analytics to continue to support the
    surveillance system built during the pandemic. CBER will begin to make
    investments for a shortage surveillance solution that leverages work
    already done in other FDA Centers to identify, manage, and track
    potential and actual shortages.
        Using Defense Production Act authorities, HHS, through ASPR, has
    expanded domestic HHS expanded domestic manufacturing capacity of
    medical countermeasures to make access to lifesaving drugs and vaccines
    more reliable and quickly scalable to respond to future threats. The
    President's FY 2025 Budget includes $75 million for ASPR to build on
    existing progress to invest in manufacturing of more essential
    medicines, medical countermeasures, and critical inputs in the United
    States.
        Finally, the President's Budget also includes $10M to establish an
    HHS supply chain resilience and shortage office to coordinate
    Department-wide activities, strategy, and guidance for drugs,
    biologics, medical devices, and medical foods, including the
    development and implementation of an action plan to strengthen supply
    chains and prevent critical shortages. This effort was initiated in FY
    2024, by establishing a Supply Chain Coordination team to provide
    advice, information, and recommendations to the Secretary on HHS-wide
    supply chain and shortage-related activities. The new funding will
    allow HHS to institutionalize these efforts in a new office within HHS
    and establish a 5-year Action Plan to outline concrete goals,
    milestones, metrics for measuring progress, and associated timelines as
    it oversees implementation of the Action Plan. The Office of the
    Assistant Secretary for Planning and Evaluation (ASPE) is the location
    for the new supply chain resilience and shortages office.
        Question. What is the agency doing to support domestic
    pharmaceutical production/producers?
        Answer. On June 8, 2021, as part of the Executive Order effort, the
    Biden-Harris Administration announced a set of actions designed to
    ensure the U.S. has access to the pharmaceuticals necessary for
    economic security, health security, and national defense. These actions
    are centered on four pillars: boosting local production and fostering
    international cooperation; promoting research and development that
    establishes innovative manufacturing processes and production
    technologies to strengthen supply chain resilience; creating robust
    quality management maturity to ensure consistent and reliable drug
    manufacturing and quality performance; and leveraging data to improve
    supply chain resilience.
        HHS led the development of the 100-Day Review of Pharmaceuticals
    and API, which was published in a report (PDF, 6 MB) by the White House
    on June 8, 2021. HHS and FDA will work with the private sector and
    Congress to implement the recommendations and develop a strategy to
    create a robust and resilient pharmaceutical and API supply chain,
    including facilitating adoption of novel methods for commercial
    production of pharmaceuticals and biologics.
        ASPR has supported the investment in domestic API production via a
    contract totaling $491M to date with Phlow Corporation (PHLOW) in
    Virginia. Originally awarded in 2021, PHLOW is on track to manufacture
    four of the top APIs identified on the FDA essential medicines list by
    September 2024. ASPR's FY25 budget request includes $95 million to
    expand and accelerate development and domestic production of medical
    countermeasures and improve visibility and management of medical supply
    chains to mitigate potential shortages of priority drugs and devices.
    In addition, ASPR awarded $35M under the BioMaP Consortium for
    manufacturing of Key Starting Materials (KSMs) and active
    pharmaceutical ingredients (APIs) to support domestic production of
    sterile injectable medicines. More information is available via https:/
    /www.biomap-consortium.org/drug-substances-at-commercial-scale.
        The COVID-19 pandemic has shown the importance of a nimble supply
    chain that is flexible enough to rapidly change manufacturing volumes
    and products in response to fluctuations in consumer demand during a
    crisis. As this review details, the pharmaceutical supply chain is
    complex, global, and vulnerable to disruptions and is highly influenced
    by certain market factors that have led to an increasing reliance on
    foreign countries to manufacture the medicines, API, and their key
    starting materials (KSMs) that serve the American public.
        There are significant economic issues that are out of our purview
    that have contributed to increased foreign manufacturing, including
    pricing pressures and labor and regulatory costs.
        Within CDER the most important thing we can do to help reduce our
    reliance on foreign manufacturing is to encourage and facilitate the
    adoption of advanced manufacturing. Ensuring that both brand and
    generic drug manufacturers will have access to information regarding
    advanced manufacturing technologies is vitally important as advanced
    manufacturing requires a skilled workforce and can help domestic
    companies operate with lower costs and fewer potential quality issues,
    improving the global competitiveness of U.S. manufacturing.
        CDER's programmatic support for advanced manufacturing includes an
    Emerging Technology Program, a dedicated effort known as the Framework
    for Regulatory Advanced Manufacturing Evaluation (FRAME) initiative to
    address the regulatory framework for advanced manufacturing
    technologies, the implementation of the advanced manufacturing
    technologies (AMT) designation program, and a robust extramural and
    intramural advanced manufacturing research program. CDER's Emerging
    Technology Program was developed to engage with companies that are
    pursuing innovative approaches to pharmaceutical product design and
    manufacturing early in the development process. The Emerging Technology
    Team (ETT) can help identify and discuss scientific and regulatory
    challenges prior to a regulatory submission, which can streamline the
    application submission process. The ETT has facilitated the approval of
    drugs manufactured using continuous manufacturing (a type of advanced
    manufacturing) for a range of product types, including solid oral
    dosage forms, and biotechnology products.
        With respect to the implementation of the AMT designation program,
    FDA published draft guidance on the program on December 13, 2023, in
    advance of the applicable statutory deadline. The Agency is currently
    considering comments to the draft guidance and incorporating revisions
    as necessary with the intent to finalize the guidance in late 2024.
        CBER encourages development and adoption of AM technologies to
    support fewer interruptions in production, fewer product failures, and
    greater assurance that biologic products will provide the expected
    clinical performance. The CBER Advanced Technologies Team offers pre-
    submission regulatory support to meet with prospective innovators and
    developers of AM technologies to provide informal consultation during
    early-stage development. CBER also works closely with FDA's ORA on new
    inspection strategies. To address manufacturing challenges, CBER has
    made several extramural awards to support research projects that
    promote the development and adoption of innovative approaches. Results
    have been communicated to stakeholders in over 17 scientific
    publications.
        Question. Please provide an update on the agency's progress to
    obtain multi-entry visas or other tools for FDA's pharmaceutical
    investigators to travel and complete site visits and inspections more
    frequently in China.
        Answer. The Agency remains committed to improve its foreign
    inspection efficiencies and processes. The Agency has sent U.S.-based
    FDA investigators on details to FDA's foreign office in China in order
    to limit travel from the United States to sites located in that country
    and allow us to accomplish more inspections. We have also worked to
    obtain six-month two-entry visas for China for many of our
    pharmaceutical investigators, which has saved a significant amount of
    time and avoided potential delays encountered in having to apply for a
    visa for each inspection trip to China. Currently, visas for China are
    valid for 6 months and not to exceed 2 entries.
        Question. What actions has the agency taken to maintain a resilient
    pipeline of safe and effective drugs from foreign manufacturing sites?
        Answer. FDA's shortage response focuses on intake of information
    from various sources to determine if a shortage exists or is expected,
    for example, receiving and analyzing the potential impact of
    manufacturer notifications of a discontinuance or interruption in
    manufacturing of finished products or active pharmaceutical
    ingredients. FDA can then plan and execute strategies to help mitigate
    or prevent the impact of shortages. FDA utilizes available tools to
    help mitigate a drug shortage, including prioritizing review of
    manufacturing supplements or abbreviated new drug applications (ANDAs)
    for drugs in shortage or for which there is only one approved
    application; communicating with manufacturers to understand options for
    increasing supply; or exercising temporary regulatory discretion to
    increase supply in certain circumstances. FDA also assesses
    manufacturers' compliance with reporting requirements enacted and
    effected through various laws and regulations.
        In addition, FDA remains committed to using all available tools to
    oversee the safety, effectiveness, and quality of FDA-regulated
    products. As drug manufacturing has globalized over the years, FDA has
    modernized its programs to help ensure that companies--regardless of
    where they are located--continue to meet the FDA's standards for
    producing medicines for U.S. patients that are high quality, safe, and
    effective. FDA has resumed normal inspection operations and continues
    to prioritize inspections that were delayed due to the COVID-19 public
    health emergency, while maintaining its high standards and
    responsibility for the public health. In Fiscal Year (FY) 2022, FDA
    conducted 863 human drug inspections, of which close to 70% were
    domestic firms. In FY 2023, FDA conducted a total of 1,205 human drug
    good manufacturing practice (GMP) inspections (nearly a 30% increase
    over FY 2022), with close to 60% including foreign facilities.
        Question. Do you believe there should be additional factors added
    to the ``risk-based schedule'' to prevent future drug shortages from
    foreign produced drugs?
        Answer. Under current authorities (Sec. 510(h)(4) of the FD&C Act)
    FDA can add risk factors to the Site Selection Model (SSM), as it says:
      --(G) Any other criteria deemed necessary and appropriate by the
            Secretary for purposes of allocating inspection resources.
        The governance process for the SSM includes an annual review and,
    as needed, FDA can add new risk factors and/or change the weighting or
    data sources for existing risk factors. This provides the agency with
    suitable flexibility to introduce additional data into the model, if
    and when, there is a need and we have reliable data sources.
        Question. How can Congress and the agency work together to ensure
    there are enough foreign inspections of drug manufacturing sites to
    ensure quality standards are being consistently met?
        Answer. Timely investigations and inspections are critical to
    achieving FDA's mission and often require agency staff to undertake
    extensive travel both within the US and overseas. As a part of
    reorganization efforts, committees to modernize agency travel practices
    and procedures for staff members who must travel to conduct inspections
    and investigations have been developed. These committees will help
    ensure compliance with applicable policies and regulations, including
    the Federal Travel Regulation, while at the same time identifying
    opportunities to reduce complexity and make the travel process as
    flexible, seamless, and simple as possible.
        We also need to ensure adequate, consistent and sustained funding
    to FDA inspection resources to secure sufficient investigatory staff to
    conduct inspections and investigations, domestic and foreign, at a
    travel frequency that is both sustainable by staff and allows for the
    appropriate volume of inspections to be accomplished.
        FDA is exploring various strategies to provide additional support
    and resources to our staff who conduct foreign inspections,
    acknowledging the heightened demands associated with international
    travel. Foreign inspections involve longer travel durations, traveling
    to different time zones, and potential cultural differences,
    contributing to a heavier workload for investigators. In addition, the
    FY2025 President's budget requests additional funding to expand the
    Agency's foreign office footprint and deployed personnel. This funding
    would strengthen FDA's knowledge of imported products and expand our
    ability to quickly complete in-person inspections of foreign facilities
    in specific countries.
        Question. Through the Family Smoking Prevention and Tobacco Control
    Act, Congress required the FDA to publish a rule requiring foreign
    manufacturers to register with the FDA if they wanted to sell tobacco
    products in the U.S. In a public attempt to comply, the FDA committed
    to issuing the foreign manufacturer registration rule in 2012. It has
    been more than a decade and, yet, the FDA has consistently punted the
    date for issuing the rule. By failing to act on this rule, illegal
    vapor products from China have flooded our ports and dominated the
    domestic market. Floridians are particularly impacted by this as our
    numerous ports of entry and international facilities make our state
    ripe for the importation. This has caused the state to become the
    largest market for disposable vaping products in the country.
    Manufacturers in China are free of registration requirements or any FDA
    regulatory oversight because your agency has given these bad actors a
    free pass to infiltrate the American markets.
        Is the FDA on track to publish the foreign manufacturer
    registration rule by the end of this year?
        If no, could you provide a realistic timeline for when the rule
    will be issued?
        What obstacles has caused the agency to delay the implementation of
    the rule?
        How does the FDA hope the rule will help the agency, as well as CBP
    and USPS, enforce the law against these illicit products?
        Answer. FDA continues to work on the Establishment Registration and
    Product Listing for Tobacco Products proposed rule, which appeared in
    the Fall 2023 Unified Agenda (see: Agency Rule List-Fall 2023
    (reginfo.gov)). The Unified Agenda lists the estimated date for the
    proposed rule as November 2024. The proposed regulation would prescribe
    the format, content, and procedures for establishment registration and
    tobacco product listings for both domestic and foreign manufacturers of
    tobacco products.
        Taking action against illegal tobacco products across the supply
    chain--including importation--is a top priority for FDA in coordination
    with Federal partners. FDA works with U.S. Customs and Border
    Protection (CBP) to help prevent illegal tobacco products, including e-
    cigarettes, from entering the country. Additionally, CBP and FDA, as
    well as the U.S. Postal Service at the International Mail Facilities,
    work collaboratively to screen products to determine admissibility into
    the United States.
        FDA uses Import Alerts to help flag for its staff products that can
    be detained without physical examination, including many unauthorized
    e-cigarettes from China. However, import alerts only help when products
    are accurately declared at the time of import, and bad actors are not
    typically inclined to do that. Because CBP and other Federal partners
    are best suited to identify and interdict inadmissible products,
    including those products that do not adhere to Federal legal
    requirements, the Agency continues to coordinate with them. For
    example, CBP is able to identify and may seize inadmissible products
    under the appropriate legal authority--such as the 1.4 million units of
    unauthorized e-cigarettes products seized at LAX airport last year.
        FDA is committed to enhancing our communication with CBP, engaging
    in joint operations with our Federal partners, and prioritizing this
    work, while maintaining our comprehensive approach along the entire
    supply chain to address unauthorized products from being imported,
    manufactured, distributed, and sold domestically.
        Question. Last year, on May 1, 2023, HHS' Office of Population
    Affairs (OPA) released a statement by Deputy Assistant Secretary Rachel
    Levine on National Adolescent Health Month, which touted new efforts by
    the Biden Administration to ``expand sexual and reproductive health
    information and services'' for teens. Accompanying the press release,
    OPA launched an official webpage promoting resources and guides for
    family planning clinics. However, this webpage disturbingly included
    several resources authored by fringe activist organizations that
    blatantly undermine parental rights and place vulnerable children at
    risk. One document praised ``creative ways to deliver prescriptions and
    supplies,'' like offering ``curbside pickup'' at ``locations frequented
    by youth,'' and using mobile vans to deliver birth control and
    contraceptives directly to teens in their neighborhoods. Another
    ``resource'' advised clinicians on subversive methods to keep parents
    in the dark when their children are seeking advice on contraception, or
    getting tested for a sexually transmitted disease, such as ensuring
    that children log onto virtual family appointments in a locked
    bathroom, outside, or in a parked car so parents cannot overhear their
    conversations. These are the tactics of drug dealers and sexual
    predators, not reputable medical professionals. Healthy parental
    involvement is one the most powerful protections for children's health.
    Placing HHS' stamp of approval on resources that promote fringe methods
    of blocking parents out of some of the most important decisions their
    children can make does not only recklessly endanger children's health,
    it is also against the law. For decades, Congress has included a
    provision in annual appropriations legislation specifically requiring
    clinics that receive Title X Family Planning Grants to ``encourage
    family participation'' in children's decisions about sex,
    relationships, and family formation.
        Does the Biden Administration believe it is safe for minors to
    purchase or receive over- the-counter or prescription drugs without
    their parents' awareness, consent or supervision?
        Does the Biden Administration endorse efforts to give children
    birth control, contraception, and advice about sex without the input,
    consent and supervision of their parents?
        Will you commit to providing my staff with a complete record of all
    correspondence between HHS employees and external organizations related
    to OPA's strategy for National Adolescent Health Month, including Title
    X clinics, Planned Parenthood, the Reproductive Health National
    Training Center, the Human Rights Campaign, and any other external
    organizations?
        How does the agency justify OPA's promoting of fringe methods to
    block parents from participating in vital decisions their children make
    about family formation, when Federal law specifically requires clinics
    to ``encourage family participation'' on these matters?
        Answer. The Biden-Harris Administration strongly believes that
    reproductive healthcare, including access to birth control, is an
    essential part of health and wellbeing. High-quality contraception
    improves health outcomes, advances economic stability, and promotes
    overall wellbeing. As Secretary Becerra stated in 2023, ``The
    professionals at the FDA deserve our gratitude for continuing to foster
    critical innovation for consumers while achieving the highest standards
    for safety and scientific review.''
        Adolescent health involves many aspects of health and well-being,
    including sexual and reproductive health, mental health, community
    support, and the role of caring adults. The HHS Office of Population
    Affairs (OPA) recently released Take Action for Adolescents, the first
    national action plan to advance adolescent health and wellbeing. Take
    Action for Adolescents includes eight goals and action steps that can
    help create coordinated systems, services, and supports that young
    people need to thrive:
        (1) eliminate disparities to advance health equity,
        (2) increase youth agency and youth engagement,
        (3) ensure access to safe and supportive environments,
        (4) increase coordination and collaboration within and across
    systems,
        (5) expand access to healthcare and human services,
        (6) strengthen training and support for caring adults,
        (7) improve health information and health literacy, and
        (8) support, translate, and disseminate research.
        Parents, legal representatives, and caregivers play a critical role
    in health and wellbeing of adolescents. Take Action for Adolescents
    recognizes this role by highlighting how parents and other caregivers
    can participate to advance each of the eight goals. This year, National
    Adolescent Health Month encourages families, caregivers, and all
    stakeholders to make use of resources and ideas to help young people
    thrive, including those outlined in Take Action for Adolescents.
        The Title X Family Planning program provides access to adolescent-
    friendly care and encourages family participation in the decisions of
    adolescents. Title X projects are required to encourage family
    participation to the extent practical.
        Question. Polling consistently shows that parents prefer for their
    child to be cared for by a parent or relative. For example, a 2021
    survey from American Compass found that 67 percent of lower- working
    class families with children under 5 years old prefer to have their
    child cared for by a parent or relative, while only 14 percent prefer
    to send their child to a full-time paid childcare facility. In spite of
    this, your agency--through its $5 billion request for universal Pre-K--
    seems more focused on a one-size-fits-all approach rather than
    providing flexible support for parents to make the best decision for
    their families.
        Why should policymakers only be interested in helping parents place
    their children in daycare, when this runs directly against the
    preferences of most families who would prefer to have a mom, dad, or
    grandparent care for the child at home?
        Since your agency states that the Child Care and Development Block
    Grants (CCDBG), a program that offers greater flexibility and parental
    choice, only serves one in six eligible children, shouldn't Congress
    focus our efforts and appropriations on CCDBG than on programs that
    funnel all children into center-based childcare facilities?
        Answer. The Biden-Harris Early Education and Care Plan builds on
    the current Federal investment in the Child Care and Development Block
    Grant to ensure working families have a range of affordable options
    across the mixed delivery system of care, including home-based child
    care. For the vast majority of families, child care is an economic
    necessity as two thirds of children who are not yet in school have all
    available parents in the workforce. This funding would expand choices
    for parents and provide the ability for families to select care options
    that are most responsive to their needs and preferences.
        The Budget also includes a mandatory funding proposal of $400
    billion to help scale services to more than 16 million children across
    the country whose parents earn up to $200,000 per year, and parents
    could choose from a range of care options available in their state.
    Child care prices drive parent choices, and limited care options
    prevent families from finding the care they would prefer for their
    children. The impact that the lack of affordable child care has on
    parents' ability to work has been well documented, limiting lifetime
    earnings for women and costing the economy billions of dollars a
    year.\30,31\ The Biden-Harris Plan ensures that families don't have to
    choose between quality care that meets their needs and the types of
    employment decisions that can lead to economic sustainability for their
    family.
    ---------------------------------------------------------------------------
        \30\ Ready Nation Council for a Strong America, ``$122 Billion: The
    Growing Annual Cost of the Infant-Toddler Child Care Crisis'' Sandra
    Bishop, Ph.D., February 2023, 05d917e2-9618-4648-a0ee-1b35d17e2a4d.pdf
    (strongnation.s3.amazonaws.com).
        \31\ Urban Institute, ``Lifetime Employment-Related Costs to Women
    of Providing Family Care,'' Richard W. Johnson, Karen E. Smith, and
    Barbara A. Butrica, February 2023, Lifetime-caregiving-costs_508.pdf
    (dol.gov).
    ---------------------------------------------------------------------------
        Quality early education and care is not only beneficial for
    parents, it also has a long-term impact on children's health,
    education, and well-being.\32\ This is why the Biden-Harris
    Administration proposed $200 billion in high-quality preschool for 4-
    year-olds, extending to 3-year-olds over time. This includes investing
    in compensation so that the early childhood workforce earns fair wages.
    High quality preschool education has been proven to prepare children
    for success in school and in life. Building from the foundation of Head
    Start, the Biden-Harris Plan will grow preschool access beyond the
    communities furthest from opportunity to ensure all families have
    access to the types of high-quality preschool in a setting that meets
    their family's preferences from a range of high-quality options. This
    investment can ensure that parents are offered choices that can help
    transform their child's life.
    ---------------------------------------------------------------------------
        \32\ Davis Schoch, A., Simons Gerson, C., Halle, T., & Bredeson, M.
    (2023). Children's learning and development benefits from high-quality
    early care and education: A summary of the evidence. OPRE Report #2023-
    226. Office of Planning, Research, and Evaluation, Administration for
    Children and Families, U.S. Department of Health and Human Services.
    ---------------------------------------------------------------------------

                              SUBCOMMITTEE RECESS

        Senator Baldwin. And with that, the subcommittee will stand
    in recess.
        [Whereupon, at 11:48 a.m., Tuesday, April 16, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2025

                                  ----------

                            TUESDAY, APRIL 30, 2024

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                       Washington, D.C.
        The subcommittee met at 10:01 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tammy Baldwin (chair) presiding.
        Present: Senators Baldwin, Murphy, Manchin, Capito, Hyde-
    Smith, Boozman, Britt, and Collins.

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

    STATEMENT OF HON. MIGUEL CARDONA, SECRETARY

                   OPENING STATEMENT OF SENATOR TAMMY BALDWIN

        Senator Baldwin. The Appropriations Subcommittee on Labor,
    Health and Human Services, Education, and Related Agencies will
    come to order.
        I am going to start by recognizing myself for an opening
    statement, followed by Ranking Member, Senator Capito, before
    turning to you, Secretary Cardona, for your testimony.
        Good morning. Today, we are having a hearing on the Biden
    administration's fiscal year 2025 budget request for the
    Department of Education, and I am happy to welcome Secretary
    Cardona to our subcommittee once again.
        Mr. Secretary, I am looking forward to working in a
    bipartisan manner again this year, with Senator Capito, to help
    develop an LHHS (Labor, Health and Human Services) bill that
    can pass the Senate, pass the House, and be signed into law by
    the President.
        We did our job last year, but House Republicans' insistence
    on partisan policy riders and draconian cuts to essential
    programs that set our children and young people up for success,
    led to repeated shutdowns--showdowns, and CRs (Continuing
    Resolutions), that culminated in passing final Appropriations
    Bills in March that we should have passed months before.
        That kind of chaos does nothing to help ensure our Federal
    resources are used most effectively to serve the people we
    represent. It causes Federal agencies to waste time and money
    instead of working to ensure every dollar we appropriate serves
    our constituents.
        We cannot play politics with our children's future. We need
    to do better. And Mr. Secretary, this budget is a good first
    step in that direction. It outlines important investments that
    are necessary to ensure that all students receive the education
    and support they need to fulfill their potential and move our
    Nation forward.
        Mr. Secretary, you are aware of the opportunities and
    challenges across the education spectrum. Child care and
    preschool are often unaffordable or simply unavailable. There
    are efforts by lawmakers to ban books from classroom shelves.
    We are seeing young kids getting bullied and discriminated
    against in schools and on social media just because of who they
    are.

                            POSTSECONDARY EDUCATION

        Post-secondary education costs too much for too many
    families, and leaves some students saddled with insurmountable
    debt. Career and technical education is not as widely available
    as it should be, and employers are often unable to find the
    workers with the skills they need for available jobs. These are
    some of the concerns I hear across Wisconsin.
        All said, we have some challenges; Mr. Secretary, the
    investments proposed in the President's budget would help
    tackle many of these issues head-on. There is so much we need
    to do to improve the quality and affordability of post-
    secondary education. The President's budget request contains
    investments to continue this important work, including
    investments in the cornerstone of our financial aid system, the
    Pell Grant Program. I look forward to working with you to
    protect and sustain the Pell Grant Program so it can continue
    to provide this critical assistance to millions of students
    around this country.
        I am pleased the budget request supports students, parents,
    and activities to help students complete a post-secondary
    education to further their careers. A growing number of post-
    secondary students are nontraditional students, and our
    colleges need to adapt to help ensure that they can succeed.
        The President's budget request for the Child Care Access
    Means Parents in Schools Program would help parents from low-
    income backgrounds afford childcare so that they can attend
    post-secondary education. Additional proposed investments in
    the Post-Secondary Student Success Program would support
    evidence-based activities to improve post-secondary persistence
    and completion rates, particularly among nontraditional
    students.
        The budget also rightly invests in our Nation's HBCUs
    (Historically Black Colleges and Universities), minority-
    serving institutions, and Tribal colleges. I have seen
    firsthand the important educational opportunities Tribal
    colleges provide to Native students in Wisconsin and know how
    important it is that we continue to invest in Tribal colleges,
    HBCUs, and MSIs (Minority Serving Institutions), including,
    vitally, their research infrastructure.

                    FREE APPLICATION FOR FEDERAL STUDENT AID

        This budget also proposes additional investments for
    administering Federal Student Financial Aid Programs. This
    year, a very challenging rollout of the new simplified FAFSA
    (Free Application for Federal Student Aid) has upended the
    financial aid application process around the country, leading
    to much uncertainty for students and their families. I am
    deeply concerned about low FAFSA completion rates, particularly
    given the promise of FAFSA simplification to make it easier for
    students to apply, and ultimately help more students pursue
    post-secondary education.
        I know you and your staff are working hard to fix these
    issues, but I cannot emphasize enough how important it is that
    we get this right. Accessing this aid can mean the difference
    between someone being able to go to college or not. I am
    committed to working with you to correct any ongoing issues and
    improve completion rates of the FAFSA this year. At the same
    time, we also need to be working to ensure that next year's
    FAFSA is available on time this fall, and rolled out smoothly
    to students and their families.

                         CAREER AND TECHNICAL EDUCATION

        Mr. Secretary, because not every student will choose a 4-
    year pathway, I know you share my interest and passion in
    career and technical education and the important role that
    high-quality CTE (career and technical education) can play in
    preparing students for both college and for careers. The
    budget's proposed increase in CTE would help States, school
    districts, and colleges improve the quality of CTE programs and
    better ensure CTE programs educate students for jobs of the
    future.

                       ELEMENTARY AND SECONDARY EDUCATION

        Mr. Secretary, I am also pleased to see that this budget
    continues support for important investments in key Federal,
    elementary, and secondary education programs, building on the
    increases we have been able to provide in recent years. The
    budget doubles down on our commitment to Title I-A programs to
    provide additional funding to schools serving students from
    low-income families. And it also builds on our investment in
    the IDEA (Individuals with Disabilities Education Act) State
    grants to boost the Federal share of the additional cost of
    meeting the needs of students with disabilities.

                                 MENTAL HEALTH

        I am pleased that your budget also proposes extra
    investments for school-based mental health programs that will
    increase access to support students in need. The budget also
    proposes increased funding for the Full Services Community
    Schools Program, which can also increase access to needed
    mental health programs.
        While Wisconsin marked 2023 as the Year of Mental Health,
    we know that much work needs to be done to address the
    significant mental health challenges facing too many of our
    youth. A few alarming statistics from Wisconsin's Office of
    Children's Mental Health 2023 Annual Report make that clear.
    The report indicates that 34 percent of high school students
    reported feeling sad or hopeless, 18 percent of teens reported
    seriously considering suicide, and 48 percent of LGBTQ
    (lesbian, gay, bisexual, transgender, queer/questioning) youth
    reported seriously considering suicide. Each indicator is going
    in the wrong direction. National reporting tells the same
    tragic story. We need to do more to ensure that all students
    receive the support they need to succeed.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        Finally, I would be remiss if I did not address the ongoing
    protests on college campuses across the United States,
    including in my home State of Wisconsin. Peacefully protesting
    is a fundamental right that all people in this country are
    entitled to. It is an important tool for people to have their
    voices heard and one I support.
        However, when these protests turn to threats, intimidation,
    violence, and in recent cases, anti-semitism, they must be
    called out and condemned in no uncertain terms, hate has no
    place in any educational institution in America; full stop.
        I am glad to see that the President's budget helps address
    this head-on and rightly requests an increase in funding for
    Education's Office for Civil Rights. Every student from early
    childhood education to our college campuses deserves a safe
    place to learn, free from hate, bullying, or discrimination.
    This is a fundamental idea that I am committed to through and
    through; a key tool in helping make that a reality for
    educational institutions receiving Federal assistance is the
    Office for Civil Rights.
        In recent months, some have called for increased efforts to
    root out anti-semitism in educational institutions, which I
    fully agree we must do. But they have then paradoxically called
    for cutting of funding for the very office that leads that
    work. To help eliminate all forms of discrimination we have to
    put our money where our mouth is. We need to provide OCR, the
    Office for Civil Rights, with the additional resources it needs
    to get the job done.
        In a moment, I will turn it over to Ranking Member Capito
    for her opening remarks. Following Senator Capito's opening
    statement, we will hear from you, Secretary Cardona. And after
    that, Senators will each have 5 minutes for rounds of
    questions.
        I will now turn it over to Ranking Member Senator Capito.

                   STATEMENT OF SENATOR SHELLEY MOORE CAPITO

        Senator Capito. Thank you, Chair Baldwin. And thank you,
    Secretary Cardona, for coming and being with us today to
    discuss the Department's budget for 2025.
        As our Chair said, last summer, this committee was able to
    work together to pass 12 bipartisan appropriations bills out of
    the great hard work of Senator Collins here, and Senator Murray
    leading the charge for us. And while I regret that it was so
    very delayed, last month Congress did pass the final bipartisan
    funding bills for 2024. And we were able to successfully
    complete the 2024 process because everyone worked together to
    find some common ground.
        Fiscal year 2025 is likely to face similar, if not greater,
    challenges, but I am hopeful that we will, once again, be able
    to come together and produce a bipartisan 2025 bill, Labor
    bill, that prioritizes programs that help provide the
    opportunity for a high-quality education for all. While the
    budget proposes to continue spending money on programs and
    activities that we simply can't afford, I appreciate the
    somewhat tempered approach this year compared to the previous
    budgets.
        The Fiscal Responsibility Act continues to be the law of
    the land, and will govern what is possible for moving forward.
    Just like last year, we are going to have to make some tough
    choices. So I am concerned that this budget attempts to go
    around the FRA, the Fiscal Responsibility Act, by proposing
    $140 billion in new mandatory spending for programs that this
    country simply can't afford and that the Congress has
    consistently rejected. Expensive new Federal programs, like
    free college, are ill-advised and unlikely to be considered.
    Pandemic-era spending is over, and we need to get down to
    business.
        The challenges facing K through 12, and I don't need to, as
    a former educator--or a lifelong educator I should say--facing
    K through 12 education are downright alarming for the current
    generation of our students. We are facing a crisis of chronic
    absenteeism and failing test scores, or falling test scores in
    this country. The number of kids counted as ``chronically
    absent'', missing at least 10 percent of school days each year,
    is double what it was before the pandemic.
        In West Virginia, my home State, 28 percent of the children
    in school missed more than 18 days of school last school year.
    That is almost a month of school. This isn't okay, and when
    kids don't go to school, they don't learn, they don't thrive,
    and they don't grow, not just academically, but also socially.
        I know you share this concern, and I hope that your
    Department will continue working to give States and districts
    the support they need to help get kids back into the classroom.
    Federal education spending should support States in policies
    that afford the greatest opportunity for kids to learn and
    achieve academically. Formula grant funding like Title I, IDEA,
    Career and Technical Education grants, put education decisions
    as close to the local schools as we can, to the teachers, the
    parents, and also provide the crucial flexibility that local
    communities need to best meet the needs of their students.

                                CHARTER SCHOOLS

        So I am pleased that the budget priorities do that with
    these essential programs. However, your budget also proposes to
    slash other funding intending to help public school students
    succeed. For instance, the Charter School Program, Secretary
    Cardona, this is your fourth year in front of the committee, so
    it shouldn't come to you as a surprise to you that a cut to
    charter school spending does not go over well in a bipartisan
    environment.
        This $40 million cut is based on false claims of the
    declining demand for the program, when really the Department's
    own actions are to blame. The Department's imposition of
    burdensome new program rules and failure to adequately staff
    the program office are the real reasons for any challenge in
    this program. When enrollment in traditional public schools
    declined following the pandemic, charter school enrollment
    increased. I think that is a pretty clear indication of
    increased demand.

                    FREE APPLICATION FOR FEDERAL STUDENT AID

        The budget also includes a $600 million, or almost 30
    percent increase in funding for the Office of Federal Student
    Aid, yet, the Office of Federal Student Aid already receives
    more than $2 billion a year and it is not clear what the
    American students are getting and people are getting for their
    investment.
        I am particularly concerned by the disastrous rollout of
    the new FAFSA for the 2025 school year. You know, I don't
    normally come before folks who are doing the best they can do
    in the jobs they are in, but this has just got me totally
    undone, because it has got everybody in my State and across the
    Nation just appalled at how this could be handled so ineptly.
        Congress passed the FAFSA Simplification Act to simplify--
    and the Chairwoman said this--and improve the process of
    applying for Federal student aid in December of 2020, more than
    3 years ago, yet this administration's implementation of the
    law has not made things better for students or administrators.
        It is not an understatement to say this has been an
    unmitigated disaster caused by an inexcusable failure of
    leadership. Implementation of this bipartisan Congressional
    priority should have been a top priority for the Biden
    administration. It took us a long time to pass that
    Simplification Act; we could get Lamar Alexander up here to
    tell us how long.
        The deadline to update the FAFSA should have come as no
    surprise. In fact, Congress even gave the administration an
    extra year to complete it. But instead of prioritizing this
    important work, the political leadership at the Department of
    Education chose to spend time, resources, and personnel to
    advance the administration's priorities around cancelling
    student debt. To me, that is indefensible.
        I have spoken with so many West Virginians this past
    several months, who are angry about the Department's misplaced
    priorities and feel discouraged about their future because of
    the bungled FAFSA implementation. FAFSA completions are down 36
    percent nationally compared to this time last year. In my home
    State of West Virginia, the number of high school students that
    have completed FAFSA is down almost 40 percent compared to this
    time last year. For nontraditional age students in West
    Virginia, students age 25 and up, FAFSA completion rates are
    down 35 percent. Maybe students put off post-education to work
    or to care for a family member, and now because of this mess,
    they have to delay their goal of furthering their education.
    Some students may never end up enrolling in post-secondary
    education because the hurdles to complete the FAFSA are just
    too high.
        And many of those who have managed to overcome the
    difficulties and submit their FAFSAs are still left in the dark
    about what financial aid they are eligible for in the fall.
    This is obviously a huge issue for students and their families,
    but it is a challenge for our colleges and universities.
    Because of the delays and challenges concerning the rollout of
    the new FAFSA, $482 million is hanging in the balance for
    students in West Virginia, severely jeopardizing college access
    and affordability for those students, and many of whom would be
    the first in their families to go to college.
        Tomorrow is May 1, traditionally known as College Decision
    Day. In a typical year, high school graduates across America
    will be finalizing their decisions as to which college or
    university to attend. But this year, your Department, just
    yesterday, sent colleges and the correct information they need
    to package those aid awards. So students are still unable to
    make plans, and informed financial decisions, what is likely to
    be one of the most expensive and consequential choices that
    they will make in their lives.
        I agree with your statement that there is nothing more
    important right now at the Department of Education, and I hope
    moving forward you will be singularly focused on addressing
    outstanding issues and ensuring that these problems are not
    repeated in the 2025-2026 FAFSA cycle. Our students do deserve
    better.

                                  REGULATIONS

        On that note, I am concerned with all the regulations
    coming out of the Department right now are expected to be,
    including the new Plan B Student Loan Forgiveness Title IX, new
    cash management rules that would increase the cost of
    educational materials for our students. I urge you to abandon
    these efforts.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        Finally, I would ask you to take action to protect our
    Jewish students and restore order on college campuses across
    America. Discrimination based on national origin violates Title
    VI of the Civil Rights Act, and your Department is required to
    enforce the law, that no student should have to fear for their
    safety while attending school. Last week, 26 of my Republican
    colleagues and I sent you a letter on this topic, and I look
    forward to your response.
        Mr. Secretary, we have a lot of important issues to discuss
    today, so I want to thank you so much for being here with us.
        Senator Baldwin. I see we are joined by the Vice-Chair of
    the Full Committee. Senator Collins, would you like to make an
    opening statement?
        Senator Collins. Thank you.
        Senator Baldwin. You are recognized.

                     STATEMENT OF SENATOR SUSAN M. COLLINS

        Senator Collins. Thank you, Madam Chair. I am just going to
    make a few comments because Senator Capito has raised many of
    the issues, as has the Chair.I89Free Application for Federal
    Student Aid
        But I have to tell you, Secretary Cardona, how disappointed
    I am in your leadership. What happened with the FAFSA System is
    simply inexcusable and inexplicable. As our ranking member,
    Senator Capito, has said, the Department had 3 years to
    implement the revisions and then another year to simplify the
    revisions to the Federal Financial Aid application. And I have
    heard from countless families, students, financial aid
    counselors, and administrators who have expressed their extreme
    frustration with the system, and I believe the Department owes
    them an apology.
        This is inexcusable. This wasn't something that was dropped
    on the Department at the last moment. It goes back 4 years, so
    there was plenty of time to get this right. And the fact is
    that students in my State have been up in the air about, what
    do they do. They don't know what package of assistance they are
    going to receive. And as Senator Capito points out, May 1 is
    usually Decision Day, yet the colleges just got the information
    they needed, yesterday. This is just inexcusable.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        I am also extremely concerned about the treatment of some
    Jewish students and faculty on far too many of our college
    campuses. As has been pointed out under the Civil Rights Law,
    the Department has the authority to act on the complaints, and
    there are more than a hundred investigations that have been
    filed since October 7th of last year. Every day, we hear from
    Jewish students who tell me that they are frightened on campus.
        I just cannot believe the rise of anti-semitism on our
    college campuses. That is not to say that people don't have the
    right to peacefully protest; they do, but that is not what is
    happening in far too many areas.

                      RURAL EDUCATION ACHIEVEMENT PROGRAM

        I am very concerned about the budget for rural education.
    In Maine, the majority of our schools are small and rural,
    which is why back in 2002 I co-authored the Rural Education
    Achievement Program known as REAP. We got a $5 million increase
    in the program the last fiscal year, but the administration's
    budget level funds it back--actually, doesn't level fund it;
    that would be okay, instead, the Department is going back to
    fiscal year 2023 levels.
        And finally, although there are so many other issues that I
    would love to touch on in my opening statement, including the
    TRIO Program, which is a wonderful program, and I am pleased
    there is an increase there, IDEA, what we need to start getting
    those numbers up.

                              TITLE IX REGULATIONS

        But a concern that I have is the return to a single
    investigator model under your new Title IX regulations when
    that model has been ruled by multiple courts as unlawful. So I
    just don't understand why the Department would ignore those
    court rulings and go back to a model that has been so heavily
    criticized.
        Again, I think there are a lot of issues to cover today,
    and I very much appreciate the opportunity to touch on some of
    them. Thank you.
        Senator Baldwin. Thank you, Senator Collins.
        Our witness today is Miguel Cardona, the Secretary of the
    Department of Education. Secretary Cardona, thank you for
    joining us. You will have 5 minutes for your opening remarks.
    And you may begin.

                    SUMMARY STATEMENT OF HON. MIGUEL CARDONA

        Secretary Cardona. Thank you. Thank you, Chair Baldwin,
    Ranking Member Capito, and Vice-Chair Collins, and
    distinguished Members of the Committee. Thank you for the
    opportunity to testify today on President Biden's fiscal year
    2025 budget request for the United States Department of
    Education.
        And thank you for your leadership and continued
    partnership. I am proud of how we have worked together in a
    bipartisan fashion during this administration to raise the bar
    for American education. Together, we have prioritized substance
    over sensationalism, defending public education instead of
    defunding it, and recognizing that investing in education is
    investing in a better future for all of us.
        It is in that spirit that I come here today to discuss a
    budget that is not only about our priorities at the Department
    of Education, but about what we are hearing directly from
    parents and others all over this country, in red and blue
    States alike, about where we have common ground when it comes
    to our hopes for our children. This budget is about making
    responsible choices, together, to invest in the foundation of
    American opportunity and raise the bar for our nation's future.
        It is about sustaining academic recovery from the impacts
    of the pandemic through $82.4 billion in calculated investments
    to accelerate learning and success at a crucial time for our
    students to regain lost ground, while also adhering to the
    Bipartisan Fiscal Responsibility Act. It is about investing in
    a stronger future for all Americans by boosting funding to
    close achievement gaps in low-income communities through Title
    I, support for students with disabilities through IDEA, support
    multilingual learners through Title III, and retain, recruit,
    and develop great teachers.
        It is about investing in safer schools and the mental
    health of our students by making more funding available for
    more school counselors and mental health professionals and more
    full-service community schools. It is about giving more young
    people access to the American Dream by building more pathways
    to rewarding careers and opening doors to higher education for
    all students, by improving college affordability, retention,
    and completion, including through free community college and
    increased student supports. It is about making these
    investments in our Nation's future while fully honoring the
    caps under the bipartisan agreement to reduce the deficit.
        Make no mistake. When we look beyond the headlines and all
    the noise, there is so much common ground in our country about
    what matters for our students. Whether it is getting all
    students to read by third grade, providing mental health
    supports in the midst of a youth mental health crisis, opening
    career and college pathways so more students have options for
    rewarding lives and careers, or making higher education more
    affordable and accessible for those who choose that path.
        And I know we are going to continue to work together to
    build on that common ground, prioritizing results over
    rhetoric. We can raise the bar for our nation together. And I
    look forward to working with you to do so. Thank you.
        [The statement follows:]
                      Prepared Statement of Miguel Cardona
        Chair Baldwin and Ranking Member Capito and distinguished Members
    of the Committee. I am pleased to join you today, and I am proud to
    testify on President Biden's fiscal year (FY) 2025 Budget Request for
    the Department of Education. As an educator and a father, I know that
    nothing unites America's families more than the hopes we share for our
    children, and that is why the Biden-Harris Administration continues to
    push for increased investments to ensure all students have equitable
    access to schools, colleges, and educators that welcome and support
    them, inspire their love of learning, and prepare them to succeed in
    whichever career they choose.
        The President's FY 2025 Budget continues the historic progress made
    since the President took office--with nearly 15 million jobs created
    and inflation down two-thirds--by lowering costs for working families;
    protecting and strengthening Social Security and Medicare; investing in
    America and the American people; and reducing the deficit by cracking
    down on fraud, cutting wasteful spending, and making the wealthy and
    corporations pay their fair share. This is a budget that
    unapologetically strives to raise the bar for education in America and
    position our nation to lead the world for years to come. Even in an era
    of relative restraint, where we currently find ourselves operating
    within the discretionary caps of the Fiscal Responsibility Act (FRA),
    we're continuing to push for additional, critical resources that will:
    (1) Achieve Academic Excellence; (2) Boldly Improve Learning
    Conditions; (3) Create Pathways for Global Engagement; and (4) Expand
    Access to Higher Education by Reducing Costs for Students and Investing
    in Student Supports.
              department of education topline request and baseline
        The discretionary request for Department of Education programs is
    $82.4 billion, an increase of $3.3 billion over the FY 2024 enacted
    level. However, since final appropriations were not completed by the
    time of the budget release, the baseline for our FY 2025 request levels
    was the FY 2023 enacted level, and the FY 2025 request submitted does
    not reflect final FY 2024 appropriations action. We look forward to
    working with Congress to provide technical assistance during upcoming
    FY 2025 appropriations action for appropriate review of the
    Administration's proposal, including how FY 2025 requests compare with
    final FY 2024 enacted levels.
                         achieving academic excellence
        Title I funding is absolutely essential to our efforts to ensure
    every student achieves academic excellence. To date, and in partnership
    with Congress, the Biden-Harris Administration has grown Title I
    funding for schools supporting students from low-income backgrounds by
    $1.9 billion--expanding the base of this crucial funding to close
    opportunity and achievement gaps in our nation's schools and sustain
    our academic recovery from the impacts of the pandemic. Our request,
    operating within the constraints of the FRA, calls for a $200 million
    increase in FY 2025 over FY 2023 and $180 million more than the FY 2024
    level, for a total request of $18.6 billion. The Request also includes
    critical updates to ensure States have the resources they need to
    effectively administer the Title I program and ensure every student
    receives an excellent education.
        The President and I remain committed to ensuring that children and
    youth with disabilities receive the services and support they need to
    thrive in school and graduate ready for college and career. The Budget
    Request reflects that commitment through a significant boost in support
    for children with disabilities. We are requesting $15.7 billion for
    special education programs, a more than $200 million increase above the
    FY 2023 enacted level and $190 million more than FY 2024 enacted. This
    includes $14.4 billion for IDEA Part B Grants to States, $200 million
    more than FY 2023 enacted ($180 million more than FY 2024 enacted), and
    $425 million for Preschool Grants, $5 million more than FY 2023 and FY
    2024 enacted. Our request also includes $545 million for the IDEA Part
    C Infants and Families program, $5 million more than FY 2023 and FY
    2024 enacted. However, despite these requested increases there remains
    a nearly $31 billion annual gap between current funding levels and what
    is widely considered to be full funding of IDEA, and that is why the
    Administration continues to support legislation that achieves full
    funding over the next 10 years such as the IDEA Full Funding Act.
        With the obligation deadline for the last of COVID-19 supplemental
    education funding in September 2024, we are proposing a new Academic
    Acceleration and Achievement Grants program, which would help bridge
    the gap between the crucial recovery work that American Rescue Plan
    dollars provided to sustained academic acceleration and achievement
    efforts in the long run. This mandatory proposal would provide $8
    billion over years to help Title I and Title I-eligible schools--
    including those in an improvement status and especially hard hit by the
    COVID-19 pandemic--to improve opportunities and outcomes for
    underserved students through a variety of proven, evidence-based
    strategies, including: increasing student attendance and engagement;
    providing high-quality, high-dosage tutoring; and expanding summer,
    extended, or afterschool learning time.
        The Budget proposes a new $25 million demonstration program to
    incentivize school districts to expand high-quality public preschool in
    schools and community-based settings, including by leveraging existing
    Federal investments like Head Start and Title I. This new investment
    complements the mandatory funding proposal also included in the
    President's Budget (at the Department of Health and Human Services, in
    partnership with the Department of Education), which would provide
    assistance to every State to establish and expand high-quality free
    preschool, through a Federal-state partnership.
                      boldly improving learning conditions
        Every student should have access to outstanding, well-prepared,
    well-supported educators who reflect the rich diversity of our nation.
    Our budget makes significant investments in educator recruitment,
    preparation, retention, and professional learning, improving resources
    and support for America's teachers and school leaders to expand their
    impact within and beyond their classrooms. This includes $2.9 billion
    in educator preparation, development, and leadership--an increase of
    nearly $100 million over FY 2023 levels and $200 million over FY 2024
    levels--including $30 million in Hawkins and $95 million in Teacher
    Quality Partnerships to build a diverse and well-prepared teacher
    pipeline, and $125 million to address shortages of special education
    teachers and providers. The Budget also supports an expansion of $17
    million in the National Professional Development program to help shore
    up the pipeline of bilingual educators, as well as $5 million in
    graduate fellowships for faculty in high-need areas.
        Improving learning conditions also means acknowledging that
    communities with high rates of poverty need comprehensive services to
    support and sustain student well-being and improved academic outcomes.
    Schools are ideally situated to provide such supports, which is why I
    am requesting $200 million to expand Full-Service Community Schools, an
    increase of $50 million over FY 2023 and FY 2024 enacted levels, to
    meet increasing demand for the program. I am requesting a total of $216
    million for School Safety National Activities, which will provide $40
    million in new funding to meet the mental health needs of our students,
    school staff, and teachers and build on the Administration's historic
    progress in increasing the number of school counselors, school
    psychologists, social workers, and other health professionals serving
    our students within schools. Already, the Department has obligated $571
    million in mental health programs for K-12 schools, enabled through
    partnership with Congress on the Bipartisan Safer Communities Act--
    helping accelerate our nation towards the President's ambitious goal of
    doubling the number of mental health professionals in our nation's
    schools. Our budget also includes a new $25 million investment in the
    Fund for the Improvement of Postsecondary Education (FIPSE) to help
    colleges and universities develop campus-wide strategies and improve
    institutional and systemwide capacity to address student mental health
    needs and other non- academic barriers to student success, including
    hiring additional providers on their campuses.
                    creating pathways for global engagement
        I strongly believe that being bilingual is a superpower. It is why
    we are requesting $940 million for English Language Acquisition grants,
    an increase of $50 million over FY 2023 and FY 2024 enacted. This
    increase would not only strengthen capacity for schools to meet the
    needs of English Learners and their teachers, it would also provide $75
    million to build multilingual teacher pipelines and provide
    professional development in multilingual education and $5 million for
    postsecondary education fellowships to include the quality of
    multilingual teacher preparation and preparation in other critical
    educator shortage areas.
        To further prepare our students for global success, our high
    schools should evolve to meet the career and college demands of today
    and tomorrow. Reimagining traditional educational pathways is a
    critical piece of the President's vision to increase successful
    outcomes for all students and help them compete internationally.
    Accordingly, our budget request includes $1.5 billion for Career and
    Technical Education (CTE) state grants, an increase of $40 million
    above FY 2023 enacted and $30 million above FY 2024 enacted, to invest
    in workforce development and build the capacity of existing CTE
    programs. We are also requesting $64.4 million for CTE National
    Programs (an increase of $32 million over FY 2023 enacted and $52
    million over FY 2024 enacted), which includes a $57 million investment
    in the Career Connected High Schools program to redesign our high
    schools to build career and college pathways and align with our
    postsecondary education system. This program will provide competitive
    grants to partnerships among school districts, institutions of higher
    education (including community colleges), and employers. Key activities
    would include dual enrollment, work-based learning, career-related
    credentials, career-navigation support, and educator development to
    support effective integration of academic and career-connected
    instruction across grades 11--14. Further, our request includes $12
    billion in mandatory funding over 10 years for the new Reducing the
    Costs of College Fund--and this proposal includes over $7 billion in
    the Classroom to Career program, which reduces costs for students by
    providing funds to States to expand student access to free, career-
    connected dual enrollment programs.
            making postsecondary education inclusive and affordable
        Most well-paying jobs today require some education beyond high
    school. But as college costs continue to rise, too many students and
    families are finding it harder to afford that path. And despite all the
    progress we have made, we still face serious gaps in college completion
    and attainment based on race and income. Our budget request invests in
    postsecondary success for all students, improving college
    affordability, retention, and completion.
        To expand equitable and affordable access to an education beyond
    high school, the Budget proposes to increase the maximum Pell Grant by
    $100 for the 2025-2026 award year building on successful efforts to
    raise the discretionary maximum award by $900 since the beginning of
    the Biden-Harris Administration. The Budget also increases the
    mandatory Pell add-on by $650 for a total maximum award of $8,145 for
    students attending public and non- profit institutions. This increase
    keeps the Administration on its path to double the maximum Pell Grant
    at such institutions by 2029. The Administration continues to support
    expanding all Federal student aid to students who are Dreamers--and we
    are committed to working with Congress to advance this goal.
        The Budget also proposes to create partnerships between the Federal
    government and States to make 2 years of community college free for
    first-time students and workers wanting to reskill. The Budget proposes
    mandatory funding for 2 years of subsidized tuition up to $4,500 per
    year for students from families earning less than $125,000 enrolled in
    an eligible four-year Historically Black College or University (HBCU),
    Tribally Controlled College or University (TCCU), or Minority Serving
    Institution (MSI).
        In addition to the aforementioned Classroom to Career program, the
    Reducing the Costs of College Fund proposal includes $5 billion for
    awards to colleges and universities that: (1) provide an excellent
    education at an affordable price to expand the number of students
    served and to share best practices, and (2) scale evidence-based
    strategies that increase college completion rates, reduce cost burdens
    for students, and lower costs per graduate.
        The Budget also builds on President Biden's historic actions to
    reduce student debt and college costs by eliminating origination fees
    charged to borrowers on every new Federal student loan.
        In addition to improving college affordability, it is critical to
    help students obtain the resources they need to persist in and complete
    a postsecondary education. The Budget supports innovative and promising
    strategies to improve student success and degree completion, including:
      --Enhancing institutional capacity at HBCUs, TCCUs, MSIs, and low-
            resourced institutions, including at community colleges, by
            requesting $1.3 billion in institutional support under Titles
            III and V of the Higher Education Act. Additionally, the
            Request includes a $100 million initiative in the FIPSE program
            to expand research and development infrastructure at four-year
            HBCUs, TCCUs, and MSIs.
      --$100 million for the Postsecondary Student Success Grant Program,
            which provides competitive grants to States, nonprofits,
            institutions of higher education (IHEs), and systems of IHEs to
            implement, expand, and evaluate evidence-based, data driven
            completion and success strategies to improve student outcomes.
      --$80 million to colleges and universities providing affordable
            childcare for low- income student parents, a $5 million
            increase over FY 2023 and FY 2024 enacted levels to the Child
            Care Access Means Parents in School Program, or CCAMPIS.
      --Increased funding for Federal TRIO programs and GEAR UP, $20
            million and $10 million, respectively, above FY 2023 and FY
            2024 enacted levels to expand services that promote access and
            completion in postsecondary education for underserved
            individuals.
      --$15 million to support a new Statewide Reform Grants program that
            awards grants to States and state higher education governing,
            policy, and coordinating entities to implement statewide
            improvements and reforms to the entire spectrum of
            postsecondary education--from access to career outcomes and
            student success.
      --$10 million to support a new Postsecondary Advancement and Success
            Technical Assistance Center to improve access to equitable
            college inclusion, completion, and retention opportunities.
      --$12 million for the Open Textbooks Pilot to create new open
            textbooks and expand their use, in alignment with the
            Administration's goal of lowering the cost of college and
            eliminating unnecessary junk fees.
        The Budget will improve the services we provide students and
    families to help them pay for college through an essential investment
    in Student Aid Administration. With limited resources, this
    Administration has been engaged on multiple fronts to improve the
    student aid experience, including on actions that are Congressionally
    directed. Some of these efforts include implementing an entirely new
    student aid formula, revamping a 40-year-old student aid application
    system, navigating a successful return to repayment from the pandemic-
    driven payment pause, and overhauling a broken student loan servicing
    system. We are requesting $2.7 billion to administer the Federal
    student aid programs in FY 2025, an increase of $625 million and $600
    million, respectively, over FY 2023 and FY 2024 enacted, to support
    students and student loan borrowers as they navigate these modernized
    financial aid application and student loan repayment processes. The
    increase will allow the Office of Federal Student Aid (FSA) to
    effectively operate the student aid programs, and additionally protect
    against cybersecurity breaches to ensure protection of borrowers'
    personal information, implement critical improvements to student loan
    servicing, continue to modernize its digital infrastructure, and ensure
    successful administration of the financial aid programs through a
    simplified application process for students and borrowers.
                 education research, assessment, and statistics
        Education research and data are important because high-quality
    information about effective practices and trends in student achievement
    can help improve teaching and learning, student outcomes, and the
    return on the public investment in education at the Federal, State, and
    local levels. Our Budget requests $816 million for the Institute of
    Education Sciences, an $8 million increase above the FY 2023 enacted
    level and $22 million above the FY 2024 enacted level, to conduct,
    provide and share research and scientific evidence in education.
                        enforcement of civil rights laws
        Finally, we prioritize efforts to enforce the Nation's civil rights
    laws, as they relate to education, by providing $162 for the Office for
    Civil Rights, a $22 million increase above FY 2023 and FY 2024 enacted.
    The increase would be primarily used to expand staffing capacity to
    address a complaint workload that has tripled since 2009 and has
    included alarming reports of rising Antisemitism and anti-Arab
    discrimination in our Nation's schools and college campuses.
                                closing remarks
        I want to thank the Committee for inviting me to discuss the
    President's FY 2025 Budget for the Department of Education. I have
    often said that a budget is a statement of values. As you review and
    consider our budget request, I hope you see how committed President
    Biden and I are to boldly raising the bar in education--to transform
    our education system to better serve the needs of all students. Our
    Budget is dedicated to achieving that goal. Our children and our
    country deserve it. Thank you, and I will do my best to respond to any
    questions you may have.

        Senator Baldwin. We are going to now begin rounds of 5-
    minute questioning. And I will start that out.

                    FREE APPLICATION FOR FEDERAL STUDENT AID

        Secretary Cardona, like many of my colleagues, I am
    troubled by the ongoing FAFSA implementation issues, and I am
    also deeply concerned that the number of our high school
    seniors, who have fully completed their FAFSA, is down nearly
    30 percent from last year, and even lower among students in
    low-income schools.
        I know that your staff is working hard to fix this, but as
    I said earlier, the Department has to get this right, and fast.
    Can you briefly describe what you and your staff are doing,
    right now, to get FAFSA back on track, including increasing
    completion rates this year so students don't lose access to
    financial aid?
        Secretary Cardona. Yes. Thank you, Senator. I can assure
    you that this issue is something that I take very seriously,
    very personally, and I acknowledge the frustration and
    challenges that families and schools are facing. Thirty years
    ago, when I was ready to make decisions about higher education,
    I never filled out the FAFSA. I was probably eligible, but it
    was such a big task that I was intimidated by it, and I didn't
    want to put that pressure on my family to go through that
    process. It felt too difficult.
        And for far too long in this country, too many students
    that have potential have missed out on Federal aid dollars to
    chase their dreams. So, I recognize the frustration and the
    challenge, but the problem that hasn't been touched in 40
    years. The rollout of the Better FAFSA has been riddled with
    delays and challenges, and it has been something that we have
    prioritized at the Department of Education.
        We are doing everything every day to make it right. We are
    holding FAFSA clinics. We are providing daily communication to
    colleges. We have sent information out over a month ago to
    schools, and we are on daily calls with college presidents,
    financial aid directors, hundreds of webinars in different
    languages. We are visiting States and helping with clinics for
    families. If you visit Ed.gov, and there is a spot right there
    where you can see resources for Better FAFSA.
        Just yesterday, I was on the call with national community-
    based organizations who have signed up to hold clinics to make
    sure that they are connecting the dots with schools, and we are
    providing day-to-day support to educators, parents, students
    based on what we are hearing. We recognize the importance of
    this, and we are doing everything in our power to make sure we
    are providing more opportunities for students to fill out the
    Better FAFSA.
        At the end of the day, we are expecting the Better FAFSA
    can open the doors to an additional 600,000 students for higher
    education, and that is a huge difference for the potential of
    our country and the potential of our students.
        Senator Baldwin. Thank you for that answer. While we are
    still working on FAFSA, this cycle, we know that next year is
    right around the corner, and students cannot bear another year
    of delays. So, can you commit to an on-time launch for the
    2025--2026 FAFSA by October 1 of this year? And will you commit
    that colleges will get all the data that they need from the
    FAFSA as soon as the FAFSA is launched?
        Secretary Cardona. Thank you. Yes. This is something that
    we have been focusing on while we are rolling out this year's
    FAFSA, thinking about next year's FAFSA. And I commit to make
    sure that we are moving all of our resources to make sure that
    we adhere to the time lines and do everything in our power to
    make sure not only that we are staying true to the time lines
    but also communicating with parents, students, and schools.
        Senator Baldwin. Okay. So will you be able to reach the
    October 1 deadline?
        Secretary Cardona. That is our expectation to reach the
    October 1 deadline.

                                 MENTAL HEALTH

        Senator Baldwin. Okay. Mr. Secretary, I appreciate the work
    of the Department and administration on increasing access to
    mental health services for children and youth, and related
    proposals in the President's budget. While we have made some
    progress--certainly more needs to be done to overcome
    challenges that I hear about in Wisconsin, frankly every day.
    What I hear about is kids--getting kids the support they need.
    And I am also aware of the interest back home in the
    Department's school-based mental health programs funded out of
    the School Safety National Activities Program.
        We provided $216 million for that program in the budget
    that we just passed and directed the Department to use any
    funds not needed for current activities for new school-based
    Mental Health Grants. Do I have your commitment to use every
    available dollar from the School Safety National Activities
    Program for new Mental Health Grants, just as we directed in
    the recently passed budget?
        Secretary Cardona. Yes, we are committed to adhering to
    that.
        Senator Baldwin. Thank you. And can you describe how this
    budget request would expand and improve school-based Mental
    Health Services for kids?
        Secretary Cardona. Absolutely. I have to tell you that one
    of the things that I feel pretty strongly about, as an educator
    who has had experience, even before the pandemic, addressing
    mental health needs in our schools, is that if the disruption
    of the pandemic results in us going back to the systems that we
    had for providing mental health for our students, we are
    failing our students.
        We are in a youth mental health crisis, and unfortunately
    across the country we have emergency room models of mental
    health support, meaning, after the trauma. We are committed to
    ensuring that funding and support for schools are available to
    make sure that students have the proactive support that they
    need.
        I have to say thanks to the Bipartisan Safer Communities
    Act. We have invested already $571 million in mental health
    services for students in K-12. We are committed to continuing
    to provide support funding for--in our budget proposal that is
    geared toward community--full-service community schools, will
    also bring in community providers to help students and families
    with mental health needs. There is a $40 million Grant to K-12
    Mental Health Services.
        What we are seeing is that some of it is proactive, just
    helping students understand how they are feeling, and
    communicate emotions. And we are also seeing an increase in
    support providers. There has been a 40 percent increase in
    school social workers; that is significant given where we are
    as a country. We have seen an increase of 25 percent of school
    nurses, which is again something that I know for the families
    and students that have benefited from that, they are thankful.
        So, we are committed to keeping that trajectory moving,
    recognizing that a strong system of mental health support for
    students is the foundation for academic progress and students
    reaching their potential.
        Senator Baldwin. Thank you. Senator Capito.

                   ANTISEMITISM AND CIVIL RIGHTS ENFORCEMENT

        Senator Capito. Thank you. Mr. Secretary. I mentioned in my
    opening statement the Title VI of the Civil Rights Act of 1964
    prohibits discrimination on race, color, or national origin in
    programs and activities that receive Federal financial
    assistance. No student should feel unsafe on their campus, yet
    just last week Columbia University had to move classes online,
    and Jewish students were told by a campus Rabbi to go home,
    because it was no longer safe for them on their campus.
        And late last night, protesters took over Hamilton Hall on
    campus, and the University is locked down today with access
    limited to only residential students, if there-- whoever is
    left there. I would imagine some parents have said, you must
    leave, and essential personnel. This is just totally
    unacceptable.
        So, Secretary Cardona, do you believe what his happening to
    Jewish students at Columbia and in other colleges and
    universities across this country, is okay?
        Secretary Cardona. Absolutely not. I think what is
    happening on our campuses is abhorrent, hate has no place in
    our campuses, and I am very concerned with the reports of anti-
    semitism. I have spoken to Jewish students who have feared
    going to class as a result of some of the harassment that they
    are facing on campuses.
        It is unacceptable. And we are committed, as a Department
    of Education to adhering to Title VI enforcement. We have 137
    open cases. We take this very seriously. We have increased the
    number of communications to college campuses to make sure that
    they have what they need in terms of the law and best practices
    on how to make sure they are protecting students.
        Look, as an educator, lifelong educator, protecting
    students is our number one responsibility. We take that
    seriously, and you know the anti-semitism that we have seen on
    campus is unacceptable.
        Senator Capito. Unacceptable, we agree. So you have 136
    cases you said. How long does a case take? I mean, by the time
    this goes through the system, quite frankly, it is either going
    to be all over, or one way or the other. To me that is sort of
    an--I mean, that is good.
        Secretary Cardona. Yes.
        Senator Capito. I am glad you are doing that, but you have
    more immediate means at your disposal, for instance, removing
    Federal funds from institutions that get Federal funds, which I
    imagine most all of them--well they all do----
        Secretary Cardona. Right.
        Senator Capito [continuing]. If they are in violation of
    Title VI.
        Secretary Cardona. You are absolutely right.
        Senator Capito. Are you intending to do that?
        Secretary Cardona. You are absolutely right, investigating
    the cases is the enforcement part of it, but we do have on our
    website, Ed.gov, there is a button there Supporting Campus
    Safety, with guidance and regulations around how to do that.
    And this is why in our budget we are proposing a $22 million
    increase to increase the number of investigators so we can move
    on those investigations that are open. And ultimately if a
    school refuses to comply with Title VI, yes, we would remove
    Federal dollars.
        Senator Capito. Well, I mean a school can refuse. I mean,
    can go ahead and say they are going to abide by Title VI, but
    they are not doing anything. I would commend to you, our former
    member of the Senate, who is now the President at the
    University of Florida, he is not taking a light touch here. I
    mean, he is saying, for many days we have patiently told
    protesters, many of whom are agitators, or outsiders that they
    were able to exercise their right to free speech and free
    assembly.
        We also told them that, clearly, prohibited activities
    would result in trespassing order from the University Police.
    This is not complicated, the University of Florida is not a
    daycare, and we do not treat protesters like children, they
    know the rules, they break the rules, and they will face the
    consequences.
        I mean, I would recommend this, put this on the front of
    your page on best way to deal with anti-semitism on campus.
        Secretary Cardona. We do have a statement that I have
    updated after the campus protest, that makes it very clear that
    being unsafe on campus is not going to be tolerated, and that
    we do not condone, and we definitely reject any calls for
    genocide, or any calls for anti-semitism--or any anti-semitism
    on campus. And that is something that I have been pretty
    adamant about even before October 7.
        Senator Capito. Do you have people at Columbia right now on
    the scene to see what is going on there? Do you have staff
    there to watch?
        Secretary Cardona. I do not have staff at the moment.
        Senator Capito. Does the Civil Rights Office have somebody
    up there?
        Secretary Cardona. I do not have staff at the Columbia
    University. And I should share with you that we do have an open
    investigation at Columbia University.

                    FREE APPLICATION FOR FEDERAL STUDENT AID

        Senator Capito. All right. Okay. I want to move to the
    FAFSA because I brought that up in my opening statement, the
    data that I used I put up here on a chart just so everybody
    could see. 36 percent down among freshmen nationally, in West
    Virginia down 40 percent, and I can tell you, Sarah Tucker, who
    heads up our Higher Education has been a wonderful resource for
    me on data, but also trying to help us find a way to get this
    going.
        This is disturbing as well. I talked to somebody who works
    at--a career and technical, she has more adult students, they
    are totally confused, so students that are amongst West
    Virginia students, age 25 and up, down 35 percent.
        Now, if you said, we are going to get 600,000 more students
    because of the simplification. You have lost all these students
    this year, think about that in terms of what that does going
    forward for the next four--the chances are for the next 4 years
    those students may not, some of them, maybe the majority of
    them--you are already going to lose students in that year, and
    maybe life gets in the way and they decide, I can't move
    forward on this, I am not even going to fill this out. It took
    too long. I don't understand it. I don't know what is going on.
        We have got to be more aggressive here. And I honestly get
    tired. I am on the Appropriations Committee, and it is all
    about money. But it seems like the only solution we ever hear
    is: I need more money for staff.
        Well, this could have been done a lot better. We should
    have heard from--what you said today we should have been
    hearing that a year ago, so that we could have been prepared
    for where we are. And I am sure you feel the same way; that you
    would have liked to have had that conversation a year ago.
        Is there any way--I mean is there--you know Senator Collins
    asked for an apology. Have you apologized? Have you said: We
    know we have really screwed this up and we need to make it
    better for, not just the students, but the institutions as
    well?
        Secretary Cardona. Yes. Absolutely.
        Senator Capito. I will give you a chance to----
        Secretary Cardona. Absolutely. I have spoken to parents and
    students directly. I have sat with them while they are filling
    out FAFSA. We, at the FSA have worked to return 28 million
    borrowers to repayment, we changed servicers under FAFSA--
    Better FAFSA----
        Senator Capito. You have also worked on forgiving a whole
    lot of student debt, that has diverted a lot of your resources
    into this, while you are not focusing on the fundamentals of
    people trying to go to college for the first time.
        Secretary Cardona. I would welcome an opportunity to engage
    with folks in West Virginia to share the strategies that we are
    doing. And I would love to work together with you to make sure
    that the West Virginians have access to higher education. The
    form is now about 15 minutes, we are processing. If a student
    in West Virginia applies today, by Friday the colleges are
    going to have the information. We have processed over 8.2
    million of----
        Senator Capito. Are you accurately processing now?
        Secretary Cardona. Yes, we are accurately processing.
        Senator Capito. That was an issue too.
        Secretary Cardona. We made those corrections, and we are
    accurately processing information. And to be very frank with
    you, I have been hearing students are getting their letters.
    Look, we are on the same team here, we want to get as many
    students connected.
        Senator Capito. Right.
        Secretary Cardona. And I look forward to working with you
    to make sure we can do that in your State.
        Senator Capito. Thank you.
        Secretary Cardona. Thank you.
        Senator Baldwin. Senator Murphy.
        Senator Murphy. Thank you very much, Madam Chair.
        Secretary, good to see you.
        Secretary Cardona. Yes.

                        BIPARTISAN SAFER COMMUNITIES ACT

        Senator Murphy. Meriden says, hello. I want just to take a
    moment to thank members of this committee for the work that
    they put in, now, almost 2 years ago to make the Bipartisan
    Safer Communities Act a reality, we have already referenced it
    a number of times in this hearing. $13 billion much of it going
    to our schools to help build in-school Mental Health resources
    and build support services around children in need.
        But the data, the numbers, are really compelling. Since we
    passed the Bipartisan Safer Communities Act we have seen a
    stunning drop in gun crime in this country from 2022 when we
    passed the bill to 2023, we saw a 12 percent reduction, in
    urban gun homicides, that is the biggest 1 year drop in the
    history of the country. While we are still collecting
    information on 2024, it looks as if there is going to be
    another massive drop in gun crime in 2024, in the 200 biggest
    cities in the country.
        The first 3 months of this year, compared to the first 3
    months of last year have seen a 20 percent average drop in
    crime. That is really something to celebrate.

                              CHRONIC ABSENTEEISM

        But I want to talk to you, Mr. Secretary, about a
    concerning development in our schools that, if unaddressed,
    potentially threatens to interrupt some of this really
    tremendous progress. And that is the increasing amounts of
    chronic absenteeism that we are seeing.
        There is a direct line between kids who are chronically out
    of school, and at-risk behaviors. And so, we want to continue
    to build on this remarkable success, because the story of this
    drop in crime is connected to the work that we are doing in our
    schools. You have a billion dollars in BSCA (Bipartisan Safer
    Communities Act) to use for building positive school climates,
    and then you have got a new $8 billion initiative in this
    budget, that amongst other things, is dedicated to trying to
    build--tackle chronic absenteeism, and try to build increasing
    safer and welcoming schools. Can you just talk a little bit
    about the importance of reversing this post-pandemic trend?
        Secretary Cardona. Absolutely. Thank you, Senator. You
    know, throughout my career, whether I was a fourth-grade
    teacher or school principal, we would track the absenteeism of
    our students, and it was a clear correlation between students
    who were missing school and students who were struggling to get
    ahead, academically.
        So we often refer to absenteeism as a symptom of something
    greater. So the work that we are doing, and this budget
    reflects the priority that we take, that we are making with
    addressing chronic absenteeism, and introducing additional
    strategies across the country, because after the pandemic, it
    has gotten worse. In many States, they are much worse now than
    they were before the pandemic.
        We are holding a convening at the White House in a
    bipartisan fashion on May 15, to address strategies to improve
    chronic absenteeism. We recognize that if we don't address
    chronic absenteeism, all the strategies, and the tutoring, and
    the supports we provide in school, won't have the effect that
    it is supposed to have.
        It is all hands-on-deck, we are working with State chiefs,
    we are working with superintendents, teachers groups, to make
    sure that this message is one that we can all get behind.
    Students need to be in school. Part of this strategy is also
    increasing Full-Service Community Schools, because as I said
    earlier, attendance is a symptom of something else.
        When we have full-service community schools that are
    meeting the needs of the students and families, they are more
    likely to attend school.

                       FOSTERING DIVERSE SCHOOLS PROGRAM

        Senator Murphy. Let me ask one additional question. You
    have a really interesting demonstration grant program that you
    have used Title IV-A funds for, and this is the Fostering
    Diverse Schools Program. Listen, I am a believer that we should
    be in the business of helping give our students more access to
    diverse schools. The data just tells us that if you are in a
    diverse school, racially and economically diverse school, you
    are going to be more ready to learn--to succeed as an adult.
        Do you have data, yet, to understand how those
    demonstration grants are succeeding? I think you have made
    about ten 2-year planning grants, and four 5-year
    implementation grants. And if you don't, when are we going to
    know the impact that those grants have had?
        Secretary Cardona. Sure. You know, let me just comment. You
    know, as someone who grew up in an environment where I was able
    to attend diverse schools, and really learn how to navigate
    people from different cultures, and understand people with
    different perspectives, I think that helped me in my career,
    and I do believe all students benefit from that.
        So, this is something that we do stand behind, and I would
    be happy to follow up with you, and have my team follow up with
    you on some data to support that, whether it is through our
    grants or grants that we--or programs that we have seen across
    the country.
        Senator Murphy. I always tell the story. And I will turn it
    back to you, Madam Chair. The merit in public schools--you
    know, Connecticut does not have as many diverse school
    districts as we should. Meriden is one of them. And the level
    of engagement from those students, they know what they have,
    they know how special their experience is, and you feel it when
    you walk into any of these Meriden schools. So I appreciate
    that context that you bring.
        Thank you, Madam Chair.
        Senator Baldwin. Thank you. Vice-Chair Collins.
        Senator Collins. Thank you, Madam Chair.

                    FREE APPLICATION FOR FEDERAL STUDENT AID

        Mr. Secretary, I want to ask you a very basic question, and
    that is, after all the time the Department had to implement the
    bill that Congress enacted to simplify the Federal financial
    aid forms, why wasn't it ready when it went live? I just don't
    understand, why, given that the Department had more than 3
    years, given the fact that Congress was very specific on what
    should be done, no more hundred questions on the form, for
    example?
        Secretary Cardona. Right.
        Senator Collins. What happened?
        Secretary Cardona. Yes. Thank you for that. And Congress--
    Senator, I do share the frustration you share. Our kids deserve
    better, and we are working around the clock to make sure it
    improves. We have had delays. We had issues with some of the
    coding that we had to make changes to. And you know, it is an
    overhaul, it is not just a new website, it is an overhaul of a
    new formula, it required engaging with tax information
    differently.
        So, look, there is no excuse. Our students deserve better,
    and I am committed to making sure the process works to make
    sure that more students have access to higher education, and
    into a simpler FAFSA. A FAFSA process that encourages families
    to engage, and gives students an opportunity for higher ed.
        Senator Collins. I have worked at a college in Maine,
    Husson University in Bangor, and I know how critical Federal
    financial aid and other support are for students. In many cases
    it makes a difference between whether they go to college or
    not. And this is particularly true with first-generation
    college students. And back when I worked at Husson, the
    majority of students were first-generation.
        One reason that I wanted to help Lamar Alexander and others
    simplify the process, is I heard so many complaints about it.
    And the statistics that Senator Capito showed you about what is
    happening in West Virginia, I am sure could be applied to the
    State of Maine. So the problem is that the ineptitude here has
    real-life consequences. And I am curious whether you considered
    testing the new system with a small group of schools to ensure
    that it worked before it went live?
        Secretary Cardona. Yes. Thank you for that. And thank you
    for sharing that perspective. I am in agreement with you, we
    have to get it right for our students, and this is going to
    have an impact for generations. And yes, the process did
    involve testing and getting information from colleges. We have
    been in constant communication with financial aid directors
    across the country, with college presidents, hundreds of--I
    have been in those conversations myself, to test out processes,
    to hear from them what needs adjustments, and we have been
    adjusting.
        So, I recognize the strain it has put on colleges, on
    financial aid offices, and they have bent over backwards to
    really meet students' needs, and we are appreciative of that.
    And we are listening to them as we are making decisions moving
    forward.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        Senator Collins. I want to turn to the issue of the
    incidents of anti-semitism on far too many of our college
    campuses. The Anti-Defamation League has said that in the
    country, as a whole, that anti-semitic incidents are up 360
    percent since October 7, so it isn't just our college campuses,
    it is a problem nationwide, and a very disturbing one.
        But you do have the authority to investigate these
    incidences, and I am curious what specific communications you
    have had with institutions of higher education regarding anti-
    semitism, regarding Jewish students not feeling safe, not
    feeling like they can attend classes? And when did you post any
    communications on this issue?
        Secretary Cardona. Okay. Thank you for that. And we are in
    agreement, Senator, it is unacceptable. I have spoken to Jewish
    students who have shared with me that they have had to take a
    different route to class, or that their parents don't feel safe
    sending them to school. And while you know safe and peaceful
    protests are protected by the First Amendment Right, not when
    they are unsafe, violent, or they are attacking students on
    campus.
        Look, I have a student in college myself, a child. I
    wouldn't want to send my child to a campus if I feel that they
    are not safe. That is the most important thing to me, to make
    sure that our kids are safe on campus.
        If you look on Ed.gov, there is a safer--supporting campus
    safety, it is--I repeat it because I want people to look at it.
    We have over a hundred resources and tools that many of them
    were put up after October 7th. But as you mentioned, this was
    an issue before October 7, there was a rise in anti-semitism
    before. And I have met with Jewish leaders at the Department of
    Education, I have met with students, I have been on college
    campuses talking to students, professors, presidents, who are
    struggling with it, and I have been on campuses where they are
    doing it well.
        So, if you look on that website, you will see examples of
    that. And as recently as this week, or late last week we put up
    updated information to address the issues that college campuses
    are facing. It is of utmost importance. I agree with you. We
    need to do better for our students on campus to make sure that
    they are safe.
        Senator Collins. And again, there is a big difference
    between peaceful, legitimate protest, and what we are talking
    about, harassment----
        Secretary Cardona. Absolutely.
        Senator Collins [continuing]. Intimidation that cannot be
    allowed. Thank you.
        Senator Baldwin. Senator Manchin.
        Senator Manchin. Thank you, Madam Chairman.
        And thank you, Secretary, for being here. I reiterate what
    my colleague, Senator Capito from West Virginia; we are very
    much getting inundated on people concerning FAFSA. I have
    another--a problem that I have is the student debt forgiveness.
        Secretary Cardona. Um-hum.

                        PUBLIC SERVICE LOAN FORGIVENESS

        Senator Manchin. First of all, we have a bill out called
    the SMARTER Debt Act, and when people call my office we gave
    them 50 different variations of how they can reduce their debt
    without being--and give them a way they can work it off. They
    get paid, but they can work their debt off. I will give you a
    perfect example, all these smart, young people that work in our
    offices, when they come here and they have a 1-year contract,
    they get basically--we pay since they are working, we need them
    here, they get paid while they are working, but then we also
    pay their debt commitment.
        After 10 years it is totally forgiven. But you are not
    tell--no one is doing anything. Do you know how long it took us
    to find all 50 categories, whether it be in health professions,
    whether it is in public service, there are so many ways,
    scientific research, general repayment, everything, there are
    so many things, but yet we end up giving $620 billion of debt
    cancellation, has already been implemented including $275
    billion from President Biden's new income-driven repayment, and
    then we are talking about doing another $750.
        We are spending more on giving money away than we ever did
    on education. It makes no sense to me at all. And you all have
    done nothing as the Department of Education showing me how I
    can take this burden off of me while I still get paid and I am
    contributing to society.

                        STUDENT LOAN FINANCIAL LITERACY

        We have no financial requirements whatsoever, literacy,
    when a student goes into the college, as I am understanding it,
    you please correct me if I am wrong, they will go there and
    they say how much--what is your family's income, and do you get
    the Stafford Loan. So, you can borrow--they said, well, you can
    borrow up to $12,000 with your family income.
        They might only need $6,000, but they will take all
    $12,000, and then most of them majority fall out in 2 years.
    They think it is all free money because they have no payments
    at all, there is no accrued interest whatsoever, but when it
    comes time to pay the piper it hits them hard, because we don't
    require any financial literacy on the front end.

                                  DEBT BURDEN

        This is stupid. And we just keep piling it on like it is--
    there is no end to it. Your debt is $34.5 trillion and growing
    every day, and we are not going to be able to burn this--
    education, and we are dumbing down on top of that, students
    aren't getting any better. And how about the kids who don't go
    to school? In our little State there is an awful lot of kids
    that can't go to school. They come to us as: Do you mean, I am
    working and paying my taxes, and you are giving it away to
    people who went to college and had a good time, and now they
    don't want to pay it back. Had a better chance for an
    opportunity, don't want to pay it back?
        We have got to answer. Do you want to know why the rural
    America, and urban and rural America is getting further and
    further apart, is because rural America has been being left
    behind and getting screwed. That is exactly why.
        So, sir, I don't know what in the hell you all are doing,
    but this makes no sense to me. If you would just take a look at
    our SMARTER Debt Act, we put it all together for you, it will
    be able--you can put on your website tomorrow and start showing
    people how to take the burden of high student loan debt off of
    their back by giving services back that we need in so many
    areas of our Government.
        So many areas of our country, everyone needs it, every
    State. But you all don't do it. Did you know about what we are
    talking about, the SMARTER?
        Secretary Cardona. Thank you for your comments, sir. And I
    think we share the opinion that higher education has been out
    of reach for too many people, and that we have a broken system.
    We are proud of the work that we are doing, to provide teachers
    who are making $35,000 a year, debt relief after 10 years of
    service in public service.
        So, we are committed to working with you, and others, this
    to me is about that teacher that I spoke to recently who has
    $60,000 in loans because the interest compounded. She took out
    a $30,000 loan, and is now owing $60,000, making under $40,000.
    The system is broken, and what we are trying to do is fix it.
    The Bipartisan Bill that passed --

                        STUDENT LOAN FINANCIAL LITERACY

        Senator Manchin. Why don't we just educate a person that
    basically when they take the debt out, when they sign up for
    the Stafford Loan, that they think is free money, it is not
    free money. Explain to them what their budget--so they have a
    budget when they go to college, this is your budget.
        Secretary Cardona. Um-hum.
        Senator Manchin. But if you tell a kid that they get
    $12,000, I will guarantee they will have a nice apartment and
    end up buying a car.
        Secretary Cardona. The folks that we are providing debt
    relief to, sir, are public servants, are veterans that have
    served our public, and have done it not to become rich, but to
    make their community better, people who have been taken
    advantage of by universities or colleges.
        Senator Manchin. I agree with all that.
        Secretary Cardona. So, we are trying to fix a system to
    make higher education more affordable.
        Senator Manchin. We have to--you are in the Education
    Department, you have to educate people on what is available.
        Secretary Cardona. Right?
        Senator Manchin. The education of basically the
    congressionally authorized student loan forgiveness programs.
    It is out there, 50 different categories where a student can
    say, oh, I am going to go in this education. I am going to work
    over here. I am going go in health. I am going go in scientific
    research, and I will go work over there because that takes care
    of my debt, to paying for my college tuition.
        But no, they go out and whatever happens because they have
    no idea, it comes back to roost on them. And I don't know. I am
    done.
        Senator Baldwin. Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Chairwoman Baldwin, and
    Ranking Member.
        I want to talk to you today, Mr. Secretary, and thank you
    for being here----
        Secretary Cardona. Of course.

                                    TITLE IX

        Senator Hyde-Smith [continuing]. On something that is very
    near and dear to me in the State of Mississippi. On April the
    19th, the Department of Education released its Omnibus Title IX
    Rule, which frankly flies in the face of the original intent
    for Title IX.
        I have been around a long time. I have followed this, and
    it is amazing what this new rule is doing. There are many
    troubling aspects of it, like its weakening of due process
    protections. You know, in your own comments, in your own words,
    as you said here today, you said protecting students is the
    number one priority for you. Then you said: The most important
    thing for me is student safety. So I am glad to know that you
    have stated that for us today.

                   SCHOOLS SHARING GENDER STATUS WITH PARENTS

        Redefining the word ``sex'' to include gender identity and
    compelling speech is part of this. You are redefining the
    definition of ``sex''. Does the rule require schools to share
    information with parents regarding their children's gender
    status?
        Secretary Cardona. As an educator I can tell you that
    engaging with families and communicating with families
    regularly is an important part of the work.
        Senator Hyde-Smith. But does it require the schools to
    share information with parents? Does this rule require schools
    to share the information with parents regarding their
    children's gender status? Does it require it?
        Secretary Cardona. Whether this rule does or not, parents
    and schools should be working together, and that is an
    expectation of educators, and that is what they have been
    doing. I have to tell you the rule strengthens protections for
    students. It is about keeping students----
        Senator Hyde-Smith. I don't necessarily agree with that.
    And I only have 5 minutes, so I am going to continue on. Do you
    investigate schools that socially transition children without
    notifying students' parents? Do you investigate those schools?
        Secretary Cardona. I do not investigate the schools that do
    that.
        Senator Hyde-Smith. So if they don't follow the rule, there
    are no consequences, and there is no investigation?
        Secretary Cardona. If there is a Title IX investigation
    request, we look at the merits of the request.
        Senator Hyde-Smith. So you do investigate schools that
    socially transition children without their parents' knowledge?
        Secretary Cardona. Depending on what the request is, I
    defer that to the investigators at OCR whether or not to take a
    case.

                   IMPACT OF TITLE IX REGULATIONS ON FEMALES

        Senator Hyde-Smith. With the new rule redefining the word
    ``sex'', what does your Department have to say about how this
    rule will impact biological females? I am thinking specifically
    about how it will allow transgender students to choose any
    bathroom, any locker room they wish, therefore eliminating the
    safe spaces for women and even pushing women out of athletics
    altogether? Do you agree that they are eliminating those safe
    spaces when they allow transgenders to choose the bathroom and
    the locker room that they want to go in?
        Secretary Cardona. I don't. And I will tell you why. I have
    been an educator for about 25 years, and it is the role of
    educators to make sure that students have the safety and
    privacy that they need, and that we take into account the
    perspectives of different students. You know, Senator, we
    cannot pick and choose which students we want to protect. All
    students deserve protection in our schools, and what this Title
    IX Rule does is ensure that all students, including our LGBTQI
    students, are protected.
        Senator Hyde-Smith. So when a biological male goes into the
    locker room with biological females, you think that that is a
    safe space for those young girls?
        Secretary Cardona. When girls walk into bathrooms, that
    is--you may not be recognizing students who are transgender,
    but because you don't recognize them doesn't mean that I don't
    protect them.
        Senator Hyde-Smith. But biological males going into a
    girl's locker room, and a girl's bathroom, you have no problem
    with that whatsoever, and you consider them being safe in all
    circumstances?
        Secretary Cardona. Again, I think the line of questioning
    is trying to create division. What we are trying to do is
    protect all students.
        Senator Hyde-Smith. I am not trying to create division. You
    just said protecting students is my number one priority.
        Secretary Cardona. Yes. All students.
        Senator Hyde-Smith. So do you feel like that those
    biological females are protected in that setting to the best of
    your ability, you are protecting them?
        Secretary Cardona. The Title IX regulations that we have
    protect all students, and give them access to the same
    opportunities that all other students have in our schools. As I
    said before, we can't pick and choose which students we want to
    protect, and for partly----
        Senator Hyde-Smith. I totally agree all students need
    protecting. But there is a difference in boys and girls and
    where they change clothes and undress. Do you agree with that?
        Secretary Cardona. Schools make rules on how to make sure
    students are safe and have privacy in our schools. We have been
    doing this, educators have been doing this, and the Title IX
    Rules just reinforce the work that they have to do to also
    protect students who are LGBTQ who have, unfortunately,
    historically in our country been under attack, and we need to
    protect those----
        Senator Hyde-Smith. No one is attacking anyone right now.
    We are talking about school safety and girls' locker rooms and
    bathrooms. Nobody is trying to attack anyone. We want all
    students safe.
        Secretary Cardona. We do.
        Senator Hyde-Smith. So you don't need to change the
    conversation that somebody is attacking someone. So your
    position is that they still have the safe spaces that they
    deserve when biological girls are undressing? That is your
    position?
        Secretary Cardona. It is my honor as an educator to protect
    students who have been marginalized in our community and
    because of that require additional mental health supports.
    These students, I am not saying you are attacking them. I am
    saying they are under attack in this country, and as Secretary
    of Education, it is my responsibility to protect all students,
    not just some.
        Senator Hyde-Smith. In the same breath that you say safety
    is number one.
        Thank you, Madam Chairman.
        Senator Baldwin. Senator Boozman.
        Senator Boozman. Thank you, Madam Chair.

            FREE APPLICATION FOR FEDERAL STUDENT AID AND FARM ASSETS

        Thank you, Mr. Secretary, for being here. I want to
    associate myself again with the problems of the FAFSA rollouts,
    you have heard so much about that. And it truly is a huge
    problem. One of the things that has come up is the farm and
    small business reporting requirement Question 22 Form. This
    question requires students to report the net worth of the
    family's business or for-profit agriculture operations.
        Given the fluctuation in revenue year-over-year operating a
    farm, Question 22 misunderstands how farm families operate.
    Farm assets cannot be cashed out to support a loan in the same
    capacity as traditional investments.
        Throughout the process of drafting this requirement, and I
    understand this is not something you have done, this is
    something Congress did. Okay. But it has unintended
    consequences that nobody realized. Has the Department engaged
    in conversations with farming stakeholders to understand the
    impacts of such a requirement? I think it is going to be very,
    very difficult for any farm family to actually be able to get,
    you know, the student aid that they have, in the past, in the
    future under this requirement.
        Secretary Cardona. Thank you for sharing that, Senator. And
    I am committed to making sure we are talking in--and yes to
    answer your question, our team has talked to farm families, and
    we recognize the challenge that they are under. We are
    committed to working with them, and to making sure that they
    have access. I was in Arkansas recently, in the last 2 weeks,
    working on increasing FAFSA completion. I want to work with
    you, and everyone in Arkansas to get those numbers up.
        I think one of the things that we don't really talk about a
    lot is that across our country, we have normalized a 60 percent
    completion, 70 percent completion of FAFSA. It is our
    expectation, as we work together, to get those numbers closer
    to 90-95 percent of students filling it out. And we recognize
    that in rural communities, farm families have challenges and
    concerns with it, and we are committed to working with them,
    and you, to identify those issues and support them in the
    process.

                                  ANTISEMITISM

        Senator Boozman. You know, and that is exactly what, we
    want you to do, work with us, work with Congress to make sure
    that this really isn't going to be a very, very negative thing.
    Surveys tell us that over 50 percent of the Jewish students,
    you know, feel threatened.
        Secretary Cardona. Yes.
        Senator Boozman. You have got lots of levers, and the only
    thing I would say is that we really do expect you to use those
    levers.
        Secretary Cardona. Yes.
        Senator Boozman. Nobody needs to be bullied; everyone needs
    to be safe, not only Jewish students, but students in general.
    And again, you are going to need to step up and use some of
    those levers. Some of them you can do it outwardly; others, you
    know, you have got a lot of ability to put pressure on
    institutions. And then transparency, you know, identifying
    these institutions----
        Secretary Cardona. Right.

                        STUDENT LOAN FINANCIAL LITERACY

        Senator Boozman [continuing]. That we are hearing, you
    know, report after report about, people need to understand what
    is going on. The other thing is I, you know, in listening to
    Senator Manchin, I think what he was saying really is really
    important. You know, you have students that simply are not
    financially literate when they get out of high school. I would
    be interested.
        You gave the example of the lady that had the $30,000 loan
    that ballooned to $60,000. The question is, did she know that
    was going to happen? And I suspect she didn't. I suspect that
    she had no idea that what she was signing, there is no
    incentive for the higher ed. institutions to provide that
    knowledge because this is a cash cow for them.
        You know that it is to their advantage for students to take
    these loans out. They don't care if they pay them back or not.
    They don't have any really advantage of explaining that, you
    know, this is money that is going to need to be paid back. The
    interest rate is going to be a burden, and looking at their
    potential, you know, income in the future, how are you going to
    cash flow all this out?
        So I would really encourage you. Let us help you with that.
    But that is something that I think would really, you know, we
    can debate the student loan thing. I agree with Senator Manchin
    on that also, but regardless of that, as far as eliminating the
    problem in the future, you know, if you want to have a real
    impact on people's lives and not getting them in the situations
    going forward, that really would have a tremendous impact.
        Secretary Cardona. Thank you.
        Senator Boozman. Thank you, Madam Chair.
        Senator Baldwin. Thank you. Senator Britt.
        Senator Britt. Thank you, Madam Chair.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        Mr. Secretary, thank you for being here today, I greatly
    appreciate it. As you are aware and have heard from a number of
    my colleagues, the large anti-semitic demonstrations and
    encampments that have broken out on college campuses nationwide
    are simply unacceptable. This has become, you know, some of our
    ``elite institutions'', quote/unquote. To me, it is just a
    national disgrace, and it is a disservice to America's future.
        Going back to November, Republican Senators, myself
    included, have written multiple letters urging you to uphold
    Title VI of the Civil Rights Act, and ensure that a safe
    learning environment exists for Jewish students. I know the
    Department has opened investigations, and I have heard you
    reference that today, into some of these institutions,
    including Columbia.
        However, things have clearly not gotten better over the
    last 5 or 6 months. And in fact, in recent weeks and even days,
    it has proven that they have gotten significantly worse.
        So Mr. Secretary, does the Biden administration really
    believe that it is effectively upholding Title VI, and ensuring
    a safe learning environment for Jewish students right now; just
    a simple yes or no?
        Secretary Cardona. Thank you, first of all, Senator.
    Because I agree with you, the anti-semitism that students are
    experiencing on campus is unacceptable.
        Senator Britt. Thank you.
        Secretary Cardona. We are committed to making sure we
    investigate Title----
        Senator Britt. And so investigation is one thing, but do
    you think right now that this Administration is upholding Title
    VI?
        Secretary Cardona. We are, with the resources that we have,
    we are here to request additional investigators. You know, in
    2009, the number of cases has tripled since 2009, and we have
    58 less people in the----
        Senator Britt. But how long does this have to go on? I
    mean, if you look at these, the absurdity of some of this, just
    rhetoric on these campuses when they are saying: We are Hamas.
    I mean, do you think that is acceptable for a Jewish student to
    have to hear that, or ``from the river to the sea'', or ``go
    back to Poland'', or ``kill the Jews''? My question is, do you
    think that that type of rhetoric is acceptable, and do you
    think that that allows for Jewish students to feel safe on
    campus, yes or no? Yes or no?
        Secretary Cardona. Absolutely not.
        Senator Britt. Thank you. I really appreciate that. Do you
    think that it is okay to link arms and keep Jewish students
    from attending class? Do you think that is okay?
        Secretary Cardona. Absolutely not.
        Senator Britt. Thank you. I am afraid that this
    administration is not learning the lessons from the past. When
    you look at the history, it wasn't okay to do that in the
    1960s, do you understand, and it is not okay to do that now.
    This is the United States of America, we have to uphold the
    laws in front of us. We have to make sure that different groups
    based on their race or ethnicity are not discriminated against.
    We have to have safe learning environments, and it is my
    thought that the Biden administration is utterly failing the
    American people right now, and failing the Jewish community
    across this Nation. And I ask you to do more.
        I don't know what investigation it takes. I don't know
    where the bar is. But to me, all of the things I just
    referenced are enough, and I hope that you hold these
    institutions accountable, and I hope you create a safe space
    across this Nation for Jewish students to learn, to grow, and
    to be fostered on these college campuses, and anything less is
    unacceptable.

                                    TITLE IX

        I would like to ask you about your new Title IX proposal.
    So this weekend, I sat at track sectionals watching my daughter
    run. I was so proud of her. She wanted to get her PR, which I
    have had to learn what that meant, but when I saw the
    difference and the disparities between the top female athletes,
    and then the top male athletes, they were significant.
        I am reminded, as we look back over history here, and I
    want to make it very clear, I believe we are all made in the
    image of God, and I believe each and every person should be
    treated with dignity and respect. But Title IX was created to
    create fairness, to create a level playing field, to give young
    women the opportunity to strive, to grow, and to succeed. And
    when I look at the reality of your new Title IX proposal, it
    clearly shows that that playing field is about to be tilted.
        You can look back to 1988, when you had Ms. Joyner, known
    as Flo-Jo, who created a record in both the 100 and 200 meter
    dash that still stands today, you can look in 2019 though that
    very record that stands would have been beaten by 76 high
    school biological males. And my question to you is how are we
    going to continue to create fairness if you are tilting the
    playing field and underneath this current proposal, is it true
    that a biological man could receive a scholarship designated
    for a woman for Collegiate Athletics?
        Secretary Cardona. Thank you for your passion. And I just
    want to clarify the Biden administration has over three times
    the number of investigations on Title VI than the Trump
    administration in 4 years, so we are committed.
        Senator Britt. Sir, an investigation though, is very
    different than action. And I appreciate the opportunity to look
    into it, but now is the time for action.
        Secretary Cardona. We have closed more cases also.

                    COLLEGE CAMPUS PROTESTS AND ANTISEMITISM

        Senator Britt. And so what are you doing right now on
    Columbia's Campus?
        Secretary Cardona. On campus, the situation?
        Senator Britt. Yes. Um-hum.
        Secretary Cardona. We are doing a lot. You know, we have
    updated guidance, we have a letter in draft right now, we have
    increased the Title VI investigations, we have open
    investigations that----
        Senator Britt. So when you see what happens on GW's
    Campus--and Madam Chairwoman, I understand my time has
    expired--and you see that they have actually asked for, you
    know, public safety have asked the Mayor to send in police to
    help them with that situation, and she has refused. Do you
    stand by the Mayor, or do you stand by GW?
        Secretary Cardona. I stand by the students who deserve to
    be safe on campus. As a father, that is what I expect for my
    children, I expect that for children all across----
        Senator Britt. Absolutely.
        Secretary Cardona. I agree with you on that. Let us work
    together to make sure that the message is clear, that while the
    First Amendment is their freedom, when it crosses the line and
    makes students feel unsafe or harmed on campus, that is where
    we draw the line. I have spoken to Jewish students who have had
    anti-semitic comments made at them, it is----
        Senator Britt. It is disgusting and despicable.
        Secretary Cardona [continuing]. Unacceptable I agree with
    you.
        Senator Britt. Absolutely. Well, let us work together. And
    let us not just talk about it, let us do something now. Thank
    you.

                         ADDITIONAL COMMITTEE QUESTIONS

        Senator Baldwin. Thank you, Mr. Secretary. Thank you for
    your presence here today.
        This will end our hearing. I would like to thank my fellow
    committee members. And thank you, Secretary Cardona.
        For any Senators who wish to ask additional questions,
    questions for the record will be due on May 7. The hearing
    record will also remain open until then for members who wish to
    submit additional materials for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                   Questions Submitted to Hon. Miguel Cardona
                   Questions Submitted by Chair Tammy Baldwin
        Question. Mr. Secretary, you are aware of the significant resource
    disparities between schools serving more students from families with
    low-incomes and their wealthier peers, including disproportionate
    access to experienced educators, advanced coursework, and more. These
    resource discrepancies contribute to the achievement gap between
    students of color--who represent more than half of students served in
    Title I schools--and white students. In fact, Education's National
    Center for Education Statistics School Pulse Survey recently reported
    that 84 percent of high schools with fewer than 25 percent students of
    color offered advanced academic courses but just 65 percent of high
    schools serving 75 percent or more of student of color did the same.
        As you know, an important provision included in the reauthorization
    of the Elementary and Secondary Education Act requires a review of
    resource inequities in schools which have been identified for support
    and improvement. However, recent reporting by the GAO shows just about
    half of schools required to conduct those reviews did so.
        This and other findings from the GAO report supported our direction
    to your Department to conduct additional monitoring and support,
    including through the Comprehensive Centers program, to strengthen
    implementation of school improvement requirements.
        While the Department has taken some actions, would you please share
    your thoughts on implementation of the school improvement requirements
    to date and commitment to implement direction in our recently-passed
    budget and take additional actions to improve this situation?
        Answer. The Department agrees that the requirement to identify and
    address resource inequities in comprehensive support and improvement
    (CSI) and additional targeted support and improvement (ATSI) plans is
    an essential element of the Title I accountability and school
    improvement system. The Department reviews these requirements each year
    in State educational agencies through our comprehensive consolidated
    monitoring of the ESEA formula grants programs, which includes a
    comprehensive review of the State's implementation of Title I. We know,
    however, that we can only conduct a handful of consolidated monitoring
    activities each year. That is why, in 2022, the Department conducted a
    targeted monitoring of the requirements related to resource inequities,
    as well as the requirement for each State to conduct a periodic
    resource allocation review in local educational agencies (LEAs) that
    serve a significant number of identified schools. Of the nine States
    that were included in the review, seven States did not meet this
    requirement. The Department issued a corrective action letter to each
    State that did not meet the requirement to provide evidence of how it
    ensured that all identified CSI and ATSI schools include the resource
    inequities requirement in approved support and improvement plans. This
    typically included revised CSI plan templates or revised monitoring
    protocols that ensured the SEA was reviewing CSI plans for this
    requirement prior to approving such plans. Further, the Department
    issued a Dear Colleague letter on July 11, 2023, that addresses key
    findings and highlights best practices from our targeted monitoring
    review. This letter (available at: DCL-Title-I-Resource-Equity-for-
    posting.pdf) includes four recommendations for ensuring that all CSI
    and ATSI plans identify and address resource inequities. In addition,
    the Department continues to provide technical assistance to States
    regarding these important provisions, including recent presentations to
    over 45 States at the National Association of ESEA State Program
    Administrators annual conference and to over 40 States at the Council
    of Chief State School Officers. In addition, the Department plans to
    fund a new Comprehensive Center this year that will focus on providing
    technical assistance on fiscal equity, as well as ongoing support
    around ESEA implementation.
        The Department continues to focus on State compliance with school
    improvement requirements. This summer, the Department is conducting
    targeted monitoring of five States (which includes a discussion with
    one LEA in each of those States) of the school improvement funding
    requirements in ESEA section 1003. Similar to prior targeting
    monitoring efforts, the Department will share the results of its
    review, including common findings, recommendations, and best practices,
    with all States.
        Question. How would the budget support improved compliance and a
    reduction in these disparities?
        Answer. The Administration's FY2025 budget request provided a $200
    million increase from FY2023 enacted under Title I, Part A Grants to
    LEAs. In addition, the request proposed appropriations language to
    increase the Title I administrative cap, which would result in SEAs
    having more resources to provide technical assistance and oversight to
    LEAs to meet these important requirements. Furthermore, the funding for
    the Comprehensive Centers program will also provide important technical
    assistance to States. In particular, in addition to the National Center
    and the Regional Centers, this year's Notice Inviting Applications
    includes a competition for a new Fiscal Equity Center.
        Question. Mr. Secretary, you are well aware of the challenges
    public schools have experienced over the last couple of years. Our
    public schools have faced the major disruption of the pandemic and
    communities divided by what our students should learn and whether they
    should be accepted for who they are.
        As you know, the Title I-A grant program supports roughly half of
    all schools and includes a requirement that generally requires these
    schools to spend at least 1 percent of their grant award on parent and
    family engagement activities. Of course, any reduction to this program
    like that Proposed by House Republicans last year would significantly
    cut funding for this important work.
        Please share how the Department is supporting efforts to strengthen
    these critical connections needed to support students in their learning
    and school success. How does the budget propose to further strengthen
    these efforts?
        Answer. We agree that parent and family engagement is vital to
    fostering strong connections between communities and schools and
    supporting all students to reach their full potential. The Department
    is currently working on technical updates to its Parent Involvement:
    Title I, Part A, Non-Regulatory Guidance (April 2004) to reflect
    changes to requirements in section 1118 of the reauthorized Elementary
    and Secondary Education Act, as amended by the Every Student Succeeds
    Act, which we aim to release later this year. This guidance will
    reiterate the importance of parent and family engagement and remind
    States, districts, and schools about their responsibilities to provide
    timely, useful information to parents and families and meaningfully
    engage them in planning for how best to use Federal funds to meet local
    needs.
        The Department also continues to annually review State and local
    report cards to ensure that States are making key information publicly
    available to aid local decision-making. We conducted targeted
    monitoring of State and local report cards in summer 2023 to conduct
    oversight and inform our technical assistance. Based on our
    observations and findings, we will be providing additional guidance and
    technical assistance to make recommendations for improving the
    timeliness, usefulness, and quality of data on State and local report
    cards so they are valuable tools for parents and families.
        In addition, the President's FY 2025 budget includes an increased
    request of $200 million for the Full-Service Community Schools program
    to provide comprehensive social, health, and academic services in
    school settings for students, students' family members, and community
    members by integrating existing school and community programs, among
    other evidence-based features. The budget request also includes $1.3
    billion for 21st Century Community Learning Centers, which provides
    funds for before- and afterschool and summer programs designed to
    support students from low-income backgrounds and provide programs that
    offer their families opportunities for active and meaningful engagement
    in their children's education. The budget also includes $91 million for
    Promise Neighborhoods, which provides competitive grants to support
    distressed communities in improving the developmental and academic
    outcomes for children, youth, and their families from birth through
    college. Finally, the budget request includes $20 million for Statewide
    Family Engagement Centers, which provides funding to statewide
    organizations to establish statewide centers that promote parent and
    family engagement in education and provide comprehensive training and
    technical assistance to SEAs, LEAs, schools, and organizations that
    support partnerships between families and schools.
        Question. The President's budget rightly requests an increase of
    $22 million for Education's Office for Civil Rights. Every student,
    from early childhood education to our college campuses, deserves a safe
    place to learn, free from any hate and discrimination. In recent
    months, some have called for increased efforts to root out antisemitism
    in educational institutions which I fully agree we must do but they
    have paradoxically called for cutting funding for the very office that
    leads that work. In fact, House Republicans advanced a bill last year
    that would have cut funding for OCR by $35 million/25%.
        How would that reduction impacted OCR's ability this year to timely
    and thoroughly process complaints of discrimination of all types,
    including those based on shared ancestry or ethnic characteristics, and
    establish corrective measures for the educational institutions to
    implement to provide all students a school environment free from
    discrimination?
        Answer. If Congress cuts OCR's funding by $35 million in FY 2025,
    the average caseload per investigative staff would rise from 33 cases
    per staff, as of May 2024, to an estimated 120 cases in FY 2025, which
    is not manageable. OCR would not be able to support the current full-
    time employees on board. The budgeted number of staff would require
    cutting approximately 167 full-time employees--from 563 FTE to 396 FTE.
    This cut in funding would severely hamper OCR's ability to timely
    process complaints and increase OCR's case backlog significantly. A $35
    million cut in OCR's funding, which is equivalent to a 25% reduction,
    would disproportionately impact OCR's enforcement workforce, which
    represents more than 80% of OCR's full-time equivalents (FTEs).
    Consequently, the enforcement workforce would be most severely impacted
    by the reduction.
        Question. How would that reduction impact OCR's ability to initiate
    based on shared ancestry or ethnic characteristics, and establish
    corrective measures for educational institutions to implement to
    provide all students a school environment free from discrimination?
        Answer. If Congress cuts OCR's funding by $35 million to $105
    million, OCR will have to cut the investigative staff by approximately
    150 full-time employees (90% of the total 167 FTE cut). Such a cut
    would significantly jeopardize OCR's ability to conduct and conclude
    all investigations.
        Question. How would additional resources requested in the
    President's budget for fiscal year 2025 enable OCR to better fulfill
    its mission to ensure school environments are free from discrimination
    for all students?
        Answer. The additional $22,359,000 requested for fiscal year 2025
    would enable OCR to hire at least 77 additional investigative staff to
    help process the 22,179 complaints projected to be received in FY 2025.
    The additional investigative staff the average caseload per staff from
    51 to 47 cases per investigator, which is still a very high yet
    incrementally lower caseload.
        Question. Both the Government Accountability Office (GAO) and
    Education's Inspector General have raised concerns about the risks to
    Federal funds posed by certain types of charter schools from virtual
    schools to those with contracts with for-profit management
    organizations, and the need for effective oversight of the Charter
    School Program.
        Please provide an update on actions taken and planned to address
    recommendations made by the GAO in GAO-22-10444 and recommendations 1.2
    and 1.3 of IG ED-OIG/A21IL0034. How does the budget request support
    full and timely implementation of all corrective actions and
    recommendations?
        Answer. Regarding GAO-22-10444, the Department initiated a review
    process for the data that States submitted via EDFacts for the 2021-
    2022 school year to examine participation rates of students attending
    public virtual schools on required state standardized tests. Consistent
    with the prior year, a letter will be sent to each State with a virtual
    charter school that assessed less than 95 percent of its students. The
    letter will include both the 2020-2021 and 2021-2022 school year
    participation data. Additionally, the Department provides technical
    assistance and support to states regarding their submission of data via
    the EDFacts data initiative. Each state submits data and provides an
    assurance that the data are complete and accurate. The Department's
    expectation for the submission of chronic absenteeism data is that the
    data are collected from each school using a uniform definition, as
    stated in our file specifications (see here for the 2021-2022 school
    year--file specification 195 (data group 814): https://www2.ed.gov/
    about/inits/ed/edfacts/eden/non-xml/fs195-18-0.docx). As noted in that
    document, the state is required to include a student absent ``when not
    physically on school grounds and were not participating in instruction
    or instruction-related activities at an approved off-grounds location
    for at least half the school day.'' As further specified in the file
    specification, the state should ``include all students in grades
    Kindergarten through Grade 12, and comparable ungraded levels, who were
    enrolled in the school for at least 10 school days at any time during
    the school year, and who were absent 10% of the school days in the
    school in which they were enrolled.'' Any student enrolled for 10
    school days or more in the school must be included in the file. We
    believe the guidance we have provided results in comparable data across
    virtual and brick-and-mortar schools. We have no indication at this
    time that the data are less reliable for virtual schools compared to
    brick-and-mortar schools. The Department further notes that attendance
    data does not impact funding decisions for Federal funds. Lastly,
    through new CSP regulations issued in July 2022, the Department has
    strengthened requirements to improve grantee reporting and increase
    transparency with respect to funded charter schools that are operated
    or managed through contracts with management organizations.
        Regarding recommendation 1.2 in ED-OIG/A21IL0034, The Charter
    School Program Office (CSP) is currently working with our data
    collection contractor to streamline all reporting requirements for CSP
    grantees through the development of a performance management platform.
    The platform entitled, the Charter Online Management Performance System
    (COMPS) will combine the current data collection tables, APR and FPR
    reporting requirements for the SE, CMO, and Developer grant programs
    and other business processes into one system that serves as a
    repository for grantee implementation data. Full development of COMPS
    is intended to be completed by December 2024.
        Regarding Recommendation 1.3 in ED-OIG/A2IL0034, The COMPS system
    will serve as a clearinghouse of implementation information for each
    grant. The system will allow for data to be examined by grant and
    program, to allow the CSP leadership and program officers to view the
    data at multiple levels, and to aggregate to see trends across the
    entire program.
        The FY25 budget request includes $16 million for national
    activities including actions such as monitoring and technical
    assistance that can, in part, address GAO and IG concerns. The request
    also includes appropriations language to ensure, consistent with
    statutory intent, that new awards do not support schools that are
    operated or managed by a for-profit education management organization
    or other similar for-profit entity, including through a contract with
    such an organization or entity. This language would not limit the
    ability of a newly funded charter school to contract with a for-profit
    entity for purposes other than managing or operating the school, such
    as providing food services or payroll services.
        Question. Research has found consistently that students of color
    and students growing up in poverty are disproportionately more likely
    to be taught by teachers who are inexperienced, less effective or
    teaching out-of-field. Recent research from the Education Trust on
    access to experienced teachers found Black and Latinx students are more
    likely to attend schools that have higher percentages of novice
    teachers. In 2015, Congress reauthorized the Elementary and Secondary
    Education Act, with a new requirement for States to submit plans to the
    Federal government describing how low-income and minority children
    enrolled in Title I-A schools are not served at disproportionate rates
    by ineffective, out- of- field, or inexperienced teachers, and what
    States will do to report on this data to the public.
        What steps will the Department take to ensure public reporting by
    all States include multiple years of publicly available and readily
    understandable data demonstrating progress in addressing any
    disproportionate rates of access to ineffective, inexperienced, or out-
    of-field teachers by low-income and minority children in Title I, Part
    A schools and that all States have a plan and timeline for regular
    updates of these data that are frequent enough to demonstrate progress
    being made?
        Answer. The Department's monitoring of this requirement has
    consistently identified noncompliance with ESEA's requirement on
    reporting on ensuring low-income and minority children enrolled in
    Title I schools are not served at disproportionate rates by
    ineffective, out-of- field, or inexperienced teachers. The Department
    reviews compliance with this requirement in our annual consolidated
    monitoring of ESEA programs, which includes a comprehensive review of
    implementation of provisions under Title I, Part A (Title I) in a
    handful of State educational agencies each year. However, given the
    importance of this requirement and public reporting in general, in
    2023, the Department conducted Title I targeted monitoring of the
    public reporting requirements in ESEA sections 1111(h) and
    1111(g)(1)(B) of nine States. This included the requirement for all
    States to publicly report their progress in addressing any
    disproportionate rates of access to ineffective, out-of-field, and
    inexperienced teachers by low-income and minority children in Title I
    schools. To meet requirements, each State must have reported at least
    two data points to reflect progress in addressing any disproportionate
    rates of access for these students. The Department chose to focus on
    these public reporting requirements in 2023 Title I targeted monitoring
    because we identified a pattern of non-compliance in prior monitoring
    efforts. As expected, all nine States received findings because they
    had not reported all required components of ESEA section 1111(g)(1)(B).
    For example, some States reported data for some of the teacher
    categories, but not all. Some reported statewide data but did not
    specifically report on data for students in Title I, Part A schools.
    The Department issued a letter to each State identifying the areas of
    non-compliance and we will follow up with each State to ensure it
    satisfactorily addresses the issue in order for us to close the
    monitoring finding.
        Following our Title I targeted monitoring of public reporting
    requirements, the Department is working on guidance and technical
    assistance for all States related to this requirement. For example, the
    Department will release later this year a Dear Colleague Letter that
    provides recommendations to States on these requirements. The Dear
    Colleague Letter will recommend that States post this educator equity
    data on their State and local report card for transparency and ease of
    access for stakeholders and that they publish at least every 2 years
    their progress reducing gaps in educator equity. In addition, the
    Department is making technical updates to its non-regulatory guidance,
    ``Opportunities and Responsibilities for State and Local Report Cards
    (March 2019)'' to reflect common questions and findings and provide
    examples of how the educator equity report requirements differ from the
    educator reporting requirements in ESEA section 1111(h). The Department
    will continue to provide technical assistance to States on this
    provision to States at national meetings.
        Question. The Department collects required information on
    professional qualifications of educators through its EDFacts
    collection. The Department notes in its Fiscal Year 2025 Congressional
    Justification that a number of States have not reported complete data,
    limiting the Department's ability to report on measures on the
    differences between the lowest and highest LEA poverty quartiles in the
    percentages of teachers with provision credentials or teaching out of
    field.
        Please describe the assistance provided and planned to be provided
    to support complete reporting of these important data?
        Answer. The Department agrees that having timely, complete, and
    accurate data across all ESEA programs, including on the professional
    qualifications of educators, is essential. The Department has taken a
    number of actions following the submission of incomplete, inaccurate,
    or missing data. The Department typically begins with a technical
    assistance call with any State that has missing data or significant
    data issues. If the issue persists for a second year, the Department
    typically issues a warning letter to the State. If the issue persists
    for a third year, the Department can place a grant condition on the
    associated ESEA grant that cannot be removed until the State is in
    compliance with the reporting requirement. Currently, one State has a
    grant condition related to this specific data requirement.
        Question. The Student Support and Academic Enrichment [SSAE] Grants
    program provides formula grants to States based on each State's share
    of title I--A grants, which then sub-grant to LEAs, to help support
    activities that provide students with a well-rounded education, ensure
    safe and supportive learning environments, and use technology to
    improve instruction.
        Please describe the Department's plans and timeline for reporting
    on State and local expenditures, outlined by specific authorized
    activities, and provide detailed information about the most common uses
    of funds, as well as information about how LEAs plan to evaluate the
    effectiveness of their SSAE-funded activities.
        Answer. The Department is conducting an implementation study of the
    Student Support and Academic Enrichment grant program (Title IV, Part
    A). The purpose of this study is to evaluate how this program is being
    carried out across the country, focusing on assessing how states and
    districts are using Title IV, Part A funds; how states and districts
    make decisions about how to use funds, and the use of evidenced-based
    programs and practices.
        Question. The Statewide Longitudinal Data System program supports
    competitive grants to State Educational Agencies to enable such
    agencies to develop, expand or improve Statewide, longitudinal data
    systems; improve data access and use that improves student outcomes;
    enable research and evidence-based policy-and decisionmaking; and build
    capacity in States to secure and protect data.
        Please describe FY23 and FY24 actions and FY25 plans, including in
    coordination with the Departments of Labor and Health and Human
    Services to provide guidance on and support the integration of data
    source systems across all levels of education, workforce and related
    areas, including implementation of data governance policies and
    enhancement of data privacy and security measures.
        Answer. The Department made 27 new Statewide Longitudinal Data
    Systems (SLDS) grant awards in FY23 and one in FY24. These grants are
    supporting State developments in Infrastructure and Interoperability
    (22), College and Career (3), State Policy Questions (3) and School
    Finance (2). The program has supported States and territories with data
    governance through data governance-related webinars and briefs to
    support States in governance activities. Topics have included but are
    not limited to: ``Partnering for Success: Key Elements of Effective
    ECIDS [Early Childhood Integrated Data System] Data Governance,''
    ``Improving Data Quality and Data Use Through the Critical Data Issues
    Process,'' ``Cross-Agency Data Sharing, Governance, and Practice,'' and
    ``Sustaining Core Processes for Data Governance.''
        The program also focused on data security and privacy through
    webinars and/or briefs including ``Preparing for an SLDS Security
    Audit,'' ``Securing Your SLDS,'' and ``Overcoming Challenges of
    Reporting Publicly Available Data.'' The SLDS program collaborates
    closely with the Privacy Technical Assistance Center, which reviews and
    provides feedback on states' data and security and privacy
    documentation required as part of the SLDS grant application process.
    Updated documentation is reviewed again as part of grant monitoring,
    both in Annual Performance Reports and as part of site visits.
        Our technical assistance plan includes collaboration with the
    Preschool Development Grant Birth through Five (PDG B-5) program in
    HHS. Many of the states participating in our Early Childhood Integrated
    Data System working group also have or have had PDG B-5 grants, and
    program staff from the SLDS and PDG B-5 grant program meet to discuss
    grantee progress and needs. The SLDS team also coordinates with the
    Department of Labor's Workforce Data Quality Initiative (WDQI) grants.
    Representatives from the WDQI program have been included in
    conversations about how to link workforce data to kindergarten-grade 12
    (K-12) data accurately and securely, resulting in issue briefs such as
    ``Sources and Linking Strategies for Employment Data.'' Most recently,
    the WDQI grant team participated in the SLDS Best Practices Conference
    in May and hosted a round table to discuss developments in workforce
    data, linking, and usage.
        We expect that these technical assistance and collaboration
    activities will continue through FY25, reflecting the needs in the
    field.
        Question. Please describe how current funding levels and those
    requested in the FY25 budget justification will adequately support the
    plans described in 8a.
        Answer. The President's budget requested $38.5 million for SLDS in
    FY 2025 and proposed a rescission of $10 million from unobligated FY
    2024 SLDS funds expected to be carried over into FY 2025. Due to the
    $10 million reduction to the FY 2024 SLDS appropriation we no longer
    propose a rescission of SLDS unobligated carryover (the $10 million
    SLDS reduction in FY 2024 fully offsets the proposed $10 million SLDS
    rescission from the FY 2025 request).
        If the program is level-funded at the FY 2024 level and the
    proposed rescission of $10 million of funds carried over from FY 2024
    is enacted, the program is projected to experience a $7 million
    shortfall in FY 2025. The IES appropriations bill language has
    historically provided the Department with the authority for IES to
    utilize up to $6 million from the SLDS appropriation SLDS to support
    activities to improve data coordination, quality, and use at the local,
    State, and national levels. The cost of supporting technical assistance
    to States and districts on these issues is approximately $8.3 million
    annually, including $1.8 million to support the Privacy Technical
    Assistance Center, which is administered through the Department's
    Student Privacy and Policy Office, $5 million to support the SLDS
    Education Data Technical Assistance Program, and $1.5 million to
    support the Common Education Data Standards. As the cost of supporting
    these activities increased, the National Center for Education
    Statistics (NCES) used funding from the Statistics budget to make up
    the difference and ensure continued support for these activities. NCES
    has paused or reduced the scope and frequency of several Statistics
    data collections recently due to funding issues, so continued support
    for these activities with Statistics funds is likely not sustainable
    beyond FY 2025.
        Additionally, the success of these technical assistance activities
    depends on States and territories continuing to receive SLDS grant
    funding. With a shortfall of $7 million, NCES would likely not be able
    to provide full continuation awards in FY 2025 to SLDS grantees.
        Question. The Uniform Grants Guidance 2024 Revision makes clear
    that recipients may use Federal funds for data costs including (but not
    limited to) the expenditures needed to gather, store, track, manage,
    analyze, disaggregate, secure, share, publish, or otherwise use data to
    administer or improve the program, such as data systems, personnel,
    data dashboards, cybersecurity, and related items. Data costs may also
    include direct or indirect costs associated with building integrated
    data systems--data systems that link individual-level data from
    multiple State and local government agencies for purposes of program
    improvement, management, research, and evaluation.
        Please describe the Department's plans to operationalize the 2024
    revision and assist grantees in the effective and appropriate use of
    funds for evaluation-related activities, including data infrastructure
    and integrated data systems?
        Answer. The Department will release resources and provide support
    to applicants and grantees relating to the 2024 revisions to the
    Uniform Guidance, including those clarifying the use of funds for data
    and evidence-building, in the coming months.
        Question. Mr. Secretary, please describe the Department's plans to
    work with the Department of Health and Human Services to encourage more
    states to expand Medicaid School-Based Services and allow them to be
    reimbursed by Medicaid for school-based physical and behavioral health
    services.
        What are the obstacles that you're hearing about, given that two-
    thirds of States including Wisconsin have failed to utilize this option
    to pay for the mental health services eligible students need?
        Answer. Secretary Becerra and I have teamed up to improve the
    delivery of school-based health services through Medicaid and CHIP.
    Medicaid funding is a new frontier for our schools, allowing them to
    extend the reach of mental health programs to more students and provide
    on-site physical and mental health services. In 2022, schools received
    more than $6 billion in reimbursement for Medicaid school-based
    services. To date, a total of 13 states have expanded coverage to all
    Medicaid enrolled students by working with CMS on an approved state
    plan amendment.
        ED is working closely with HHS to increase the number of States and
    schools that offer school-based services for children enrolled in
    Medicaid and ensure that schools are equipped to bill Medicaid for
    eligible services. In the past year, our Departments released
    comprehensive guidance to make it easier for schools to bill Medicaid
    and launched the new Medicaid Technical Assistance Center to help
    schools leverage this critical funding. My team will continue to
    support the Technical Assistance Center and provide subject matter
    expertise to the SEAs and LEAs engaged with the Center.
        Since BSCA's 2022 passage, ED and CMS actively engaged with more
    than 40 States and 1,200 local education leaders (through convenings,
    webinars, meetings, and technical assistance) to raise awareness about
    the availability of Medicaid funds for crucial school-based health
    services and ensure Medicaid can reach and benefit more students. This
    includes 8 individual conversations I had with Governors and ED
    meetings with state health and education leaders in more than 20
    states. My team is actively engaged in helping states and districts
    address challenges they face, including concerns related to LEA
    capacity and resources, student privacy, and more, by sharing
    resources, providing technical assistance, and developing guidance to
    clarify laws and policies related to the delivery of school-based
    services.
        Secretary Becerra and I also issued a joint letter to governors,
    emphasizing how BSCA grant funding will make it easier to provide
    health services, including mental health supports, for millions of
    students across the nation. In June, CMS awarded $50M to 18 states to
    increase and improve access to school-based services through Medicaid.
    Our agencies will continue to collaborate and support these and all
    states to develop the infrastructure to access Medicaid dollars for
    school-based services.
        Additionally, the President's FY25 Budget requested funding for 3
    additional FTE to provide technical assistance to States and districts,
    develop guidance, and coordinate with CMS to support increased access
    to school-based services through Medicaid.
        Question. The FY25 Congressional Justification indicates the
    Institute of Education Sciences (IES) plans to allocate $14.041 million
    in FY24 and $15 million in FY25 to the What Works Clearinghouse.
        How will the additional resources planned to be allocated to the
    What Works Clearinghouse improve the timely and reliable delivery of
    information education stakeholders need to implement evidence-proven
    approaches to important questions of policy and practice?
        Answer. What Works Clearinghouse Practice Guides are routinely
    cited by educators, district and state education administrators,
    educator preparation program faculty, and providers of professional
    development to classroom teachers as one of IES's most actionable and
    important publications for driving evidence-based practices. As such,
    IES is prioritizing their production. Requested resources are expected
    to support the development of new What Works Clearinghouse practice
    guides in 8 areas: (1) behavioral interventions, (2) college and career
    readiness, (3) STEM, (4) English Language Arts and literacy, (5)
    student success in secondary school, (6) supporting young children with
    disabilities, (7) improving school attendance, and (8) improving
    educator recruitment, retention, performance, and well-being. In 2024
    and 2025, IES plans to release 2 new practice guides for educators each
    year. Starting in 2026, supported by the higher level of funding
    (starting in FY 2025), IES plans to release 3 new practice guides for
    educators annually.
        Question. How did IES solicit feedback from the educators and other
    key stakeholders in identifying focal domains for completed systematic
    reviews?
        Answer. IES identified topics by meeting with organizations
    representing educators in various content areas such as mathematics
    education, teacher preparation, and special education. IES also
    leveraged the need-sensing activities of the Regional Educational
    Laboratories and formed panels of practitioners and researchers with
    relevant content expertise to inform and guide systematic reviews.
        Question. What policies and processes will it adopt going forward
    for stakeholder engagement on such reviews and increased awareness and
    use of the clearinghouse?
        Answer. IES plans to support broader, more frequent, and more
    systematic engagement with stakeholders to identify high-priority
    topics for future reviews, publications, and products that could
    strengthen evidence-based classroom practice and improve student
    outcomes. IES also plans to deepen its capacity to constantly monitor
    the supply of existing education research to detect innovative
    policies, programs, and practices more rapidly. Between FY 2025 and FY
    2028, IES intends to launch six ``Evidence Hub'' contracts to support
    this work in the following broad domains: (1) English Language Arts and
    literacy in K-12 education; (2) supporting K-12 student success and
    well-being; (3) K-12 science, technology, engineering, and mathematics
    (STEM) education; (4) postsecondary and adult education; (5) preschool
    and pre-kindergarten education; and (6) teacher policies and school
    systems. IES will also partner with stakeholders to disseminate
    existing practice guide resources.
        Question. According to the Department's FY25 Congressional
    Justifications, the Administration is requesting a $15 million
    rescission in the FY24 funding appropriated for the RELs. The
    Justifications state that this rescission ``As a significant amount of
    carryover funding has built up over time, a $15 million rescission
    would not have an impact on planned continuation awards.'' However, The
    FY24 appropriations act reduced funding for the RELs by $5 million.
        Given that fact, is it still the Administration's position that
    significant carryover has built up and the $15 million rescission would
    not have an impact on planned continuation awards?
        Answer. The President's budget requested $58.7 million for the RELs
    in FY 2025 and proposed a rescission of $15 million from unobligated FY
    2024 RELs funds expected to be carried over into FY 2025.
        Given that, in FY 2024, the REL Program was funded at $53.7 million
    instead of the $58.7 million requested by the President for FY 2024, a
    $15 million recission of FY 2024 carryover funds would impact planned
    continuation awards and likely result in a reduction of direct REL
    supports to states, districts, schools, and students.
        IES staff have carefully considered potential measures to spare
    direct REL services from being discontinued while fulfilling statutory
    requirements related to independent peer review of research and
    providing an independent evaluation of each of the regional
    laboratories. Since we submitted an FY 2024 operating plan to the
    Appropriations Committees, we have determined that we can scale back
    the REL evaluation and still meet the statutory requirement, which
    could save as much as $1 million in FY 2024 and FY 2025. However, even
    with those savings, we have concluded that it is not possible for the
    program to sustain a $15 million recission combined with the FY 2024
    cut without reducing the amount available for the RELs.
        It is also important to stress that the strategic use of carryover
    funds allows IES to provide uninterrupted funding for the REL contracts
    during fiscal years in which multiple short continuing resolutions are
    enacted. Strategic use of carryover funding allows IES to gradually
    build up sufficient funding during the 5-year contract award period to
    ensure that sufficient funding is available during the final year of
    the contracts to continue support for REL activities while also meeting
    Federal procurement requirements for the availability of funds for the
    next cycle of awards.
        Question. All of the funds appropriated for the RELs are used for
    the contracts for the RELs, and associated activities like web
    development and evaluation.
        Isn't it the case that a $15 million rescission in FY24 funding
    would result in a reduction in the amounts that the RELs receive
    through their contracts and in the activities they can carry out during
    FY24 or FY25 or both?
        Answer. When combined with the reduction of $5 million in the
    enacted FY 2024 appropriation for the REL program, a rescission of $15
    million in unobligated funds carried over from FY 2024 to FY 2025 would
    reduce the amount available for REL contracts in FY 2025 by
    approximately $700,000 if the President's budget request of $58.7
    million in FY 2025 is not enacted.
        Question. Please provide a table that displays the amount of
    funding that will go into the REL contacts by individual REL, into web
    development, into evaluation, and into any other activities in FY 2024,
    with and without a rescission of $15 million.
        Answer. As requested, we have provided a table showing the amount
    of funding each REL contract will receive in FY 2024. However, as the
    proposed rescission would apply to any unobligated funds carried over
    from FY 2024 to FY 2025, effects would not be felt until FY 2025.

    ------------------------------------------------------------------------
                                                              FY 2024 Amount
                Regional Educational Laboratories                   ($)
    ------------------------------------------------------------------------
    Regional Educational Laboratory West....................       5,699,896
    Regional Educational Laboratory Northwest...............       4,746,534
    Regional Educational Laboratory Midwest.................       5,800,000
    Regional Educational Laboratory Appalachia..............       4,787,391
    Regional Educational Laboratory Mid-Atlantic............       4,785,540
    Regional Educational Laboratory Central.................       4,699,484
    Regional Educational Laboratory Northeast & Islands.....       5,451,572
    Regional Educational Laboratory Pacific.................       4,702,259
    Regional Educational Laboratory Southeast...............       5,963,713
    Regional Educational Laboratory Southwest...............       5,500,000
    Associated Regional Educational Laboratory Program
     Activities:
    Evaluation of the Regional Educational Laboratory              1,000,000
     program................................................
    Peer Review of Regional Educational Laboratory products.       2,503,200
    Regional Educational Laboratory Website.................         883,558
    Technical and Administrative Support for the Regional            331,354
     Educational Laboratory program.........................
    Contractor Security Clearance Support...................          90,106
    ------------------------------------------------------------------------

        Those effects would be realized in FY 2025 through the end of the
    current REL contract awards. As noted in our response to the previous
    question, we would have a shortfall of approximately $700,000 for REL
    contracts in FY 2025, even after IES reduced planned amounts for
    associated activities in FYs 2024 and 2025. REL contract activities are
    not directed by IES, but rather proposed by the RELs based on needs
    identified by stakeholders at the State and local level. For this
    reason. IES cannot provide estimates of the amount of funding that
    would be available in FY 2025 for each REL contract with and without a
    rescission prior to consulting with the RELs. IES cannot determine for
    each REL what work would be stopped or otherwise curtailed should
    funding levels decrease. The direct technical assistance and applied
    research supports RELs provide States, districts, and schools are
    proposed by each REL as part of a 5-year plan of work. As such, they
    represent multi-year commitments to design, launch, sustain, and
    evaluate programs and services, often with complex dependencies.
        For example, REL Southeast's Mississippi Adolescent Literacy
    Partnership seeks to ensure Mississippi educators beyond grade 3 can
    integrate evidence-based literacy strategies into a wide range of
    academic courses. The partnership began with REL Southeast developing
    and piloting a series of trainings for grade 6-12 content area leaders
    in partner districts to support classroom implementation of the
    evidence-based recommendations of two literacy-focused WWC Practice
    Guides. Data collected during these pilot trainings will inform the
    development of a year-long professional learning resource that will be
    scaled up statewide in 2025 and 2026. Were REL program funding to be
    reduced in, those trainings for educators would be at risk of being
    cut, and the benefits of the direct supports REL Southeast provided to
    their three partner districts would not be shared across the State.
        As noted above, the combined effects of reduced appropriations,
    particularly if sustained in FYs 2025-2027, and the proposed rescission
    would also affect IES ability to carry over REL funds to avoid
    disruption to funding during prolonged continuing resolutions and
    ensure sufficient funding is available to fulfill procurement
    requirements for the next REL contract cycle while also supporting REL
    activities in the final year of this cycle.
        Question. Please describe how additional resources requested for
    IES program administration would support duties of the Evaluation
    Officer and support implementation of Title I of the Foundations for
    Evidence-based Policymaking Act.
        Answer. Optimal staffing of program evaluation functions, as
    described in Title I of the Evidence Act, leverages the subject matter
    and methodological expertise of senior staff (GS- 14/15) to
    conceptualize, design, and oversee high-quality, policy-relevant
    evaluations while delegating day-to-day responsibility for their
    execution to qualified junior staff (GS-12/13). In addition to using
    Program Administration funds more efficiently, this approach promotes
    thoughtful succession planning and brings new, innovative talent into
    IES. The Evaluation Officer will use the additional resources requested
    for IES Program Administration in FY25 to hire 2 full-time equivalent
    (FTE) employees at the GS-12/13 level, freeing existing senior staff
    for high-leverage work including but not limited to the design of
    rigorous evaluations of programs authorized by the Higher Education Act
    of 1965, as amended.
        Question. Please provide a table and narrative showing FTE and
    budget amounts supported by IES program administration for fiscal years
    2022, 2023, 2024, and 2025 for each of IES's centers.
        Answer.

    ----------------------------------------------------------------------------------------------------------------
                                            OD &       ADMIN &
                  OFFICE                  SCIENCE       POLICY       NCSER         NCES         NCER         NCEE
    ----------------------------------------------------------------------------------------------------------------
    FY 22
    FTE...............................            8           14            8           91           18           25
    Budgeted Amount...................   $1,128,145   $1,899,766   $1,020,960  $12,967,901   $2,591,591   $3,644,552
                                       -----------------------------------------------------------------------------
    FY23
    FTE...............................            8           15            7           93           17           25
    Budgeted Amount...................    1,584,115    2,945,237    1,261,894   18,560,067    3,594,366    5,139,993
                                       -----------------------------------------------------------------------------
    FY24
    FTE...............................            8           13            8           97           19           30
    Budgeted Amount...................    1,718,348    2,737,262    1,709,167   20,562,344    4,143,509    6,472,793
                                       -----------------------------------------------------------------------------
    FY25
    FTE...............................           12           12           10          106           21           38
    Budgeted Amount...................    2,602,692    2,602,692    2,168,910   22,990,446    4,554,711    8,241,858
    ----------------------------------------------------------------------------------------------------------------

        Question. The Department's FY25 Congressional Justification states
    ``Beginning in fiscal year 2024, the Department will be undertaking a
    comprehensive review of all technical assistance offerings, including
    those offered under this [Comprehensive Centers] program, for reach and
    effectiveness for SEAs, LEAs, and schools.''
        Please describe this review process and scope, including the
    quantitative and qualitative information to be used to assess the
    quality and quantity of technical assistance services and products
    offered; the quantitative and qualitative information to be used to
    assess recipient usage of technical assistance services and products;
    and the quantitative and qualitative information to be used to assess
    the impact of technical assistance services and products on recipient
    organizational change and improved capacity, SEA and LEA policy
    changes, including those needed to address applicable requirements of
    Federal law, and SEA and LEA practice change, including those needed to
    address applicable requirements of Federal law.
        Answer. The Department is developing a thoughtful, Department-wide
    approach to the review of technical assistance activities to best
    support the education community. We are considering how best to measure
    the usage and value of technical assistance resources. As part of this
    effort, we will review the topic areas covered under current
    investments to identify lessons learned and opportunities to best serve
    those who can and could benefit from technical assistance. We will
    discuss project data and program performance measures and available
    customer feedback, among other sources of information as we undergo our
    review.
        Question. Please provide the amount of funding allocated to
    individual regional content centers and in total in FY23 at the
    appropriation level of $55,000,000 and the amount of funding expected
    to be allocated to individual regional content centers in FY25 at the
    request level of $50,000,000. Please describe the impact of this
    funding reduction on the services and products that the regional
    content centers are able to provide to SEAs, LEAs, and schools.
        Answer. Fiscal Year 2023 was the final year in the previous
    Comprehensive Centers competition and included 19 Regional Centers and
    1 National Center. There was also a single content center funded in FY
    2021 that is on a separate 5-year track. For FY 2023, the total amount
    awarded to Regional Centers was $45,387,357. The individual amounts to
    Regional Centers were as follows:

    ------------------------------------------------------------------------
                                                              FY 2023 Amount
                        Regional Centers                            ($)
    ------------------------------------------------------------------------
    Region 1 (ME, MA, NH, VT)...............................       1,000,000
    Region 2 (CT, NY, RI)...................................       2,360,643
    Region 3 (PR, USVI).....................................       1,000,000
    Region 4 (DE, DC, MD, NJ, PA)...........................       2,557,246
    Region 5 (KY, TN, VA, WV)...............................       2,444,033
    Region 6 (GA, NC, SC)...................................       3,356,125
    Region 7 (AL, FL, MS)...................................       3,378,769
    Region 8 (IN, MI, OH)...................................       3,212,089
    Region 9 (IL, IA).......................................       1,722,122
    Region 10 (MN, WI)......................................       1,302,719
    Region 11 (NE, ND, SD, WY)..............................       1,243,525
    Region 12 (CO, KS, MO)..................................       1,963,421
    Region 13 (BIE, NM, OK).................................       1,647,431
    Region 14 (AR, LA, TX)..................................       5,413,464
    Region 15 (AZ, CA, NV, UT)..............................       6,472,657
    Region 16 (AK, OR, WA)..................................       3,313,113
    Region 17 (ID, MT)......................................       1,000,000
    Region 18 (FSM, GU, CNMI, PW)...........................       1,000,000
    Region 19 (AS, HI, RMI).................................       1,000,000
    ------------------------------------------------------------------------

        For Fiscal Year 2025, the estimated amount available for Regional
    Centers at the budget request level is $37,500,000. This amount will be
    for continuation awards to 14 Regional Centers. The estimated awards
    for Regional Centers in Fiscal Year 2025 will range from $1,000,000 to
    $5,300,000. The remaining funds will be for continuation awards for a
    National Center and five Content Centers. The FY 2024 appropriation for
    Comprehensive Centers was $50,000,000.
        As a result of the reduction in funding in the Fiscal Year 2024
    appropriation as well as ED's decision to fund four new Content Centers
    in the new competition, the Regional Centers will receive a reduced
    share of total program funds as well as reduced individual amounts
    which will impact their capacity to provide services.
        Question. Please describe the Department's key actions completed
    and plans for ensuring States and school districts comply with ESSA's
    policy requiring the reporting of actual personnel and non-personnel
    expenditures, disaggregated by Federal, state and local source of funds
    for each school and school district and such information is reliable
    and made available to the public in an accessible and understandable
    manner.
        Answer. The Department is taking several steps to ensure that SEAs
    meet the report card requirements in ESEA section 1111(h), including
    the requirement to post per pupil expenditures that include actual
    personnel and non-personnel expenditures, disaggregated by Federal,
    State, and local source of funds for each school and school district
    and that such information is made available to the public in an
    accessible and understandable manner.
        For each of the past 5 years, the Department has conducted an
    annual review in January of each State's website to check whether the
    State has posted State and local report cards. Each year we review a
    subset of the requirements. The Department selects different elements
    each year; due to the importance of the per-pupil expenditure
    information (as well as the fact that this was a new requirement in the
    latest reauthorization of the ESEA), the Department has reviewed for
    this information each of the past 5 years. Each year, we follow up with
    the State if it is missing any of the elements that we have reviewed,
    including sending a letter that requires each State to address the
    issue in a timely manner, until the State shows evidence that the
    information has been publicly reported on State and local report cards.
        In addition, in summer of 2023, the Department conducted Title I
    targeted monitoring of nine States of all public reporting requirements
    in Title I, Part A including all requirements in ESEA section 1111(h)
    and the public reporting requirement on disproportionate rates of
    access to ineffective, out-of-field, or inexperienced teachers for low-
    income and minority students in Title I, Part A schools. The Department
    issued corrective action letters to each State that was missing any
    report card requirements; these letters are available at https://
    oese.ed.gov/offices/office-of-formula-grants/school-support-and-
    accountability/key- documents/(note: filtering the year for 2023 will
    help you identify these letters). Following its Title I targeted
    monitoring of public reporting requirements, the Department is drafting
    a Dear Colleague Letter that provides recommendations to States on
    these requirements; the Department is also making technical updates to
    its non-regulatory guidance document, ``Opportunities and
    Responsibilities for State and Local Report Cards (March 2019)'' to
    reflect common questions and findings. Finally, the Department
    continues to provide technical assistance to States on this provision
    at national meetings. Most recently, at the National Association of
    ESEA State Program Administrators meeting, the Department conducted a
    professional development session that reviewed key findings from the
    Title I targeted monitoring across States and hosted a panel with two
    States that have strong report cards.
        In addition, a complete review of State and local report cards is
    included in the Department's Title I, Part A consolidated monitoring,
    which we conduct for four States each year. The full Title I monitoring
    protocols can be found at: https://oese.ed.gov/offices/office-of-
    formula- grants/school-support-and-accountability/performance-review/.
    An important aspect of our consolidated monitoring is a thorough
    review, for each State monitored in a particular year, of the State's
    report card to ensure that it includes all required elements.
        Question. How many competitive grant programs will include an
    evidence priority in fiscal years 2024 and 2025? For programs in which
    the evidence requirement of demonstrates a rationale, how is the
    Department supporting ongoing efforts of grantees to evaluate the
    effects of such activities, interventions or strategies?
        Answer. In fiscal year 2024, the Department is running 30 grant
    competitions that include an evidence priority. The Department is still
    in the process of planning FY 2025 competitions.
        The Department supports grantee evaluation through regular contact
    and monitoring activities. Additionally, the Department uses portions
    of national activities funding for technical assistance contracts that
    assist grantees in the implementation of their grants including in
    evaluation activities, as applicable.
        Question. Please also describe the ways in which the Department is
    supporting or plans to support evidence building and use in ESEA
    formula grant programs.
        Answer. The Department released updated guidance to support state
    and local use of evidence-based approaches to supporting teaching and
    learning, including for ESEA formula programs. The guidance, Non-
    Regulatory Guidance: Using Evidence to Strengthen Education Investments
    (PDF), provides information on using and building evidence along a
    cycle that includes identifying local needs, selecting relevant and
    evidence-based approaches, planning for implementation, implementing,
    examining and reflecting. The Department widely disseminates this
    guidance to the field and highlights it further during formula grant
    director convenings. In addition, IES promotes use of evidence at
    various formula grant director convenings, explains how the field can
    identify evidence-based approaches on the IES website, and aligns its
    resources and studies with the evidence levels in the ESEA.
        Question. Please provide an update on how the Department is using
    the funding Congress provided for assessment development in fiscal year
    2021, 2022 and 2023 to encourage states to improve their statewide
    assessments to provide more timely and relevant data to educators and
    stakeholders that can improve the timely use of assessment data needed
    to improve teaching and learning and accountability for high quality
    educational opportunities for all students.
        Answer. In September 2022, the Department made 11 awards totaling
    over $29 million to SEAs under the Competitive Grants for State
    Assessments (CGSA) program with FY2021 and FY2022 funds appropriated
    for this program. The 2022 CGSA competition focused on two priorities
    as directed by Congress: assessments based upon multiple measures and
    comprehensive assessments based on competency-based educational
    frameworks. The focus of the program is on improving State assessment
    systems and we hope these projects will provide models not only for
    these 11 States but for all States. (Abstracts for these 11 awards are
    available at https://oese.ed.gov/files/2022/08/CGSA-2022-
    Abstracts.pdf.)
        In March 2024, the Department announced a new CGSA competition for
    FY 23 funds (approximately $19 million). The 2024 competition once
    again includes a priority for assessments based upon multiple measures
    or comprehensive assessments based on competency- based educational
    frameworks. This competition also includes a priority for funds for
    SEAs planning to submit an application under the Innovative Assessment
    Demonstration Authority authorized in ESEA section 1204. The Department
    expects to make these awards by September 2024. The announcement for
    the current CGSA competition can be viewed at https://
    www.Federalregister.gov/d/2024-04972.
        Question. Please describe the challenges Education is hearing about
    that led to the FY25 budget proposal to increase the amount of funds
    States may reserve for administration purposes under section 1004 of
    the Elementary and Secondary Education Act (ESEA).
        Answer. The current cap has been in place since the 2001
    reauthorization of the Elementary and Secondary Education Act (No Child
    Left Behind) and has not been adjusted to account for inflation or the
    additional demands that have been placed on State educational agencies
    (SEAs) in the intervening 23 years. The current threshold was first
    exceeded in FY 2008 so it has been almost two decades since SEAs have
    been able to reserve a full 1 percent of their allocations for
    administration. During meetings with the Department, SEAs have shared
    that the current administrative cap limits them from:
      --Having sufficient resources to conduct extensive oversight or
            provide technical assistance to LEAs and schools to ensure
            compliance with all ESEA requirements.
      --Attracting the most qualified staff to administer Title I programs,
            including to:
        --Provide robust technical assistance to subgrantees
        --Effectively monitor subgrantees
        --Implement complex accountability systems
        --Support LEAs' implementation of equitable services
        --Allocate funds consistent with requirements
        --Collect and report extensive data, including publicly reporting
                data on State and local report cards and to the Department
                through EDFacts
      --Developing their staff through high-quality professional
            development opportunities.
      --Retaining qualified staff (to the detriment of students served by
            Title I programs some very strong State staff have left their
            positions in recent years.)
        The Council of Chief State School Officers (CCSSO) has also shared
    similar concerns with the Department. The National Association of ESSA
    State Program Administrators (NAESPA) has recently instituted a new
    director training series to provide support for new SEA staff due to
    the very large number of new staff in SEAs across the country. The lack
    of experienced SEA staff means more technical assistance must be
    focused on the basics of administering the grant programs and less time
    and attention is able to be spent on helping districts and schools use
    their Federal funds in new and innovative ways to support needed school
    reforms.
        Question. How would the proposal further implementation of
    accountability requirements of the law?
        Answer. The proposal would make available additional resources for
    SEAs to help implement Title I, Part A requirements, including
    accountability reporting, and school improvement requirements; conduct
    oversight of LEAs; and provide additional technical assistance. Funds
    would help expand the capacity of SEAs to implement the complex
    accountability system required to meaningfully differentiate and
    identify comprehensive support and improvement (CSI) schools; targeted
    support and improvement (TSI) schools; and additional targeted support
    and improvement (ATSI) schools, by providing additional resources to
    hire, train, and retain staff; monitor LEA implementation of program
    requirements; collect, analyze, review data on a timely basis; and
    provide support and technical assistance to LEAs.
        Question. How does the National Center on Improving Literacy
    support improved services for the significantly higher share of
    students with disabilities, including the likely higher share with
    dyslexia, served through the Title I-D neglected and delinquent
    program?
        Please describe completed actions and plans to improve transition
    and re-entry supports for students served in this program.
        Answer. The National Center on Improving Literacy (NCIL) develops
    products and services to increase (1) access to, and use of, evidence-
    based approaches to screen, identify, and teach students with literacy-
    related disabilities, including dyslexia and (2) individual and
    organizational capacity to assess students' literacy-related skill,
    identify students with disabilities or those at risk of disabilities,
    and fully implement evidence-based literacy programs and professional
    development. NCIL does not target students served by the Title I-D
    neglected and delinquent program; however, the products and services
    are appropriate for a variety of students including those served
    through the Title I-D neglected and delinquent program.
        Question. The FY25 Congressional Justification states that the
    request for Program Administration includes additional resources to
    establish the position of Chief Artificial Intelligence Officer with
    one supporting staff. Education has named its Deputy Chief Information
    Officer, Gary Stevens, to the position as of May 2024.
        Please elaborate on how much funding is being requested in total
    and for each of the Chief AI Officer and supporting staff position.
        Answer. A total of $415,000 is being requested for two positions
    (SES $224,000 & GS- 15 $191,000).
        Question. Does Education intend to hire an additional person to
    fill the Chief AI Officer position and relieve the Chief Technology
    Officer of the additional AI responsibilities?
        Answer. Yes, ED intends to hire a dedicated CAIO/Digital Services
    lead and a Sr. Technologist experienced in AI Management and the
    Solutioning of AI technologies and Digital Services.
        Question. What key activities does Education plan to initiate and/
    or complete in FY24?
        Answer. In alignment with the Executive Order 14110, ED has
    initiated and is working to:
      --Complete phases 1 & 2 for the Development and delivery of an
            Enterprise Technology Platform to support AI technology
            development and insertion.
      --Continue the maturity of AI governance through the establishment of
            working groups and evaluation boards.
      --Finalize the Department's AI policy.
      --Complete the development of process guidance to administer
            Generative AI (GenAI) request.
      --Collaborate with our business owners on the development of AI use-
            cases.
      --Continue the evaluation of existing AI systems for compliance with
            EO principles.
      --Continue to define needs to establish a qualified Red Team
      --Partner with the National Science Foundation on AI Data inventories
            for shared services.
        Question. What would the funding level identified in 26(a) enable
    Education to initiate and/or complete in FY25?
        Answer. In 2025, the Department will utilize these funds to
    complete the establishment of an AI program to meet the requirements of
    Executive Orders 14110 and 13960--to promote the safe, secure, and
    trustworthy development and use of Artificial Intelligence. We plan to
    focus on targeting resources to establish and implement policies,
    practices, and plans to acquire AI technologies and continue to build
    out the necessary infrastructure to house and manage such technologies
    consistent with EO requirements and OMB mandates. We will also leverage
    resources to train and upskill our workforce to bolster institutional
    competencies and capabilities to ensure we are postured to address AI
    vulnerabilities and threats to the mission. We are looking to acquire
    resources to complete the Red Team.
        Question. When will the Department launch the public comment period
    for the 2025- 26 FAFSA?
        Answer. To ensure a smooth user experience during the upcoming
    FAFSA cycle, the 2025-26 FAFSA form will remain consistent with the
    2024-25 form. As a result, and similar to previous years when we have
    not had major shifts in functionality, the 2025-26 form will not be
    made available for public comment. However, we will continue to focus
    our efforts on improving the user experience for students, families,
    and our partners and will collect feedback to inform our efforts
    through a series of listening sessions and a Request for Information
    (RFI) this summer to solicit feedback from those not able to attend the
    sessions.
        The Department will request specific feedback on ways to improve
    the help text on the form, student tip sheets, or other direct
    communication to students to ensure students can successfully complete
    and submit the form. The Department will also request feedback from
    financial aid administrators, counselors and others on ways the
    Department can provide additional support to them in their work. The
    listening sessions and RFI will also lead to the development of a new
    Better FAFSA Better Future Roadmap--to be released in late summer--that
    will outline new tools the Department is making available, such as
    additional trainings, webinars, counselor guides, and student tip
    sheets.
        Question. When will the Department post 2022-23 and 2023-24 FAFSA
    Data by Demographic Characteristics on the FSA Data Center?
        Answer. The Department has posted the 2022-23 FAFSA Data by
    Demographic Characteristics on the FSA Data Center, available here.
    This report is posted approximately 6-8 months after the end of a FAFSA
    cycle. As the 2023-2024 FAFSA application cycle does not end until June
    2024, this report is expected to be posted in early 2025.
        Question. When does the Department anticipate that all data
    resulting from 2025-26 FAFSA submissions, including the Institutional
    Student Information Records (ISIRs), will begin flowing to institutions
    once the 2025-26 FAFSA launches? Please provide an estimated number of
    days after the public availability of the 2025-2026 FAFSA.
        Answer. We have heard from students, families, institutions,
    states, and those that support them that it is important for the FAFSA
    form to launch on October 1. The Department is working toward this goal
    and toward launching other functionality to ensure students receive
    timely aid offers for the 2025-26 award year as quickly as possible.
        Question. Please provide all relevant information on the scope of
    the consumer or user testing that was conducted for 2024-2025 FAFSA
    cycle, including but not limited to:
          the number of users who participated in consumer testing;
          how users were selected for consumer testing;
          the applicable numbers of users who met the categories described
            in the Higher Education Act, such as prospective first-
            generation college students, representatives of students
            (including low-income students, English learners, first-
            generation college students, adult students, veterans,
            servicemembers, and prospective students), and students'
            families (including low-income families, families with English
            learners, families with first-generation college students, and
            families with prospective students;
          the specific dates when such consumer testing was conducted; 28e.
            if and how users were compensated for such testing;
          which contractors involved were involved in any aspect of
            consumer testing, and the scope of their contract;
          which Federal agencies and offices were involved in providing
            input or receiving the results of such testing; and
          any other applicable details related to the consumer testing
            process.
        Answer. To enhance the 2024-25 FAFSA form experience, Federal
    Student Aid (FSA) and its Office of Student Experience and Aid Delivery
    have conducted 21 comprehensive user experience research studies to
    date with over 300 participants. This consumer testing, which began in
    March 2022,\1\ included 1:1 usability testing observing participants
    engaging with early designs before development, as well as usability
    testing once the form went live in late December 2023. The participant
    selection was aligned to the FAFSA Simplification Act's consumer
    testing requirement and outreach to required audiences. In addition,
    FSA ensured participants were recruited from a wide audience, including
    students, parents, financial aid advisors, and high school counselors.
    Participants were also drawn from various specialized groups, such as
    first-generation college students, English learners, veterans, service
    members, low-income families (earning $50,000 and below), incarcerated
    students, adult students over the age of 25, homeless students, and
    others. Students and parents were recruited from all over the United
    States and sessions were predominantly held online via video
    conference.
    ---------------------------------------------------------------------------
        \1\ Several user experience research activities were completed for
    the 2023-24 FAFSA form, which included implementing certain elements of
    the FAFSA Simplification Act. That testing began in November of 2021.
    ---------------------------------------------------------------------------
        The testing methodologies were extensive, covering roles and
    taxonomy surveys, stakeholder interviews, cognitive walk-throughs, card
    sorting exercises, customer feedback surveys, email content testing,
    and co-creation workshops. This approach enabled a detailed evaluation
    of various elements of the application system, including the main form,
    embedded questions, dashboard, summary page, my activity feature, the
    FAFSA Submission Summary, and the overall user experience.
        The FSA design team within SEAD collaborated with various teams
    within FSA to manage and deliver the FAFSA user experience research.
    Individual studies were managed by FSA's vendor, Accenture Federal
    Services (AFS). Participants were recruited from a third-party
    recruitment platform along with partner organizations and school
    contacts to assemble the participant groups. AFS compensated each
    participant an average of $50 for their valuable input. This meticulous
    approach ensured that the insights obtained were thorough and aligned
    with FSA's broader objectives to optimize the application process to
    meet the needs of the millions of students and parents who interact
    with the FAFSA form.
        Question. When the 2025-2026 FAFSA launches, will all contributors
    who do not have a Social Security Number (SSN) be able to create an FSA
    ID and fill out the form at the same time as contributors and
    applicants who do have an SSN?
        Answer. Yes.
        Question. The Department created an incarcerated student
    application for the 2024-2025 FAFSA cycle. Does the Department
    acknowledge that students who are incarcerated, or whose parent(s) are
    incarcerated, can fill out a FAFSA online as a provisionally
    independent student using FAFSA On the Web?
        Answer. An applicant or contributor who is incarcerated can
    complete an application online if they have access to the Internet and
    the ability to complete the necessary multi-factor authentication.
    These applicants can be considered for all of the same professional
    judgment reviews as any other student. Applicants can proceed through
    the form as a provisional independent student but will be subject to
    financial aid administrator review to confirm that status.
        Question. Please describe the Department's plans to help applicants
    accurately fill out the FAFSA questions related to family size, such as
    divorce, marriage, death, births, or older siblings no longer living at
    home, and especially circumstances where family size changes may
    increase students' eligibility for aid.
        Answer. Data to support the determination of family size are
    provided directly via the IRS FA-DDX. If an applicant needs to manually
    enter family size or update the reported family size due to a change in
    circumstances, the Department provides help to applicants via the FAFSA
    application as well as separate help pages including, https://
    studentaid.gov/2425/help/family-size, https://studentaid.gov/2425/help/
    family-size-changed, and https://studentaid.gov/2425/help/parent-
    family-size.
        Question. Under Section 483 (a)(2)(B)(ii)(XVII) of the Higher
    Education Act (HEA), the Secretary is authorized to add ``any other
    means-tested program determined by the Secretary to be appropriate'' to
    the list of information to be considered before determining eligibility
    for Federal financial aid. Therefore, will the Department consider
    adding the following means-tested programs to the list of benefits on
    the 2025-2026 FAFSA, please answer yes or no and provide a brief
    rationale:
          Low Income Home Energy Assistance Program (LIHEAP)
          Unemployment Insurance (UI)
          Child Tax Credit (CTC)
          American Opportunity Tax Credit (AOTC) and/or Lifetime Learning
            Credit (LLC)
        Answer. Yes, the Department will consider adding other means-tested
    benefits, such as the ones listed, to future releases of the FAFSA
    form.
        Question. Please describe the Departments views on adding an
    affirmative consent ``check box'' to the 2025-2026 FAFSA to provide
    applicants with the option to share their FAFSA information with
    applicable agencies that handle applications for means-tested Federal
    benefit programs, in accordance with Section 483(a)(2)(D)(ii) of the
    Higher Education Act.
        Answer. The Department is assessing when the consent box can be
    added to the FAFSA form, including planning for both adding it to the
    development cycle and computer matching agreements with other Federal
    agencies to share the data once it is collected.
        Question. Please indicate whether the Department currently
    maintains data-sharing Agreements under Section 483(c)(3) of the Higher
    Education Act for the purpose of connecting students to means-tested
    benefits, or the estimated timeline for establishing any such data-
    sharing agreements, with the following agencies:
          Treasury
          Labor
          Health and Human Services 42d. Agriculture
          Housing and Urban Development 42f. Commerce
          Veterans Affairs; and 42h. Interior
        Answer. The Department does not currently have data sharing
    agreements with these agencies for the purposes under 483(c)(3). We are
    assessing when these agreements can be established.
        Question. When does the Department anticipate updating GEN-22-02
    guidance for institutions of higher education regarding the use of
    FAFSA data to connect students to public and tax benefit programs?
        Answer. The Department will be issuing updated guidance in the
    coming weeks.
        Question. Please describe the Department's efforts to comply with
    the requirements of Section 483(b)(1) of the Higher Education Act
    regarding the disclosure, in a consumer-tested format, of information
    to students regarding potential adjustments of their financial aid
    eligibility, including examples of such communications provided
    directly to students, and how such communications were tested with
    consumers.
        Answer. General usability testing of the application form pages was
    conducted in October 2022. This testing included the interstitial pages
    that display at the beginning of every section of the FAFSA form.
        The interstitial page that displays at the beginning of each
    Finances section (student's, parent's, student spouse's and parent
    spouse's) includes a general overview of the information we'll collect
    in that section. Almost all usability study participants mentioned
    appreciating the explanation of why the questions are asked. The text
    on the (student version of the) page says: ``The FAFSA form helps
    determine your ability to pay for school. In this section, we ask about
    your financial information.'' This is followed by the hyperlink: ``What
    if you have special financial circumstances?'' (which links to https://
    studentaid.gov/help/reporting-special- financial-circumstances). The
    linked help topic provides some examples of special circumstances as
    well as guidance to submit the FAFSA form as instructed and then reach
    out to the financial aid office.
        Question. In October 2023, the Department issued new
    ``administrative capability'' regulations which, among other things,
    strengthen financial aid communications with students by requiring
    institutions to include the institution's cost of attendance, the
    source and type of aid offered, whether aid must be earned or repaid,
    the net price, and deadlines for accepting, declining, or adjusting
    award amounts on their financial aid offers. Please provide the
    following information:
        Whether these new requirements are applicable to award offers being
    sent to students now, for award year 2024-2025;
        Answer. New provisions in 34 CFR 668.16(h) take effect on July 1,
    2024. Financial aid counseling and communications occurring prior to
    that date are not subject to the new rule, without regard to the award
    year to which they pertain, but will be evaluated under existing
    regulations. In determining (as part of an overall assessment of
    administrative capability) whether an institution's counseling and
    financial aid communications advise students and families to accept the
    most beneficial types of financial assistance available to them and
    include the information stipulated in new 34 CFR 668.16(h), we will
    look at financial aid counseling and communications that occur on or
    after July 1, 2024, again without specific regard to award year.
        Question. If the answer to (45a) is no, will the requirements be in
    place for the 2025-2026 award year?
        Answer. As discussed above, compliance with the new regulations is
    not keyed to the award year for which the student will receive Title IV
    assistance. Financial aid counseling and communications to a student
    who enrolled on say August 1, 2024 (having occurred after July 1, 2024)
    would be subject to evaluation under the new rule though that student's
    initial period of enrollment would be during the 2024-2025 award year.
        Question. How the Department plans to enforce the provisions added
    to Sec. 668.16
        Answer. Enforcement of this provision will be through the program
    review and annual compliance audit functions.
        Question. Whether the Department plans to issue any additional
    guidance or best practices related to this provision, beyond the
    College Financing Plan.
        Answer. Currently, the Department has no plans to issue further
    guidance on this rule. We believe the regulatory language is clear and
    that schools are well familiar with the terms and practices referenced
    therein. However, we will monitor compliance with the new rule as well
    as requests for technical assistance to determine if additional
    guidance is needed.
        Question. Accrediting agencies and state authorizers make up
    critical aspects of the program integrity triad and are expected to
    ensure adequate oversight of institutions of higher education
    participating in the Federal financial aid programs. What is the
    Department's expected timeline for proposing regulations regarding each
    of the issues discussed in the January-March 2024 negotiated rulemaking
    related to accrediting agencies and state authorizers?
        Answer. The Department expects to release proposed regulations for
    accreditation and state authorization this fall.
        Question. Now that funding has been awarded for the Career
    Connected High School Program, what evidence and data will the
    Department collect from grantees, how will the Department measure the
    success of the program, and how will the Department use lessons learned
    from these grantees to help school districts and technical colleges
    around the country improve their CTE programs?
        Answer. We are collecting data about Career-Connected High School
    (CCHS) grant implementation and student outcomes so that we can learn
    from and share the results with States, LEAs, and community colleges.
    The statute requires grantees to report on the core indicators of
    performance established for the Perkins State formula grant program,
    but we decided to collect more comprehensive outcome data from the
    grantees beyond the formula grant indicators. Furthermore, each grantee
    is supporting an independent evaluation that will collect and report on
    the number and percentage of students who graduated from high school
    having:
      --Earned through dual or concurrent enrollment 12 or more
            postsecondary credits that are part of a program of study that
            culminates with an associate, bachelor's, or advanced degree,
            or completion of a Registered Apprenticeship Program.
      --Completed 40 or more hours of work-based learning for which they
            received wages or academic credit, or both.
      --Attained an industry-recognized credential that is in-demand in the
            local, regional, or State labor market and associated with one
            or more jobs with median earnings that exceed the median
            earnings of a high school graduate.
      --Met, in each year of high school, with a school counselor, college
            adviser, career coach, or other appropriately trained adult for
            education and career counseling during which they reviewed and
            updated a personalized postsecondary educational and career
            plan.
        These outcomes must be disaggregated by major racial and ethnic
    groups, sex, and special population status, as well as by each CTE
    program and program of study. Additionally, each grantee will report
    annually on the extent to which CTE participants and CTE concentrators
    in each CTE program or program of study reflect the demographics of the
    school, including sex, major racial and ethnic groups, and special
    populations status.
        We will disseminate what we learn from this program to States and
    subrecipients of Carl D. Perkins Career and Technical Education Act
    funds to inform and, we hope, propel more systemic reforms to expand
    access to career-connected learning.
        We are also excited to learn from the 13 CCHS grants that are
    predominantly serving rural communities that often do not have the
    resources to implement wide-scale reforms in career-connected learning.
    The CCHS investment in these communities may demonstrate new strategies
    for improving opportunities in rural communities that can inform State
    and Federal policymaking on CTE and rural economic development.
        Question. Earlier this year, the National Center for Education
    Evaluation of the i3 Fund, the program upon which the Education
    Innovation and Research was largely based, found that just more than
    half of scale-up grantees--those with the most rigorous prior research
    findings of effectiveness--reported positive effects on student
    outcomes from their grants. The report also noted that those scale-up
    evaluations included little reporting on what was learned about
    effective approaches to scaling.
        The FY25 Congressional Justification indicates the Department would
    reserve up to $13.45 million in fiscal year 2025 Education Innovation
    and Research appropriation for technical assistance, including
    technical assistance to help grantees develop and implement rigorous
    evaluations, and dissemination. How will these funds and other
    resources be used to increase the percentage of scale-up grantees with
    positive effects on student outcomes, expand and disseminate knowledge
    about effective implementation and approaches to scaling, and further
    learning from findings of no effect?
        Answer. The Department's Office of Elementary and Secondary
    Education and Institute of Education Sciences are collaborating on how
    best to utilize an increase in the Department's reservation for
    national activities under Education Innovation and Research (EIR) to
    improve grantee performance. Among the Department's efforts may be
    expanded technical assistance on performance measurement and analysis;
    studying conditions that make grantees with certain characteristics
    more or less likely to succeed in their EIR projects; pre-application
    evaluation design webinars to improve initial evaluation design; and
    support to grantees on dissemination strategies, including how to
    translate findings to non-scientific audiences.
        Question. The Institute of Education Sciences budget includes $2.2
    million for joint work with the National Science Foundation on a new AI
    Institute on Intelligent Tutoring.
        How much funding is requested within the NSF budget for this joint
    work?
        Answer. Each NSF Artificial Intelligence Research Institute is
    funded at up to $4.0 million per year for up to 5 years. Additional
    information on NSF's FY 2025 Request for these AI Research Institutes
    is located on the NSF Centers website.
        Across the 5 years of the grant, NSF and IES will be investing
    approximately $20M to support the AI Institute on Inclusive and
    Innovative Intelligent Technologies for Education (INVITE AI
    Institute). NSF and IES will split 50% of the costs to support the
    joint work (approximately $2M per FY/per agency).
        Question. Please describe how this new institute would build on the
    Digital Learning Platforms Research Network and develop AI-driven
    innovations that will reduce achievement gaps and address the needs of
    all learners, especially those from historically underserved student
    populations and diverse learners, including Native American students.
        Answer. The INVITE AI Institute is developing AI tools and
    approaches to track and promote skills that underlie successful
    learning and contribute to academic success: persistence, academic
    resilience, and collaboration. Fostering such skills can help improve
    academic achievement for learners from historically marginalized groups
    and close persistent achievement gaps. INVITE will also form a national
    community of practice with a shared mission to advance diversity,
    equity, and inclusion in computer science, as a pathway to
    participation in AI. Primary activities will focus on engaging members
    of the community of practice in taking action to deliver equitable and
    inclusive K-12 learning experiences in computing and introductory AI;
    providing K-12 teachers with knowledge of CS and AI provides an
    opportunity to introduce concepts to K-12 students. INVITE will
    collaborate with the STARS Computing Corps, which includes 53
    institutional members, including nine Historically Black Colleges and
    Universities (HBCUs) and engages higher education computing around a
    shared commitment to take action to advance diversity, equity, and
    inclusion in computing. Through this collaboration with STARS Computing
    Corps, the INVITE Institute will offer the INVITE Teaching Fellows
    program, which aims to equip K-12 teachers with K-12 computing
    education materials and practices that value the cultural wealth of
    Black and LatinX students and connect them with undergraduate students.
        The Digital Learning Platforms Research Network (also known as
    SEERNet) is a separate IES program that is part of IES's Accelerate,
    Transform, Scale (ATS) Initiative. The goal of this network is to
    leverage existing, widely used digital learning platforms for rigorous
    education research. Five digital learning platforms have developed
    tools and processes to support research, and IES is now providing
    funding to research teams to use those platforms to conduct their
    studies. NSF has recently funded the SafeInsights project through the
    Mid-scale Research Infrastructure program, which builds on and extends
    infrastructure development in this area. A more comprehensive overview
    of IES's investments in AI can be found here.
        Question. The Department's latest regulatory agenda identified
    plans to amend the Family Educational Rights and Privacy Act
    regulations. The agenda further indicated a Notice of Proposed
    Rulemaking was expected in 5/2024. Please provide an update on whether
    and when such action is expected.
        Answer. The Department plans to amend the Family Educational Rights
    and Privacy Act (FERPA) regulations to implement amendments to the
    FERPA contained in the Healthy, Hunger-Free Kids Act of 2010 (Public
    Law 111296) and the Uninterrupted Scholars Act of 2013 (Public Law
    112278); to provide needed clarity regarding the of terms definitions
    and other key provisions of FERPA; and to make necessary changes
    identified as a result of the Department's experience administering
    FERPA and the current regulations. For an updated timeline on the
    expected Notice of Proposed Rulemaking, please see the Spring 2024
    regulatory agenda once it is published by the Office of Management and
    Budget.
                                     ______

                  Questions Submitted by Senator Patty Murray
        Question. The FAFSA form was supposed to be cut by two-thirds.
    Millions of additional students were supposed to get more money for
    college. Students experiencing homelessness, incarcerated students,
    justice-involved students, parenting students, and many others were to
    gain access to college aid through a new and streamlined process. Yet,
    continued technical challenges and another 6 months of delays from when
    the form should usually launch in October have left students, families,
    and institutions of higher education uncertain of their future. In the
    face of these shortcomings, one of the Department of Education's
    (Department) main contractors running the FAFSA, General Dynamics
    Information Technology (GDIT), received $122 million to modernize FAFSA
    systems.
        Have you been informed of potential shortcomings with this
    contractor?
        Answer. Senior leadership within the Department became aware of
    challenges with the FAFSA timeline, including what contractors held
    responsibility for different FAFSA components, in fall 2022. We have
    been working closely with Federal Student Aid and other offices within
    the Department since that time to set priorities, oversee project
    planning and implementation, and ensure accountability for the
    development and launch of the 2024-25 FAFSA. This detailed and frequent
    oversight will continue leading up to and through the 2025-26 FAFSA.
        How much in Federal funds has GDIT received to date under its June
    2022 FAFSA contract with the Department?
        Question. As of May 23, 2024, the Department had paid
    $17,262,821.63 to GDIT.
        What accountability metrics were in place to ensure that GDIT
    completed the FAFSA form modernization in a timely manner?
        Answer. GDIT's contract has contained various service level
    agreements intended to measure their performance focused across several
    areas including testing, security, system development and architecture,
    and system performance.
        Question. One important way that other government agencies and the
    private sector pilot major new systems is through user testing. The
    FAFSA Simplification Act, requires the Department to put the new FAFSA
    through rigorous consumer testing before it was launched. This could
    have helped avoid some of the bugs and data errors we see today. In
    your FY25 request for Student Aid Administration, the Department cites
    that consumer testing is still one of the ``remaining provisions'' of
    the law that must still be implemented.
        Please confirm that user-testing of the FAFSA was done in advance
    of this year's launch as required by law, and provide details about the
    size and scope.
        Answer. To enhance the 2024-25 FAFSA form experience, Federal
    Student Aid (FSA) and its office of Student Experience and Aid Delivery
    have conducted 21 comprehensive user experience research studies to
    date with over 300 participants. This consumer testing, which began in
    March 2022,\2\ included 1:1 usability testing observing participants
    engaging with early designs before development, as well as usability
    testing once the form went live in late December 2023. The participant
    selection was aligned to the FAFSA Simplification Act's consumer
    testing requirement and outreach to required audiences. In addition,
    FSA ensured participants were recruited from a wide audience, including
    students, parents, financial aid advisors, and high school counselors.
    Participants were also drawn from various specialized groups, such as
    first-generation college students, English learners, veterans,
    servicemembers, low-income families (earning $50,000 and below),
    incarcerated students, adult students over the age of 25, homeless
    students, and others. Students and parents were recruited from all over
    the United States and sessions were predominantly held online via video
    conference.
    ---------------------------------------------------------------------------
        \2\ Several user experience research activities were completed for
    the 2023-24 FAFSA form, which included implementing certain elements of
    the FAFSA Simplification Act. That testing began in November of 2021.
    ---------------------------------------------------------------------------
        The testing methodologies were extensive, covering roles and
    taxonomy surveys, stakeholder interviews, cognitive walk-throughs, card
    sorting exercises, customer feedback surveys, email content testing,
    and co-creation workshops. This approach enabled a detailed evaluation
    of various elements of the application system, including the main form,
    embedded questions, dashboard, summary page, my activity feature, the
    FAFSA Submission Summary, and the overall user experience.
        The FSA design team within SEAD collaborated with various teams
    within FSA to manage and deliver the FAFSA user experience research.
    Individual studies were managed by FSA's vendor, Accenture Federal
    Services (AFS). Participants were recruited from a third-party
    recruitment platform along with partner organizations and school
    contacts to assemble the participant groups. AFS compensated each
    participant an average of $50 for their valuable input. This meticulous
    approach ensured that the insights obtained were thorough and aligned
    with FSA's broader objectives to optimize the application process to
    meet the needs of the millions of students and parents who interact
    with the FAFSA form.
        Question. Please describe what steps you are taking to ensure that
    a beta version of the online form will be available in September 2024.
        Answer. The Department will make a prototype of the form available
    several weeks prior to launch. The Department recently announced that,
    to ensure a smooth user experience during the upcoming FAFSA cycle, the
    2025-26 FAFSA form will remain consistent with the 2024-25 form. This
    mitigates the need for a beta version of the 2025-26 form.
        Question. New data from the Office of Federal Student Aid reveals a
    significant drop in the number of FAFSA completions for the 2024-2025
    school year for high school seniors. This decrease shows that only
    about 29 percent of the class of 2024 completed a FAFSA form compared
    to 46.8 percent of the class of 2023 through the same date last year.
        What action steps will the Administration be taking later this
    spring and summer to get FAFSA completions back on track compared to
    last year?
        Answer. The Department has already received over 12.22 million
    FAFSA forms, 11.68 million of which have been processed as of July 9,
    2024. The Department has made significant progress in closing the gap
    in FAFSA submissions to 5.7 percent as of July 9 compared to this time
    last year, down from nearly 40 percent in March. Submissions from high
    school seniors are currently less than 12 percent behind last year, as
    of July 2, 2024.
        In addition to the Department's existing messaging and media, the
    Department launched the Student Support Strategy in May to distribute
    $50 million to organizations on the ground supporting current cycle
    FAFSA completion efforts, specifically targeting this year's high
    school senior class. Organizations receiving funding are implementing
    projects such as paying for additional summer staffing, developing
    supportive resources, and working directly with students and families.
        This spring and summer the Department is taking significant action
    to get FAFSA completions at the levels of previous cycles. Over the
    summer months the Department is implementing four primary strategies to
    close completion gaps:
          1. Updating key messaging and asks by stakeholder group for the
            summer months.
          2. Maximizing first-time FAFSA submissions and completions
            through a community college specific campaign, adult learner
            campaign, and territories-specific support.
          3. Converting students who have started but not submitted the
            FAFSA to completed status through direct emails and text
            campaigns from FSA, as well as other initiatives like
            additional trainings for counselors.
          4. Ensuring that all returning students have completed the FAFSA
            through tactics focused on students who may have stopped out of
            higher education and/or who may be transfer students.
        The Deputy Secretary is hosting office hour sessions for state
    officials working on statewide FAFSA initiatives. The office hours have
    three objectives: (1) share information,
        (2) get feedback/open communication, (3) answer questions from the
    field.
        Finally, the Department has launched a Summer Resources campaign to
    new stakeholder groups who oversee locations that students frequent
    over the summer. These groups will provide a folder of promotional
    materials and resources to remind students to complete the FAFSA and
    offer support. The campaign includes more than 30 new stakeholder
    groups including: public recreation centers, gyms, movie theaters,
    libraries, supermarkets, one-stop centers, food pantries, malls, summer
    sports orgs, volunteer sites, etc.
        Question. What steps is the Department taking to ensure that the
    FAFSA form will launch on time in October 2024 in time for the 2025-
    2026 academic school year?
        Answer. We have heard from students, families, institutions,
    states, and those that support them that it is important for the FAFSA
    form to launch on October 1. The Department is working toward this goal
    and toward launching other functionality to ensure students receive
    timely aid offers for the 2025-26 award year as quickly as possible.
        The Department has announced Jeremy Singer, president of the
    College Board, as a new FAFSA Executive Advisor. He will lead FSA's
    overall strategy on the 2025-26 FAFSA form, working closely with the
    Department's leadership and the FAFSA implementation team to strengthen
    internal systems and processes, bolster technical capabilities, and
    drive innovation to help ensure optimal performance leading to the
    launch of the 2025-26 FAFSA form.
        Senior leadership at the Department will continue to work closely
    with career staff to ensure the 2025-26 FAFSA is launched and ready for
    students to submit applications on an expected timeline of October 1,
    2024.
        To ensure a consistent and smooth user experience during the
    upcoming FAFSA cycle, the 2025-26 FAFSA will remain consistent with the
    2024-25 form. As a result, and similar to previous years when we have
    not had major shifts in functionality, the 2025-26 form will not be
    made available for public comment.
        However, we will continue to focus our efforts on improving the
    user experience for students, families, and our partners and will
    collect feedback to inform our efforts through a series of listening
    sessions and a Request for Information (RFI) this summer to solicit
    feedback from those not able to attend the sessions.
        The Department will request specific feedback on ways to improve
    the help text on the form, student tip sheets, or other direct
    communication to students to ensure students can successfully complete
    and submit the form. The Department will also request feedback from
    financial aid administrators, counselors and others on ways the
    Department can provide additional support to them in their work.
        The listening sessions and RFI will also lead to the development of
    a new Better FAFSA Better Future Roadmap--to be released in late
    summer--that will outline new tools the Department is making available,
    such as additional trainings, webinars, counselor guides, and student
    tip sheets.
        Question. The FY25 budget request includes appropriations language
    to increase to 10 percent the amount of grant funds States are allowed
    to reserve for evaluation of the comprehensive literacy development
    grants program.
        Please describe the justification for this proposal and how it
    would further the purpose of this program.
        Answer. ESEA section 2222(f) allows a State educational agency
    (SEA) receiving a CLSD grant to reserve not more than 5 percent for
    State level activities, including evaluation. Grantees have repeatedly
    expressed to the Department the need for a higher reservation of CLSD
    grant funding for such State level activities as supporting funding of
    literacy personnel, professional development, subgrantee monitoring,
    and evaluation.
        Additionally, current applicants have expressed concern with the 5
    percent cap and their ability to cover SEA expenses to administer the
    grant.
        Question. Please describe planned activities to support cross-
    program efforts to help States and LEAs better serve students
    experiencing homelessness.
        Answer. The Department is committed to taking a cross-program
    approach to implementing programs for students experiencing
    homelessness, including the Education for Homeless Children and Youth
    (EHCY) program and the American Rescue Plan funding for Homeless
    Children and Youth (ARP-HCY) program, and programs focused on other
    highly mobile student populations. For example, the Department
    presented at the 2024 National Association of ESEA State Program
    Administrators (NAESPA) conference on the importance of supporting
    highly mobile students through cross-systems efforts. The Department's
    2024 annual meeting for State Coordinators of EHCY programs also
    featured discussions with staff from career and technical education
    (CTE) programs and Head Start programs, underscoring the need for
    cross-program collaboration to address the unique needs of both young
    children and older youth experiencing homelessness. Finally, the May
    2024 convening for State Coordinators of Title I, Part D programs
    included a session focused on addressing the unique needs of students
    who move between the juvenile justice, child welfare, and homelessness
    systems.
        The Department also worked with our National Center for Homeless
    Education (NCHE), to release a suite of resources focused on the
    importance of cross-program coordination to effectively identify and
    support students in foster care. For example, NCHE conducted webinars
    focused on cross-program implementation strategies, including webinars
    focused on support for English learners experiencing homelessness
    (https://nche.ed.gov/supporting-english-learners-els-experiencing-
    homelessness-an-arp-hcy-implementation-spotlight/), migratory students
    experiencing homelessness (https://nche.ed.gov/serving-migrant-
    students-experiencing-homelessness/?highlight=migrant), and students
    with disabilities experiencing homelessness (https://nche.ed.gov/
    strengthening-the-provision-of-special-education-services-for-children-
    with-disabilities-and-their-families-experiencing-homelessness/). NCHE
    has also focused its technical assistance on cross-systems efforts to
    support students experiencing homelessness, such as providing a suite
    of resources related to using program funds for systems navigation,
    including. For example, NCHE published a brief in April 2023 on systems
    navigators (see: https://nche.ed.gov/leveraging-systems-navigators-
    brief/?highlight=systems%20navigator).
        Additionally, the fiscal year 2025 request also includes a proposal
    to improve coordination of services for students who face multiple risk
    factors and, as a result, are eligible for multiple Federal programs,
    including students experiencing homelessness. Each of these programs is
    designed to support the unique needs of students through coordination
    with multiple agencies and systems, such as state and local child
    welfare agencies, housing agencies and providers, and community-based
    organizations. The number of students who qualify for services provided
    under multiple Federal programs and deal with life circumstances that
    jeopardize their educational stability and success is significant. The
    Administration is requesting appropriations language under General
    Provisions to authorize a limited demonstration project to provide
    additional resources to SEAs and LEAs to address the challenge of
    coordinating services for students. The proposal would authorize the
    Department to reserve up to one-half of 1 percent of funds appropriated
    for the Migrant Education, Neglected and Delinquent, and Education for
    Homeless Children and Youths program for the Department to make
    competitive grants to SEAs to improve service delivery and coordination
    for at-risk students who are eligible to receive services under
    multiple Federal education programs. SEAs would have the authority to
    make subgrants to LEAs to carry out these activities. Ultimately, this
    authority would support better coordination of services across funding
    streams, help ensure more effective and efficient use of Federal
    resources for benefitting students, reduce duplication in services,
    ensure service continuity, and provide improved service delivery and
    direct student support. Funding could support personnel, training and
    professional development, data collection and analysis, and
    documentation of best practices to shore up SEA and LEA capacity to
    address needs of students that qualify for multiple programs (like
    migratory students and students experiencing homelessness) across ED
    grant funds.
        Question. Please also describe what actions are planned to work
    with State Title I directors and State Coordinators for Education of
    Homeless Children and Youths on effectively using a sufficient amount
    of Title I-A funds for identifying and meeting the needs of students
    experiencing homelessness.
        Answer. In the past 2 years, the Department has increased both our
    oversight and technical assistance with respect to the requirement that
    LEAs reserve a portion of their Title I-A funds to meet the needs of
    students experiencing homelessness. For example, we recently revised
    our monitoring protocols for the EHCY program to include a section
    focused on the Title I-A set-aside. We have issued findings in several
    States regarding this requirement and have required the SEAs to address
    this issue by providing guidance and technical assistance to LEAs. We
    have presented on the monitoring findings at several national
    conferences in 2024, including sharing both the common findings and how
    SEAs have addressed the finding. In addition, the Department has taken
    steps to improve the transparency of SEA data. In February 2024, for
    the first time, the Department required each State to submit data on
    LEA reservations of Title I-A funds, including the amount reserved for
    students experiencing homelessness. The Department is currently
    reviewing these data, after which we will make the data public. Having
    these data will help the Department compare the Title I-A homeless set-
    aside to the homeless count. The analysis will inform our monitoring
    and technical assistance in FY 2025.
        Question. What is the Department's plan to ensure that applicants
    who indicate homelessness on the FAFSA, but do not have documentation
    from authorized entities, receive timely and accurate information on
    the process for the determination of their unaccompanied homeless youth
    status, including the responsibility of the FAA to make determinations
    based solely on a written statement from the student or a documented
    interview?
        Answer. While completing the FAFSA form, applicants can obtain
    assistance in answering the question regarding being unaccompanied and
    homeless or at risk of homelessness via a tool tip located next to the
    question. Upon selecting the tool tip icon, applicants are taken to
    https://studentaid.gov/2425/help/unaccompanied-homeless.
        Additionally, we communicate the impacts of selecting ``None of
    these apply'' after the applicant indicates they are unaccompanied and
    homeless or at risk of homelessness in several ways. First on the
    Dependency Results page, we say:
          ``Based on your answers, you're a provisionally independent
            student. This means you don't need to answer questions about
            your parents to submit your application. To complete your
            application, you'll need to contact your college's or career
            school's financial aid office and provide documentation to
            verify your circumstances.
          We won't be able to calculate your Student Aid Index (SAI) until
            you confirm your circumstances with your financial aid office.
            Until then, we will provide only an estimate of your Federal
            student aid eligibility as an independent student.''
        Then on the confirmation page, we explain the provisional
    independent status again with similar language.
        Once the FAFSA form is processed, the applicant receives this
    additional guidance on the FAFSA Submission Summary:
          ``You didn't report information about your parents because you
            indicated that you are an unaccompanied youth and homeless, or
            an unaccompanied youth at risk of homelessness. You need to
            follow up with your college's or career school's financial aid
            office before your eligibility for Federal student aid can be
            determined. A financial aid administrator may request
            documentation of your status in order to complete their review
            of your FAFSA form.''
        As follow-up, the processed results are made available to
    applicants. The Department has emailed all FAFSA applicants who answer
    the FAFSA question on whether the student was unaccompanied and either
    (1) homeless or (2) self-supporting and at risk of being homeless in
    the affirmative. These emails are sent weekly to over 50,000 FAFSA
    applicants and have included information on what students should expect
    from the process and working with their FAAs.
        Question. What is the Department's plan to ensure that its FAFSA
    outreach initiatives, materials, and campaigns include tailored
    strategies for reaching homeless and foster youth, as well as the
    educators and service providers who work with them?
        Answer. In its April 2023 guidance on unaccompanied homeless youth,
    the Department stated that ``In all situations, institutions should be
    able to show that their Policies for reviewing and making homeless
    youth determinations are compliant with statutory requirements.'' The
    Department will also continue to collaborate with advocates of
    vulnerable unaccompanied and foster youth as part of our outreach
    strategy. We will also explore clarifications and update to existing
    guidance around supporting unaccompanied homeless and foster youth.
        Question. What is the Department's plan for oversight and
    monitoring institutions' compliance with these requirements?
        Answer. The Department will continue to ensure that institutions
    comply with all statutory and regulatory requirements through program
    reviews and other regular oversight activities.
        Question. How does the Department plan to ensure that unaccompanied
    youth at-risk of or currently experiencing homelessness are routed
    correctly on the FAFSA through a path that is separate and distinct
    from provisionally independent students on the 2025-2026 FAFSA?
        Answer. Currently, unaccompanied youth at-risk or currently
    experiencing homelessness with a designation are routed through the
    independent path. Students who need an administrator to confirm their
    designation are directed to a page that alerts them of the action
    needed by the institutional administrator but are then routed through
    the independent path where they will receive a provisional SAI pending
    their determination.
        Question. Public comments have previously suggested that the
    Department change the FAFSA questions for students who are experiencing
    homelessness, or at risk of homelessness, to inquire about whether
    student applicants were in such status during the previous 2 years
    (e.g. 2022 or 2023) instead of the previous year, consistent with the
    use of ``prior- prior year'' windows elsewhere throughout the form.
    Please indicate whether the Department will change the 2025-2026 FAFSA
    homeless filtering question (question 6 on the current form) to ask
    whether students were experiencing homelessness or at risk of
    homelessness, in 2023 or 2024, or the previous 2 years.
        Answer. To ensure a smooth user experience during the upcoming
    FAFSA cycle, the 2025-26 FAFSA form will remain consistent with the
    2024-25 form. The Department is assessing suggested changes to the user
    experience that do not require the public comment process, such as
    those impacting students experiencing or at risk of homelessness, to
    determine if changes can be implemented in 2025-26.
        Question. Based on the most recent data calculated by the
    Department, nearly 44,000 FAFSA applicants in the 2022-23 cycle
    indicated that they were, or were at risk of becoming, unaccompanied
    homeless youth, but had a status was ``unknown'' because no
    determination was made in response their requests for schools to
    consider their special circumstance of being homeless.
        What actions has the Department taken, and what steps will it take
    going forward to communicate directly with these applicants to make
    sure they have the information and resources needed to obtain financial
    aid?
        Answer. The Department's weekly email to students who indicate they
    are unaccompanied and experiencing homelessness or are unaccompanied
    and at risk of experiencing homelessness contains information on what
    students should do if their school has not already contacted them to
    determine eligibility for Federal student aid. This email makes clear
    that a student's financial aid administration is required to make a
    determination of the student's status based on a written statement from
    the student or a formal interview.
                                     ______

                Questions Submitted by Senator Richard J. Durbin
        Question. Over the past few years, the Department has provided
    widespread relief to defrauded students through group borrower defense
    discharge. This relief has totaled nearly $12 billion for 891,000
    borrowers. I applaud the Department for taking steps to offer group
    borrower defense discharge to students, including former students of
    Corinthian Colleges (Corinthian), ITT Technical Institute, Inc. (ITT
    Tech), Westwood College (Westwood), Ashford University, the University
    of Phoenix, the Arts Institutes, DeVry University (DeVry), and
    Marinello Schools of Beauty. These students were misled by unscrupulous
    for-profit colleges, and they are not the only students who are
    crippled with student loan debt and a worthless degree. Since June
    2018, the Department has released borrower defense data on a quarterly
    basis:
        Please provide a breakdown of ``total denied'' borrower defense
    claims to date by institution.
        Please provide a breakdown of ``total ineligible'' borrower defense
    claims to date by institution.
        Please provide a breakdown of ``total closed'' borrower defense
    claims to date by institution.
        Answer. Provided in attached Excel.
    Please note that denied or ineligible have been used interchangedly in
            the past.

                      Total Denied Cases By Primary School
                               As of May 31, 2024
    ------------------------------------------------------------------------
     Case counts and totals are rounded to the nearest ten and redacted for
                              values less than 10.
    -------------------------------------------------------------------------
                                                                      Case
                            Primary School                           Count
    ------------------------------------------------------------------------
    Heald College................................................        430
    Altierus Career College......................................        130
    Everest College..............................................         70
    Everest Institute............................................         70
    Clark Atlanta University.....................................         60
    Galen Health Institutes......................................         60
    Northern Illinois University.................................         60
    St. Petersburg College.......................................         60
    WyoTech......................................................         50
    Arizona College..............................................         40
    Belhaven University..........................................         40
    Collin County Community College District.....................         40
    Everest University...........................................         40
    Faulkner University..........................................         40
    Henry Ford College...........................................         40
    Midlands Technical College...................................         40
    Stark State College..........................................         40
    University of South Florida..................................         40
    Ball State University........................................         30
    LeMoyne-Owen College.........................................         30
    Middle Tennessee State University............................         30
    Peirce College...............................................         30
    Regency Beauty Institute.....................................         30
    Roosevelt University.........................................         30
    South College................................................         30
    St. George's University, School of Medicine..................         30
    Texas Woman's University.....................................         30
    University of Houston--Downtown..............................         30
    University of North Texas....................................         30
    University of Southern Mississippi...........................         30
    Virginia Commonwealth University.............................         30
    Academy for Nursing and Health Occupations...................         20
    Altierus Career Education....................................         20
    Amridge University...........................................         20
    Arlington Career Institute...................................         20
    Auburn University Montgomery.................................         20
    Austin Peay State University.................................         20
    Bridgewater State University.................................         20
    Brightpoint Community College................................         20
    California Baptist University................................         20
    California State University--Sacramento......................         20
    California State University, Long Beach......................         20
    Central State University.....................................         20
    Clark State College..........................................         20
    Cleveland State University...................................         20
    Cuyahoga Community College...................................         20
    Dallas Baptist University....................................         20
    Darton State College.........................................         20
    Dowling College..............................................         20
    Eastern College of Health Vocations..........................         20
    Eastern Illinois University..................................         20
    Florida State University.....................................         20
    Full Sail University.........................................         20
    George Mason University......................................         20
    Georgia Career Institute.....................................         20
    Gwinnett Technical College...................................         20
    Indiana Institute of Technology..............................         20
    Indiana University--Bloomington..............................         20
    Iowa Central Community College...............................         20
    Jacksonville University......................................         20
    Kirkwood Community College...................................         20
    LA College International.....................................         20
    Lane College.................................................         20
    Lincoln College..............................................         20
    Louisiana State University in Shreveport.....................         20
    Metropolitan State University of Denver......................         20
    Miami University.............................................         20
    Mid-America Christian University.............................         20
    Midwestern Career College....................................         20
    National Louis University....................................         20
    Oakland University...........................................         20
    Ohio Valley University.......................................         20
    Palm Beach State College.....................................         20
    Park University..............................................         20
    Pikes Peak State College.....................................         20
    Saint John's University......................................         20
    Saint Xavier University......................................         20
    San Diego State University...................................         20
    Santa Fe College.............................................         20
    Seminole State College of Florida............................         20
    Specs Howard School of Media Arts............................         20
    Springfield College..........................................         20
    Strayer University...........................................         20
    Tarrant County College District..............................         20
    Thomas Edison State University...............................         20
    Tyler Junior College.........................................         20
    University of Nevada , Reno..................................         20
    Wake Technical Community College.............................         20
    Washtenaw Community College..................................         20
    Western Illinois University..................................         20
    Winston-Salem State University...............................         20
    Allen University.............................................         10
    Allied American University...................................         10
    American Musical & Dramatic Academy..........................         10
    Ashland University...........................................         10
    Auburn University............................................         10
    Baker University.............................................         10
    Central Carolina Technical College...........................         10
    Central Florida Institute....................................         10
    Central Texas College District...............................         10
    Claflin University...........................................         10
    College of Charleston........................................         10
    CUNY John Jay College of Criminal Justice....................         10
    Dade Medical College.........................................         10
    Daytona State College........................................         10
    Eastern Iowa Community College District......................         10
    Eastern Kentucky University..................................         10
    Edward Waters University.....................................         10
    Everest University--Pompano Beach............................         10
    Felician University..........................................         10
    Francis Marion University....................................         10
    Frontier Nursing University..................................         10
    Gateway Community and Technical College......................         10
    Generations College..........................................         10
    Georgia Gwinnett College.....................................         10
    Grand Rapids Community College...............................         10
    Hocking Technical College....................................         10
    Houston Christian University.................................         10
    Indiana University--Purdue University Indianapolis...........         10
    International Air & Hospitality Academy......................         10
    Jarvis Christian University..................................         10
    Laurus Technical Institute...................................         10
    Lewis University.............................................         10
    Limestone University.........................................         10
    Livingstone College..........................................         10
    Macomb Community College.....................................         10
    Metropolitan College of New York.............................         10
    Midwestern State University..................................         10
    Mississippi University for Women.............................         10
    Mountain State University....................................         10
    MTI College of Business and Technology.......................         10
    Nashville College of Medical Careers.........................         10
    National Paralegal College...................................         10
    Newbridge College--San Diego East............................         10
    Newbury College..............................................         10
    North Carolina Wesleyan University...........................         10
    Northeastern Illinois University.............................         10
    Northwest Career College.....................................         10
    Ottawa University............................................         10
    Owens Community College......................................         10
    Palm Beach Atlantic University...............................         10
    Pfeiffer University..........................................         10
    Philander Smith College......................................         10
    Rowan University.............................................         10
    Saint Joseph's University....................................         10
    San Francisco State University...............................         10
    San Jacinto Community College District.......................         10
    Southeastern College (Jacksonville)..........................         10
    Southwestern Illinois College................................         10
    St. Joseph's University New York.............................         10
    Stephen F Austin State University............................         10
    Tallahassee Community College................................         10
    Trumbull Business College....................................         10
    Tulsa Community College......................................         10
    University of Advancing Computer Technology..................         10
    University of Alabama........................................         10
    University of Bridgeport.....................................         10
    University of Denver.........................................         10
    University of Massachusetts--Dartmouth.......................         10
    University of North Florida..................................         10
    Western Hills School of Beauty & Hair Design.................         10
    Wichita State University.....................................         10
    Wilmington University........................................         10
    Winthrop University..........................................         10
    A & W Healthcare Educators...................................        <10
    Aaron's Academy of Beauty....................................        <10
    ABC Technical & Trade Schools................................        <10
    Abcott Institute.............................................        <10
    Abdill Career College........................................        <10
    Abraham Lincoln University...................................        <10
    Academy College..............................................        <10
    Academy Di Capelli...........................................        <10
    Academy of Aesthetic Arts....................................        <10
    Academy of Art University....................................        <10
    Academy of Career Training...................................        <10
    Academy of Massage and Bodywork..............................        <10
    Academy of Salon and Spa.....................................        <10
    AccuTech Career Institute....................................        <10
    Ace Institute of Technology..................................        <10
    ACT College..................................................        <10
    Adams State University.......................................        <10
    Adelphi Business College.....................................        <10
    Adelphi University...........................................        <10
    Adirondack Community College--SUNY Office of Community               <10
     Colleges....................................................
    Advanced Institute of Hair Design............................        <10
    Advantage Career Institute...................................        <10
    Agnes Scott College..........................................        <10
    Aiken School of Cosmetology and Barbering....................        <10
    Aiken Technical College......................................        <10
    Aims Community College.......................................        <10
    Akron Institute of Herzing University........................        <10
    Alabama State University.....................................        <10
    Alaska Career College........................................        <10
    Alaska Pacific University....................................        <10
    Albany Law School of Union University........................        <10
    Albany State University......................................        <10
    Albright College.............................................        <10
    Alcorn State University......................................        <10
    Alfred University............................................        <10
    All Beauty College...........................................        <10
    Allan Hancock College........................................        <10
    Allen County Community College...............................        <10
    Alliant International University.............................        <10
    Allied Medical and Technical Institute.......................        <10
    Allure School of Cosmetology.................................        <10
    Alma College.................................................        <10
    Alpine College...............................................        <10
    Altoona Beauty School........................................        <10
    Alverno College..............................................        <10
    Ambria College of Nursing....................................        <10
    American Academy McAllister Institute........................        <10
    American Academy of Art College..............................        <10
    American Beauty Academy......................................        <10
    American Business Institute (Closed).........................        <10
    American Career Academy......................................        <10
    American Career Training Travel School.......................        <10
    American Careers Institute...................................        <10
    American College of Acupuncture & Oriental Medicine..........        <10
    American College of Business.................................        <10
    American College of Healthcare and Technology................        <10
    American Institute...........................................        <10
    American Institute of Alternative Medicine...................        <10
    American Institute of Beauty.................................        <10
    American Institute of Medical Sciences & Education...........        <10
    American Institute of Medical Sonography.....................        <10
    American Jewish University...................................        <10
    American Medical Academy.....................................        <10
    American Public University System............................        <10
    American Transportation College..............................        <10
    American University (The)....................................        <10
    American University of Antigua College of Medicine...........        <10
    AmesEd.......................................................        <10
    AMG School of Nursing........................................        <10
    Andrew College...............................................        <10
    Andrews University...........................................        <10
    Angeles College..............................................        <10
    Angelo State University......................................        <10
    Angley College...............................................        <10
    Anne Arundel Community College...............................        <10
    Anoka Technical College......................................        <10
    Antelope Valley College......................................        <10
    Anthem Institute.............................................        <10
    Antioch University...........................................        <10
    Antonelli Medical & Professional Institute...................        <10
    Apollo Business & Technical School...........................        <10
    Apollo College of Medical & Dental Careers...................        <10
    Appalachian College of Pharmacy..............................        <10
    Aquinas College..............................................        <10
    Arcadia University...........................................        <10
    Aristotle College of Medical and Dental Technology...........        <10
    Arizona Culinary Institute...................................        <10
    Arizona State University.....................................        <10
    Arkansas Tech University.....................................        <10
    Arkansas Technical School....................................        <10
    Arlington Medical Institute..................................        <10
    Armstrong State University...................................        <10
    Art Center College of Design.................................        <10
    Artisan College of Cosmetology (The).........................        <10
    Artistic Nails & Beauty Academy..............................        <10
    ASA College..................................................        <10
    Asheville Buncombe Technical Community College...............        <10
    ASPIRA City College..........................................        <10
    Associated Technical Institute...............................        <10
    Assumption University........................................        <10
    ATA Career Education.........................................        <10
    Atelier Esthetique Institute of Esthetics....................        <10
    Athens State University......................................        <10
    Atlanta College of Art.......................................        <10
    Atlanta School of Massage....................................        <10
    Atlanta Technical College....................................        <10
    Atlantic Cape Community College..............................        <10
    Augsburg University..........................................        <10
    Augusta State University.....................................        <10
    Augusta University...........................................        <10
    Augustana College............................................        <10
    Aurora University............................................        <10
    Austin Community College.....................................        <10
    Avalon School of Cosmetology.................................        <10
    Avalon Vocational Technical Institute........................        <10
    Avant Gard The School........................................        <10
    Ave Maria School of Law......................................        <10
    Aveda Institute--Fort Myers..................................        <10
    Aveda Institute--South Florida...............................        <10
    Aviation Institute of Maintenance............................        <10
    Avila University.............................................        <10
    Award Beauty School..........................................        <10
    Azusa Pacific University.....................................        <10
    Baker College................................................        <10
    Balin Inst of Techlgy........................................        <10
    Baltimore Studio of Hair Design..............................        <10
    Baptist Bible College........................................        <10
    Baptist College of Florida (The).............................        <10
    Barat College................................................        <10
    Barber--Scotia College.......................................        <10
    Barclay College..............................................        <10
    Barnes Business College......................................        <10
    Barry University.............................................        <10
    Barton College...............................................        <10
    Baton Rouge School of Computers..............................        <10
    Bay Area Legal Academy.......................................        <10
    Bay De Noc Community College.................................        <10
    Bay Path University..........................................        <10
    Beauty Academy of South Florida..............................        <10
    Beauty Institute Schwarzkopf Professional (The)..............        <10
    Beck School of Practical Nursing.............................        <10
    Becker College...............................................        <10
    Bel--Rea Institute of Animal Technology......................        <10
    BELBO Beauty Institute.......................................        <10
    Bella Capelli Academy A Paul Mitchell Partner School.........        <10
    Bellarmine University........................................        <10
    Bellefonte Academy of Beauty.................................        <10
    Bellevue University..........................................        <10
    Bellus Academy...............................................        <10
    Belmont Abbey College........................................        <10
    Belmont College..............................................        <10
    Belmont University...........................................        <10
    Beloit College...............................................        <10
    Bemidji State University.....................................        <10
    Benedict College.............................................        <10
    Benedictine College..........................................        <10
    Benedictine University.......................................        <10
    Bene's Career Academy........................................        <10
    Benjamin Franklin Cummings Institute.........................        <10
    Berkeley School of Theology..................................        <10
    Berklee College of Music.....................................        <10
    Berry College................................................        <10
    Best Care College............................................        <10
    Bethany College..............................................        <10
    Bethune Cookman University...................................        <10
    Beulah Heights University....................................        <10
    Big Sandy Community and Technical College....................        <10
    Binghamton University........................................        <10
    BioHealth College............................................        <10
    Biola University.............................................        <10
    Birmingham-Southern College..................................        <10
    Black Hawk College...........................................        <10
    Blackburn University.........................................        <10
    Blake Austin College.........................................        <10
    Blue Ridge Community and Technical College...................        <10
    Blue Ridge Community College.................................        <10
    Bluefield College............................................        <10
    Bluefield State University...................................        <10
    Bluegrass Community & Technical College......................        <10
    Bob Jones University.........................................        <10
    Boca Beauty Academy..........................................        <10
    BOCES Rensselaer School of Practical Nursing.................        <10
    Boise State University.......................................        <10
    Bos-Man's Barber College.....................................        <10
    Boston Conservatory..........................................        <10
    Boston Graduate School of Psychoanalysis.....................        <10
    Bowling Green State University...............................        <10
    Brandeis University..........................................        <10
    Branell Institute............................................        <10
    Brensten Education...........................................        <10
    Brescia University...........................................        <10
    Bridgewater College..........................................        <10
    Brillare Hairdressing Academy................................        <10
    Brookline College............................................        <10
    Brown College of Court Reporting.............................        <10
    Bryant & Stratton College....................................        <10
    Bryant University............................................        <10
    Bryman College...............................................        <10
    Bryman School of Arizona (The)...............................        <10
    Bryn Mawr College............................................        <10
    Bucknell University..........................................        <10
    Buckner Barber School........................................        <10
    Bucks County Community College...............................        <10
    Bucks County School of Beauty Culture........................        <10
    Buena Vista University.......................................        <10
    Burlington College...........................................        <10
    Business Career Training Institute...........................        <10
    Business Informatics Center..................................        <10
    Butler Business School.......................................        <10
    Butler County Community College..............................        <10
    Butler Technology and Career Development Schools.............        <10
    Butler University............................................        <10
    Cabot College................................................        <10
    Cains Barber College.........................................        <10
    Caliber Training Institute...................................        <10
    California Career Institute..................................        <10
    California College of the Arts...............................        <10
    California College of Vocational Careers.....................        <10
    California Hair Design Academy...............................        <10
    California Healing Arts College..............................        <10
    California Intercontinental University.......................        <10
    California Nurses Educational Institute......................        <10
    California Polytechnic State University......................        <10
    California State Polytechnic University, Humboldt............        <10
    California State Polytechnic University, Pomona..............        <10
    California State University Channel Islands..................        <10
    California State University, Bakersfield.....................        <10
    California State University, Chico...........................        <10
    California State University, East Bay........................        <10
    California State University, Fullerton.......................        <10
    California State University, Los Angeles.....................        <10
    California State University, Monterey Bay....................        <10
    California State University, San Marcos......................        <10
    California State University, Stanislaus......................        <10
    Calumet College of Saint Joseph..............................        <10
    Calvin University............................................        <10
    Cambridge Junior College.....................................        <10
    Cambridge Techl Inst.........................................        <10
    Cameo Beauty Academy.........................................        <10
    Cameron University...........................................        <10
    Campbellsville University....................................        <10
    Canadian College of Naturopathic Medicine....................        <10
    Canisius University of Buffalo, New York.....................        <10
    Canton City School District Adult Career & Technical                 <10
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    Capital Area Career Center...................................        <10
    Capital University...........................................        <10
    Capitol City Careers.........................................        <10
    Capitol City Trade & Technical School........................        <10
    Capitol Court Reporting & Captioning Institute...............        <10
    Capitol Technology University................................        <10
    Capri Beauty College.........................................        <10
    Cardiac and Vascular Institute of Ultrasound.................        <10
    Career & Technology Education Centers of Licking County......        <10
    Career College of Northern Nevada............................        <10
    Career Colleges of America...................................        <10
    Career Institute of Health and Technology....................        <10
    Career Networks Institute....................................        <10
    Career Point Business School.................................        <10
    Career Quest Learning Centers................................        <10
    Career School of NY..........................................        <10
    Career Technical College.....................................        <10
    Career Technical Institute...................................        <10
    Career Training Academy......................................        <10
    Carl Albert State College....................................        <10
    Carlow University............................................        <10
    Carmichael Beauty College....................................        <10
    Carnegie Career College......................................        <10
    Carnegie Institute...........................................        <10
    Carnegie Mellon University...................................        <10
    Carolina Beauty College......................................        <10
    Carolina Christian College...................................        <10
    Carolina University..........................................        <10
    Carousel Beauty College......................................        <10
    Carroll College..............................................        <10
    Carroll University...........................................        <10
    Carson--Newman University....................................        <10
    Carthage College.............................................        <10
    Carthage R-9 School District/Carthage Technical Center.......        <10
    Casa Loma College............................................        <10
    Casper College...............................................        <10
    Catholic University of America (The).........................        <10
    Cazenovia College............................................        <10
    CBT Technology Institute.....................................        <10
    CCIC Beauty College..........................................        <10
    CDE Career Institute.........................................        <10
    CDI Career Developement Institute............................        <10
    Cecil College................................................        <10
    Cedar Crest College..........................................        <10
    Celebrity School of Beauty...................................        <10
    Centenary University.........................................        <10
    Center for Allied Health Education...........................        <10
    Central Alabama Community College............................        <10
    Central Arizona College......................................        <10
    Central Baptist College......................................        <10
    Central California School of Continuing Education............        <10
    Central Career School........................................        <10
    Central Christian College of Kansas..........................        <10
    Central City Business Institute..............................        <10
    Central College..............................................        <10
    Central Connecticut State University.........................        <10
    Central Georgia Technical College............................        <10
    Central Nursing College......................................        <10
    Central Oregon Community College.............................        <10
    Central Piedmont Community College...........................        <10
    Central Susquehanna LPN Career Center........................        <10
    Central Washington University................................        <10
    Centura College..............................................        <10
    Centura Institute............................................        <10
    Century Schools..............................................        <10
    Chaffey Community College....................................        <10
    Chaminade University of Honolulu.............................        <10
    Champlain College............................................        <10
    Chancellor University........................................        <10
    Charles A. Jones Career and Education Center.................        <10
    Charles R. Drew University of Medicine and Science...........        <10
    Charleston Cosmetology Institute.............................        <10
    Charter College..............................................        <10
    Chatham University...........................................        <10
    Chattanooga College--Medical, Dental and Technical Careers...        <10
    Chemeketa Community College..................................        <10
    Chester Career College.......................................        <10
    Chester County Intermediate Unit Practical Nursing Program...        <10
    Chicago ORT Technical Institute..............................        <10
    Chicago State University.....................................        <10
    Chippewa Valley Technical College............................        <10
    Chowan University............................................        <10
    Christian Brothers University................................        <10
    Cincinnati State Technical & Community College...............        <10
    Cisco College................................................        <10
    Citadel, The Military College of South Carolina..............        <10
    Citrus College...............................................        <10
    City College.................................................        <10
    City College of San Francisco................................        <10
    City Colleges of Chicago Harry S Truman College..............        <10
    Clarion University of Pennsylvania...........................        <10
    Clark College................................................        <10
    Clark University.............................................        <10
    Clarke University............................................        <10
    Clarkson College.............................................        <10
    Clarkson University..........................................        <10
    Clayton State University.....................................        <10
    Clearwater Christian College.................................        <10
    Cleary University............................................        <10
    Clemson University...........................................        <10
    Cleveland Institute of Art (The).............................        <10
    Cleveland University-Kansas City.............................        <10
    Clinton College..............................................        <10
    Coalition of African American Nurses.........................        <10
    Coastal Bend College.........................................        <10
    Coba Academy.................................................        <10
    Cochise College..............................................        <10
    Cochran School of Nursing--St. John's Riverside Hospital.....        <10
    Coe College..................................................        <10
    Colleen O'Hara's Beauty Academy..............................        <10
    College for Creative Studies.................................        <10
    College of Central Florida...................................        <10
    College of Court Reporting...................................        <10
    College of Eastern Idaho.....................................        <10
    College of Idaho (The).......................................        <10
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    College of Mount Saint Vincent...............................        <10
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    College of Southern Idaho....................................        <10
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    College of the Holy Cross....................................        <10
    College of the Siskiyous.....................................        <10
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    College of Wilmington........................................        <10
    Collins School of Cosmetology................................        <10
    Colorado Christian University................................        <10
    Colorado Mountain College....................................        <10
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    Colorado State University-Pueblo.............................        <10
    Columbia--Greene Community College--SUNY Office of Cmnty             <10
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    Columbia College.............................................        <10
    Columbia College Chicago.....................................        <10
    Columbia College Hollywood...................................        <10
    Columbia International University............................        <10
    Columbia School of Broadcasting, Home Study..................        <10
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    Commercial Programming Unlimited.............................        <10
    Commonwealth University of Pennsylvania......................        <10
    Community College of Aurora..................................        <10
    Community College of Philadelphia............................        <10
    Compass Career College.......................................        <10
    Compass College of Cinematic Arts............................        <10
    Computer Dynamics Institute..................................        <10
    Computer Learning Center of Alexandria.......................        <10
    Concord University...........................................        <10
    Concordia College--Moorhead..................................        <10
    Concordia University.........................................        <10
    Connecticut College..........................................        <10
    Connors State College........................................        <10
    Contra Costa Medical Career College..........................        <10
    Cooper Career Institute......................................        <10
    Copiah-Lincoln Community College.............................        <10
    Coppin State University......................................        <10
    Corcoran College of Art and Design...........................        <10
    Cornell College..............................................        <10
    Cornerstone University.......................................        <10
    Corning Community College--SUNY Office of Community Colleges.        <10
    Cornish College of the Arts..................................        <10
    Cosmetic Arts Institute......................................        <10
    Cosmetology and Spa Academy..................................        <10
    Cosmetology Career Institute.................................        <10
    Cottey College...............................................        <10
    County College of Morris.....................................        <10
    Covenant College.............................................        <10
    Covenant School of Nursing and Allied Health.................        <10
    Cowley County Community College & Area Vocational Technical          <10
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    Cox College..................................................        <10
    Coyne College................................................        <10
    Creative Images Institute of Cosmetology.....................        <10
    Creighton University.........................................        <10
    Crowder College..............................................        <10
    Crown College................................................        <10
    Culinary Tech Center.........................................        <10
    Culver-Stockton College......................................        <10
    CUNY Bernard Baruch School of Business.......................        <10
    CUNY Borough of Manhattan Community College..................        <10
    CUNY Graduate School & University Center.....................        <10
    CUNY Hunter College..........................................        <10
    CUNY School of Law...........................................        <10
    Curry College................................................        <10
    Cuyamaca College.............................................        <10
    Dakota College at Bottineau..................................        <10
    Dakota Wesleyan University...................................        <10
    Dallas Christian College.....................................        <10
    Dallas College...............................................        <10
    Dallas Theological Seminary..................................        <10
    Dana College.................................................        <10
    Daniel Webster College.......................................        <10
    Danville Area Community College..............................        <10
    Daoist Traditions College of Chinese Medical Arts............        <10
    Davis College................................................        <10
    Dawn Career Institute........................................        <10
    Daytona College..............................................        <10
    DCI Career Institute.........................................        <10
    De Anza Community College....................................        <10
    Dean Institute of Technology.................................        <10
    Debbie's Alabama Beauty College..............................        <10
    Decker College...............................................        <10
    Del Mar College..............................................        <10
    Delaware County Technical School.............................        <10
    Delaware State University....................................        <10
    Delaware Valley Academy of Medical & Dental Assistants.......        <10
    Delaware Valley University...................................        <10
    Delgado Community College....................................        <10
    Delta College................................................        <10
    Delta College of Business & Technology.......................        <10
    Delta Junior College.........................................        <10
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    DePaul University............................................        <10
    Des Moines Area Community College............................        <10
    Destination Academy for Spa and Salon Professionals..........        <10
    Detroit Business Institute--Downriver........................        <10
    Dickinson College............................................        <10
    Dickinson Warren College.....................................        <10
    Digital Media Arts College...................................        <10
    Doane University.............................................        <10
    Dominican University.........................................        <10
    Dominion School of Hair Design...............................        <10
    Don Roberts School of Hair Design............................        <10
    Donnelly College.............................................        <10
    Drake College of Business....................................        <10
    Drake School of the Bronx....................................        <10
    Drake School of Westchester..................................        <10
    Drake University.............................................        <10
    Draughons College............................................        <10
    Drexel University............................................        <10
    Drury University.............................................        <10
    DuBois Business College......................................        <10
    Dudley Hall Car Inst.........................................        <10
    Duke University..............................................        <10
    Duluth Business University...................................        <10
    Dunwoody College of Technology...............................        <10
    Duquesne University of the Holy Spirit.......................        <10
    Durham Technical Community College...........................        <10
    D'Youville University........................................        <10
    Eagle Rock College...........................................        <10
    East Carolina University.....................................        <10
    East Central Community College...............................        <10
    East Coast Bible College.....................................        <10
    East Ohio College............................................        <10
    East Texas Baptist University................................        <10
    Eastern Florida State College................................        <10
    Eastern Hills Academy of Hair Design.........................        <10
    Eastern International College................................        <10
    Eastern New Mexico University................................        <10
    Eastern Oklahoma State College...............................        <10
    Eastern Oregon University....................................        <10
    Eastern Virginia Career College..............................        <10
    Eastern Virginia Medical School..............................        <10
    Eastern Washington University................................        <10
    Eastwick College--Hackensack Campus..........................        <10
    eClips School of Cosmetology and Barbering...................        <10
    ECPI University..............................................        <10
    Edgewood College.............................................        <10
    Edison State Community College...............................        <10
    Edmondson Junior College.....................................        <10
    El Paso Community College....................................        <10
    Elaine Steven Beauty College.................................        <10
    Electronic Program Institute of Omaha........................        <10
    Elgin Community College......................................        <10
    Elite School of Cosmetology..................................        <10
    Elizabeth City State University..............................        <10
    Elizabethtown College........................................        <10
    Elizabethtown Community and Technical College................        <10
    Elmhurst University..........................................        <10
    Elmira College...............................................        <10
    Embry-Riddle Aeronautical University.........................        <10
    Emerson College..............................................        <10
    Emory & Henry College........................................        <10
    Empire College...............................................        <10
    Empire State University......................................        <10
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    Emporia State University.....................................        <10
    Endicott College.............................................        <10
    Ensign College...............................................        <10
    Epic Bible College...........................................        <10
    Erie Institute of Technology.................................        <10
    Erikson Institute............................................        <10
    Erskine College..............................................        <10
    ETI Technical College of Niles...............................        <10
    Eureka College...............................................        <10
    Evangel University...........................................        <10
    Everest College Phoenix......................................        <10
    Everett Community College....................................        <10
    Evergreen State College (The)................................        <10
    Fairleigh Dickinson University...............................        <10
    Fairmont State University....................................        <10
    Ferrum College...............................................        <10
    FINE Mortuary College........................................        <10
    Finger Lakes Community College--SUNY Office of Community             <10
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    First Institute..............................................        <10
    Fitchburg State University...................................        <10
    Five Branches University.....................................        <10
    Flagler College..............................................        <10
    Flathead Valley Community College............................        <10
    Florence--Darlington Technical College.......................        <10
    Florida Agricultural & Mechanical University.................        <10
    Florida Atlantic University..................................        <10
    Florida Gulf Coast University................................        <10
    Florida Institute of Technology..............................        <10
    Florida International Training Institute.....................        <10
    Florida Memorial University..................................        <10
    Florida National University..................................        <10
    Florida School of Traditional Midwifery......................        <10
    Florida Southern College.....................................        <10
    Florida State College at Jacksonville........................        <10
    Fontbonne University.........................................        <10
    Fordham University...........................................        <10
    Forest Institute of Professional Psychology..................        <10
    Forsyth Technical Community College..........................        <10
    Fort Valley State University.................................        <10
    Fountain of Youth Academy of Cosmetology.....................        <10
    Fountainhead College of Technology...........................        <10
    Four-D College...............................................        <10
    Fox Valley Technical College.................................        <10
    Framingham State University..................................        <10
    Francis Tuttle Technology Center School District No. 21......        <10
    Franciscan Missionaries of Our Lady University...............        <10
    Franciscan University of Steubenville........................        <10
    Franklin College.............................................        <10
    Franklin Pierce University...................................        <10
    Franklin Technology Center...................................        <10
    Frederick Community College..................................        <10
    Freed-Hardeman University....................................        <10
    Friends University...........................................        <10
    Fullerton College............................................        <10
    Furman University............................................        <10
    FVI School of Nursing and Technology.........................        <10
    Galiano Career Academy.......................................        <10
    Gannon University............................................        <10
    Garden State Science and Technology Institute................        <10
    GateWay Community College....................................        <10
    General Communications.......................................        <10
    Genesee Community College....................................        <10
    Genesis Vocational Training..................................        <10
    Geneva College...............................................        <10
    George Fox University........................................        <10
    Georgetown University........................................        <10
    Georgia College & State University...........................        <10
    Georgia Institute of Cosmetology.............................        <10
    Georgia Military College.....................................        <10
    Georgia School of Bartending.................................        <10
    Georgian Court University....................................        <10
    Glen Dow Academy of Hair Design & Salons.....................        <10
    Glenville State University...................................        <10
    Glitz School of Cosmetology..................................        <10
    Global Tech College..........................................        <10
    Gogebic Community College....................................        <10
    Goldey-Beacom College........................................        <10
    Goldfarb School of Nursing at Barnes-Jewish College..........        <10
    Good Samaritan College of Nursing and Health Science.........        <10
    Gordon College...............................................        <10
    Gould's Academy..............................................        <10
    Governors State University...................................        <10
    Grabber School of Hair Design................................        <10
    Grace Christian University...................................        <10
    Grace College and Theological Seminary.......................        <10
    Grace School of Theology.....................................        <10
    Grambling State University...................................        <10
    Grand Valley State University................................        <10
    Grand View University........................................        <10
    Great Basin College..........................................        <10
    Great Falls College Montana State University.................        <10
    Great Lakes Institute of Technology..........................        <10
    Great Oaks Career Campuses-Scarlet Oaks......................        <10
    Greater Altoona Career & Technology Center...................        <10
    Green Mountain College.......................................        <10
    Guilford College.............................................        <10
    Guilford Technical Community College.........................        <10
    Gulf Coast State College.....................................        <10
    Hair Academy.................................................        <10
    Hair Academy II..............................................        <10
    Hair Design Institute at Livingston Street...................        <10
    Hair Expressions--Paul Mitchell Partner School...............        <10
    Hair Professionals School of Cosmetology.....................        <10
    Hamline University...........................................        <10
    Hammel College...............................................        <10
    Hampden Sydney College.......................................        <10
    Hannibal--LaGrange University................................        <10
    Harding University...........................................        <10
    Hargest Vocational Technical College.........................        <10
    Harper College...............................................        <10
    Harris--Stowe State University...............................        <10
    Harrisburg Area Community College............................        <10
    Harrison Career Institute....................................        <10
    Harrison College.............................................        <10
    Hartford School of Music (The)...............................        <10
    Hartwick College.............................................        <10
    Hawaii College of Oriental Medicine..........................        <10
    Hawaii Community College.....................................        <10
    Hawkeye Community College....................................        <10
    Headmasters School of Hair Design............................        <10
    Headquarters Academy of Hair Design (The)....................        <10
    Head's West Kentucky Beauty College..........................        <10
    Heald Business College.......................................        <10
    Heald College, School of Business............................        <10
    Heald College-School of Business.............................        <10
    Heald Institute of Technology................................        <10
    Healing Arts Center..........................................        <10
    Heidelberg University........................................        <10
    Henderson Community College..................................        <10
    Henderson State University...................................        <10
    Heritage College.............................................        <10
    Heritage Institute...........................................        <10
    Hickey College...............................................        <10
    High Desert Medical College..................................        <10
    High Point University........................................        <10
    Highland Community College...................................        <10
    Hilbert College..............................................        <10
    Hill College.................................................        <10
    Hillsborough Community College...............................        <10
    Hiram College................................................        <10
    Hofstra University...........................................        <10
    HoHoKus School of Trade and Technical Sciences...............        <10
    Hollins University...........................................        <10
    Hollywood Beauty College.....................................        <10
    Hollywood Institute..........................................        <10
    Holy Names University........................................        <10
    Holyoke Community College....................................        <10
    Hood College.................................................        <10
    Hopkinsville Community College...............................        <10
    Hospitality Institute........................................        <10
    Hoss Lee Academy.............................................        <10
    Houston Allied Health Careers................................        <10
    Houston Community College....................................        <10
    Howard Community College.....................................        <10
    Howard County Junior College District........................        <10
    Howard University............................................        <10
    Hunter Business School.......................................        <10
    Huntington Junior College....................................        <10
    Huston--Tillotson University.................................        <10
    Hutchinson Community College.................................        <10
    ICDC College.................................................        <10
    Idaho State University.......................................        <10
    Illinois College.............................................        <10
    Illinois Institute of Technology.............................        <10
    Illinois School of Health Careers............................        <10
    Illinois State University....................................        <10
    Illinois Valley Community College............................        <10
    Indian Hills Community College...............................        <10
    Indian River State College...................................        <10
    Indiana Barber/Stylist College...............................        <10
    Indiana County Technology Center.............................        <10
    Indiana State University.....................................        <10
    Indiana University--Northwest................................        <10
    Indiana University--South Bend...............................        <10
    Indiana Wesleyan University..................................        <10
    Infinity College.............................................        <10
    Institute of Audio Research..................................        <10
    Institute of Hair Design.....................................        <10
    Institute of Medical Education...............................        <10
    Institute of Technical Arts..................................        <10
    InterCoast Colleges..........................................        <10
    International Beauty Education Center........................        <10
    International Beauty School..................................        <10
    International Business College-..............................        <10
    International College of Broadcasting........................        <10
    International Cosmetology Academy............................        <10
    International Institute of Chinese Medicine..................        <10
    International Institute of Cosmetology.......................        <10
    International Salon and Spa Academy..........................        <10
    International School of Beauty...............................        <10
    International School of Skin and Nailcare....................        <10
    Iowa Lakes Community College.................................        <10
    Itawamba Community College...................................        <10
    Ithaca College...............................................        <10
    Iverson Institute............................................        <10
    Ivy Tech Community College of Indiana........................        <10
    Ivy Tech Community College of Indiana--Region 1..............        <10
    Ivy Tech Community College of Indiana--Region 12.............        <10
    Ivy Tech Community College of Indiana--Region 5..............        <10
    J. Everett Light Career Center...............................        <10
    Jackson State University.....................................        <10
    Jacksonville State University................................        <10
    Jefferson Community and Technical College....................        <10
    John Brown University........................................        <10
    John Wesley University.......................................        <10
    Johns Hopkins University.....................................        <10
    Johnson & Wales University...................................        <10
    Johnson County Community College.............................        <10
    Johnston Community College...................................        <10
    Jones County Junior College..................................        <10
    Jones International University...............................        <10
    Jordan College...............................................        <10
    JPS Institute for Health Career Development..................        <10
    Judson College...............................................        <10
    Juniata College..............................................        <10
    Kalamazoo Valley Community College...........................        <10
    Kankakee Community College...................................        <10
    Kansas City Art Institute....................................        <10
    Kansas City University.......................................        <10
    Kansas State University......................................        <10
    Kansas Wesleyan University...................................        <10
    KD Conservatory College of Film and Dramatic Arts............        <10
    Kellogg Community College....................................        <10
    Kelsey--Jenney College.......................................        <10
    Kendall College..............................................        <10
    Kennesaw State University....................................        <10
    Kenneth Shuler School of Cosmetology & Hair Design...........        <10
    Kenneth Shuler School of Cosmetology & Nails.................        <10
    Kent State University........................................        <10
    Kentucky Christian University................................        <10
    Kentucky State University....................................        <10
    Kettering University.........................................        <10
    Keuka College................................................        <10
    Keune Academy by 124.........................................        <10
    Key College..................................................        <10
    Keystone Technical Institute.................................        <10
    Kilian Community College.....................................        <10
    Kings College................................................        <10
    King's College...............................................        <10
    King's University (The)......................................        <10
    Kirtland Community College...................................        <10
    Kishwaukee College...........................................        <10
    Knox County Career Center....................................        <10
    KRS Computer & Business School...............................        <10
    La Roche University..........................................        <10
    La Salle University..........................................        <10
    La Sierra University.........................................        <10
    Lackawanna College...........................................        <10
    Lacy Cosmetology School......................................        <10
    Lake Erie College............................................        <10
    Lake Erie College of Osteopathic Medicine....................        <10
    Lake Forest Graduate School of Management....................        <10
    Lake Land College............................................        <10
    Lakeland University..........................................        <10
    Lakeside School of Massage Therapy...........................        <10
    Lake-Sumter State College....................................        <10
    Lambuth University...........................................        <10
    Lancaster Bible College......................................        <10
    Lane Community College.......................................        <10
    Lansing Community College....................................        <10
    Larry's Barber College.......................................        <10
    Las Vegas College............................................        <10
    LaSalle Tech.................................................        <10
    Lasell University............................................        <10
    Latin Beauty Academy.........................................        <10
    Lawrence Technological University............................        <10
    Lawton School for Medical and Dental Assistants..............        <10
    Le Moyne College.............................................        <10
    Lebanon County Career and Technology Center..................        <10
    Lee University...............................................        <10
    Lenoir-Rhyne University......................................        <10
    Lesley University............................................        <10
    LeTourneau University........................................        <10
    Lexington Baptist College....................................        <10
    Lexington College............................................        <10
    Lexington Healing Arts Academy...............................        <10
    Liberty University...........................................        <10
    Life Chiropractic College West...............................        <10
    Life Pacific University......................................        <10
    Lighthouse Career Institute..................................        <10
    LIM College..................................................        <10
    Lincoln Christian University.................................        <10
    Lincoln Land Community College...............................        <10
    Lindenwood University........................................        <10
    Linn-Benton Community College................................        <10
    Lionel University............................................        <10
    Lipscomb University..........................................        <10
    Logan University.............................................        <10
    Lone Star College System.....................................        <10
    Long Island Beauty School....................................        <10
    Long Island University.......................................        <10
    Longwood University..........................................        <10
    Lorain County Community College..............................        <10
    Loras College................................................        <10
    Louisburg College............................................        <10
    Louisiana School of Professions..............................        <10
    Louisiana State University & Agricultural & Mechanical               <10
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    Louisiana Tech University....................................        <10
    Lourdes University...........................................        <10
    Loyola Marymount University..................................        <10
    Lubbock Christian University.................................        <10
    Luther College...............................................        <10
    Luther Rice College & Seminary...............................        <10
    Macon Beauty School..........................................        <10
    Macon State College..........................................        <10
    Magna Inst...................................................        <10
    Maharishi International University...........................        <10
    Maine College of Art.........................................        <10
    Malone University............................................        <10
    Manchester University........................................        <10
    Mandl School.................................................        <10
    Manhattan Beauty School......................................        <10
    Manhattan College............................................        <10
    Manor College................................................        <10
    Mansfield Business College...................................        <10
    Margaret's Hair Academy......................................        <10
    Marian Court College.........................................        <10
    Marian University............................................        <10
    Marietta College.............................................        <10
    MarJon School of Beauty......................................        <10
    Marquette University.........................................        <10
    Marshall University..........................................        <10
    Marycrest International University...........................        <10
    Marygrove College............................................        <10
    Maryland Institute College of Art............................        <10
    Maryland University of Integrative Health....................        <10
    Marymount California University..............................        <10
    Marymount College............................................        <10
    Marymount University.........................................        <10
    Maryville College............................................        <10
    Marywood University..........................................        <10
    Massachusetts College of Art and Design......................        <10
    Massachusetts Maritime Academy...............................        <10
    Massachusetts School of Law at Andover.......................        <10
    Masters Institute............................................        <10
    Masters of Cosmetology College...............................        <10
    Mattia College...............................................        <10
    May Technical College........................................        <10
    Mayfield College.............................................        <10
    Maysville Community and Technical College....................        <10
    MBTI Business Training Institute.............................        <10
    McDaniel College.............................................        <10
    MCI Institute of Technology..................................        <10
    McKendree University.........................................        <10
    McLennan Community College...................................        <10
    McNally Smith College of Music...............................        <10
    McPherson College............................................        <10
    Mech Tech College............................................        <10
    Med Help Training School.....................................        <10
    Medical Careers Institute....................................        <10
    Medical Training College.....................................        <10
    Medical University of South Carolina.........................        <10
    Medtech Health Care Training.................................        <10
    Memphis College of Art.......................................        <10
    Mercer County Community College..............................        <10
    Mercer University............................................        <10
    Meredith College.............................................        <10
    Meridian Institute of Surgical Assisting.....................        <10
    Merit College................................................        <10
    Merryfield Academy of Animal Technology......................        <10
    Mesa Community College.......................................        <10
    Messiah University...........................................        <10
    Methodist College............................................        <10
    Methodist University.........................................        <10
    Metro Barber College.........................................        <10
    Metropolitan Community College...............................        <10
    Metropolitan State University................................        <10
    Miami Dade College...........................................        <10
    Miami Lakes Educational Center and Technical College.........        <10
    Miami Technical Institute....................................        <10
    MIAT College of Technology...................................        <10
    Michael's School of Beauty...................................        <10
    Michigan Career Institute....................................        <10
    Michigan Computer Institute..................................        <10
    Michigan Jewish Institute....................................        <10
    Michigan State University....................................        <10
    Michigan Technological University............................        <10
    Mid Michigan College.........................................        <10
    MidAmerica Nazarene University...............................        <10
    Middlesex College............................................        <10
    Middlesex Community College..................................        <10
    Midland College..............................................        <10
    Mid-State Technical College..................................        <10
    Midway University............................................        <10
    Midwest College of Oriental Medicine.........................        <10
    Midwest Institute............................................        <10
    Milan Institute..............................................        <10
    Mildred Elley................................................        <10
    Miles College................................................        <10
    Millerhawkins Business College...............................        <10
    Millikin University..........................................        <10
    Millsaps College.............................................        <10
    Milwaukee Area Technical College.............................        <10
    Milwaukee Career College.....................................        <10
    Milwaukee College of Business................................        <10
    Milwaukee Institute of Art & Design..........................        <10
    Milwaukee School of Engineering..............................        <10
    Mineral Area College.........................................        <10
    Minneapolis Technical College................................        <10
    Minnesota North College......................................        <10
    Minnesota State University, Mankato..........................        <10
    MiraCosta College............................................        <10
    Misericordia University......................................        <10
    Mississippi College..........................................        <10
    Mississippi State University.................................        <10
    Mississippi Valley State University..........................        <10
    Missouri Baptist University..................................        <10
    Missouri State University....................................        <10
    Missouri Technical School....................................        <10
    Missouri Valley College......................................        <10
    Missouri Western State University............................        <10
    Mitchell Hamline School of Law...............................        <10
    Moberly Area Community College...............................        <10
    Modern College of Design (The)...............................        <10
    Mohave Community College.....................................        <10
    Moler Barber College.........................................        <10
    Molloy University............................................        <10
    Monmouth College.............................................        <10
    Monroe College...............................................        <10
    Montana State University--Billings...........................        <10
    Montana State University Bozeman.............................        <10
    Montana Technological University.............................        <10
    Monterey Peninsula College...................................        <10
    Montgomery Beauty School.....................................        <10
    Montserrat College of Art....................................        <10
    Moore Career College.........................................        <10
    Moravian University..........................................        <10
    Morehead State University....................................        <10
    Morehouse College............................................        <10
    Morehouse School of Medicine.................................        <10
    Morgan State University......................................        <10
    Morningside University.......................................        <10
    Morris Brown College.........................................        <10
    Mount Aloysius College.......................................        <10
    Mount Mary University........................................        <10
    Mount Mercy University.......................................        <10
    Mount Saint Mary College.....................................        <10
    Mount Saint Mary's University................................        <10
    Mount San Antonio College....................................        <10
    Mount Vernon Nazarene University.............................        <10
    Mountain State College.......................................        <10
    Mr. Bela's School of Cosmetology.............................        <10
    Ms Roberts Academy of Beauty Culture.........................        <10
    MSTA Business College (Closed)...............................        <10
    MTI College..................................................        <10
    Mueller College..............................................        <10
    Murray State University......................................        <10
    Muskegon Community College...................................        <10
    Muskingum University.........................................        <10
    Nashville Auto-Diesel College................................        <10
    Nassau Community College.....................................        <10
    National Academy of Beauty Arts..............................        <10
    National American University.................................        <10
    National College of Technology...............................        <10
    National Education Center--Capitol Hill Campus...............        <10
    National Education Center Kee Business College Campus........        <10
    National Education Center-Bauder College Campus..............        <10
    National Graduate School of Quality Management (The).........        <10
    National Hispanic University (The)...........................        <10
    National Massage Therapy Institute...........................        <10
    National Technical Institute.................................        <10
    National University..........................................        <10
    Nazarene Bible College.......................................        <10
    Nebraska Wesleyan University.................................        <10
    Neosho Beauty College........................................        <10
    Neumont College of Computer Science..........................        <10
    Nevada Career School.........................................        <10
    New Age Training.............................................        <10
    New England College..........................................        <10
    New England Conservatory of Music............................        <10
    New England School of Photography............................        <10
    New Jersey Institute of Technology...........................        <10
    New Mexico Junior College....................................        <10
    New Mexico State University..................................        <10
    New River Community College..................................        <10
    New School Center for Media..................................        <10
    New York Automotive & Diesel Institute.......................        <10
    New York College of Podiatric Medicine.......................        <10
    New York Conservatory For Dramatic Arts (The)................        <10
    New York Film Academy........................................        <10
    New York Institute of Technology.............................        <10
    New York Medical Career Training Center......................        <10
    New York School of Interior Design...........................        <10
    New York University..........................................        <10
    Newman University............................................        <10
    Nicholls State University....................................        <10
    Nightingale Medical Institute................................        <10
    North Adrian's College of Beauty.............................        <10
    North American College.......................................        <10
    North American Trade Schools.................................        <10
    North Central Missouri College...............................        <10
    North Central State College..................................        <10
    North Central University.....................................        <10
    North Dakota State University--Fargo.........................        <10
    North Florida Cosmetology Institute..........................        <10
    North Hills School of Health Occupations.....................        <10
    North Iowa Area Community College............................        <10
    North Lake College...........................................        <10
    North Park University........................................        <10
    North Technical Education Center.............................        <10
    Northcentral Technical College...............................        <10
    Northcoast Medical Training Academy..........................        <10
    Northeast College of Health Sciences.........................        <10
    Northeast Community College..................................        <10
    Northeast Iowa Community College.............................        <10
    Northeast Texas Community College............................        <10
    Northeastern State University................................        <10
    Northern Essex Community College.............................        <10
    Northern Oklahoma College....................................        <10
    Northern Tier Career Center..................................        <10
    Northern Wyoming Community College District..................        <10
    North-West College...........................................        <10
    Northwest College of Art & Design............................        <10
    Northwest Iowa Community College.............................        <10
    Northwest Missouri State University..........................        <10
    Northwest Nazarene University................................        <10
    Northwest Regional Technology Institute......................        <10
    Northwest University.........................................        <10
    Northwestern College.........................................        <10
    Northwestern Health Sciences University......................        <10
    Northwestern Michigan College................................        <10
    Northwestern Oklahoma State University.......................        <10
    Northwestern State University................................        <10
    Northwestern Technological Institute.........................        <10
    Norwich University...........................................        <10
    Notre Dame of Maryland University............................        <10
    Nova Southeastern University.................................        <10
    NRI Institute of Health Sciences.............................        <10
    NTMA Training Centers of Southern California.................        <10
    Oak Point University.........................................        <10
    Oakland City University......................................        <10
    Oakland College of Dental Medical Assistants.................        <10
    Oakton Community College.....................................        <10
    Ocean (The)..................................................        <10
    Ocean County Vocational--Technical Schools...................        <10
    Ogle School Hair Skin Nails..................................        <10
    Ohio Christian University....................................        <10
    Ohio Dominican University....................................        <10
    Ohio Institute of Allied Health..............................        <10
    Ohio Institute of Health Careers.............................        <10
    Ohio School of Financial Education...........................        <10
    Ohio State University (The)..................................        <10
    Ohio Technical College.......................................        <10
    Oklahoma Christian University................................        <10
    Oklahoma City University.....................................        <10
    Oklahoma Health Academy......................................        <10
    Oklahoma Junior College......................................        <10
    Oklahoma School of Photography...............................        <10
    Oklahoma State University....................................        <10
    Oklahoma State University--Oklahoma City.....................        <10
    Oklahoma State University Institute of Technology--Okmulgee..        <10
    Old Dominion University......................................        <10
    Old Town Barber College......................................        <10
    Olivet Nazarene University...................................        <10
    Olympian Academy of Cosmetology..............................        <10
    Omnitech Institute...........................................        <10
    Onondaga Community College...................................        <10
    Oral Roberts University......................................        <10
    Orange County Community College..............................        <10
    Oregon College of Oriental Medicine..........................        <10
    Oregon Institute of Technology...............................        <10
    Oregon State University......................................        <10
    Orion Technical College......................................        <10
    Orleans Technical College....................................        <10
    Otis College of Art and Design...............................        <10
    Otterbein University.........................................        <10
    Owensboro Community & Technical College......................        <10
    Ozarks Technical Community College...........................        <10
    Pace Institute...............................................        <10
    Pace University..............................................        <10
    Pacific College..............................................        <10
    Pacific Lutheran University..................................        <10
    Pacific Northwest College of Art.............................        <10
    Pacific University...........................................        <10
    Palladium Technical Academy..................................        <10
    Palmer College of Chiropractic...............................        <10
    Palo Alto University.........................................        <10
    Panola College...............................................        <10
    Paris II Educational Center..................................        <10
    Parisian Beauty Academy Paul Mitchell Partner School.........        <10
    Parisian Spa Institute.......................................        <10
    Park West Barber School......................................        <10
    Parker University............................................        <10
    Parkland College.............................................        <10
    Pasco--Hernando State College................................        <10
    Passaic County Community College.............................        <10
    Patsy And Rob's Academy of Beauty............................        <10
    Patten University............................................        <10
    Paul Mitchell The School Costa Mesa..........................        <10
    Paul Mitchell the School Dallas..............................        <10
    Paul Mitchell The School New Orleans.........................        <10
    Paul Mitchell The School Overland Park.......................        <10
    PB Cosmetology Education Centre..............................        <10
    PC Age.......................................................        <10
    PCI Health Training Center...................................        <10
    Pearl River Community College................................        <10
    Pennco Tech..................................................        <10
    Pennsylvania Academy of the Fine Arts........................        <10
    Pennsylvania College of Art & Design.........................        <10
    Pennsylvania College of Technology...........................        <10
    Pennsylvania Highlands Community College.....................        <10
    Pennsylvania State University (The)..........................        <10
    Pennsylvania Western University..............................        <10
    Penrose Academy..............................................        <10
    Pensacola School of Massage Therapy & Health Careers.........        <10
    Pensacola State College......................................        <10
    Pentecostal Theological Seminary.............................        <10
    Pepperdine University........................................        <10
    Performance Training Institute...............................        <10
    Peru State College...........................................        <10
    Phillips College Inland Empire Campus........................        <10
    Phillips College of Atlanta..................................        <10
    Phillips Graduate University.................................        <10
    Phillips Junior College of Spokane...........................        <10
    Phoenix College..............................................        <10
    Pierpont Community & Technical College.......................        <10
    Pike County Career Technology Center.........................        <10
    Pillar College...............................................        <10
    Pima Medical Institute.......................................        <10
    Pinnacle College.............................................        <10
    Pioneer Pacific College......................................        <10
    Pittsburg State University...................................        <10
    Pittsburgh Technical College.................................        <10
    Plaza Beauty School..........................................        <10
    Point Loma Nazarene University...............................        <10
    Pontifical Catholic University of Puerto Rico (The)..........        <10
    Post University..............................................        <10
    Pratt Community College......................................        <10
    Pratt Institute..............................................        <10
    Premiere Career College......................................        <10
    Prescott College.............................................        <10
    Prince George's Community College............................        <10
    Princeton Theological Seminary...............................        <10
    Printing Trades School.......................................        <10
    Prism Career Institute.......................................        <10
    Pro Way Hair School..........................................        <10
    Professional Business School.................................        <10
    Professional Culinary Academy................................        <10
    Professional Golfers Career College..........................        <10
    Professional Hands Institute.................................        <10
    Profile Institute of Barber-Styling..........................        <10
    Providence College...........................................        <10
    PSI Institute................................................        <10
    PSI Institute of Washington..................................        <10
    Pueblo Community College.....................................        <10
    Purdue University Fort Wayne.................................        <10
    Queens University of Charlotte...............................        <10
    Quincy University............................................        <10
    Quinsigamond Community College...............................        <10
    Radford University...........................................        <10
    Randall University...........................................        <10
    Randolph--Macon College......................................        <10
    Randolph College.............................................        <10
    Randy Rick Beauty Academy....................................        <10
    Ranken Technical College.....................................        <10
    Rasmussen College............................................        <10
    Rasmussen College--Mankato...................................        <10
    Rasmussen University.........................................        <10
    Real Barbers College (The)...................................        <10
    Red Rocks Community College..................................        <10
    Redlands Community College...................................        <10
    Reed College.................................................        <10
    Refrigeration School (The)...................................        <10
    Regency Beauty Institute--Cleveland..........................        <10
    Regina's College of Beauty...................................        <10
    Regis University.............................................        <10
    Reinhardt University.........................................        <10
    Rend Lake College............................................        <10
    Rhode Island College.........................................        <10
    Rhodes College...............................................        <10
    Richland Community College...................................        <10
    Rider University.............................................        <10
    Ridgewater College...........................................        <10
    Riggs Lemar Beauty College...................................        <10
    Riley College................................................        <10
    Ringling College of Art and Design...........................        <10
    Rio Grande Valley College....................................        <10
    Rio Salado Community College.................................        <10
    Riverland Community College..................................        <10
    Riverside County Office of Education.........................        <10
    Riverside School of Aeronutics...............................        <10
    Rivertown School of Beauty, Barber, Skin Care and Nails......        <10
    Rizzieri Aveda School for Beauty and Wellness................        <10
    Robert Fiance Beauty Schools.................................        <10
    Rochester Institute of Technology............................        <10
    Rochester University.........................................        <10
    Rockford University..........................................        <10
    Rockland Community College...................................        <10
    Rocky Mountain College of Art + Design.......................        <10
    Roger Williams University....................................        <10
    Rollins College..............................................        <10
    Rome Academy of Cosmetology..................................        <10
    Rosalind Franklin University of Medicine and Science.........        <10
    Rosedale Technical College...................................        <10
    Roseman University of Health Sciences........................        <10
    Rosemont College.............................................        <10
    Rowan College of South Jersey................................        <10
    Royal Beauty Careers.........................................        <10
    Royal College of Surgeons in Ireland.........................        <10
    Royale College of Beauty and Barbering.......................        <10
    Ruben's Five Star Academy....................................        <10
    Ruesing University Of Beauty.................................        <10
    Russell Sage College.........................................        <10
    Rutgers, the State University of New Jersey..................        <10
    Saba University School of Medicine...........................        <10
    SABER College................................................        <10
    Sacred Heart University......................................        <10
    SAE Expression College.......................................        <10
    Sage College.................................................        <10
    Saginaw Valley State University..............................        <10
    Saint Augustine's University.................................        <10
    Saint Charles Community College..............................        <10
    Saint Elizabeth School of Nursing............................        <10
    Saint Francis College........................................        <10
    Saint Gregory's University...................................        <10
    Saint Johns River State College..............................        <10
    Saint Joseph's College.......................................        <10
    Saint Leo University.........................................        <10
    Saint Louis University.......................................        <10
    Saint Martin's University....................................        <10
    Saint Mary of the Woods College..............................        <10
    Saint Mary's University of Minnesota.........................        <10
    Saint Olaf College...........................................        <10
    Saint Paul's College.........................................        <10
    Saint Peter's University.....................................        <10
    Saint Thomas University......................................        <10
    Salem State University.......................................        <10
    Salem University.............................................        <10
    Salon Professional Academy--Melbourne, The...................        <10
    Salon Professional Academy (The).............................        <10
    Salon Success Academy........................................        <10
    Sam Houston State University.................................        <10
    Samford University...........................................        <10
    Samuel Merritt University....................................        <10
    San Antonio Court Reporting Institute........................        <10
    San Diego College............................................        <10
    San Francisco Art Institute..................................        <10
    San Joaquin College of Law...................................        <10
    San Joaquin Valley College...................................        <10
    San Juan College.............................................        <10
    Santa Barbara and Ventura Colleges of Law (The)..............        <10
    Santa Barbara City College...................................        <10
    Santa Clara University.......................................        <10
    Santa Fe Community College...................................        <10
    Santa Monica College.........................................        <10
    Santa Rosa Junior College....................................        <10
    Savannah College of Art and Design...........................        <10
    Sawyer College...............................................        <10
    Sawyer School................................................        <10
    Sawyer School (The)..........................................        <10
    Schilling--Douglas School of Hair Design.....................        <10
    School of Court Reporting (The)..............................        <10
    School of Hair Design........................................        <10
    School of the Art Institute of Chicago.......................        <10
    School of Visual Arts........................................        <10
    Schoolcraft College..........................................        <10
    Schuylkill Technology Centers................................        <10
    Scientific College of Beauty / Barbering.....................        <10
    Scioto County Career Technical Center........................        <10
    Searcy Beauty College........................................        <10
    Seattle Film Institute.......................................        <10
    Seattle Institute of East Asian Medicine.....................        <10
    Seattle Pacific University...................................        <10
    Seneca College of Applied Arts & Technology..................        <10
    Sessions College for Professional Design.....................        <10
    Seton Hill University........................................        <10
    Shawnee State University.....................................        <10
    Shear Excellence Hair Academy................................        <10
    Sheldon Jackson College......................................        <10
    Shenandoah University........................................        <10
    Sherman College of Straight Chiropractic.....................        <10
    Shirley Baker Career Institute...............................        <10
    Shore Beauty School..........................................        <10
    Shorter College..............................................        <10
    Sierra Nevada College........................................        <10
    Simpson College..............................................        <10
    Slippery Rock University.....................................        <10
    Sojourner-Douglass College...................................        <10
    Soma Institute--The National School of Clinical Massage              <10
     Therapy.....................................................
    Sonoma State University......................................        <10
    Sonoran Desert Institute.....................................        <10
    South Arkansas College.......................................        <10
    South Coast College..........................................        <10
    South Hills School of Business & Technology..................        <10
    South Plains College.........................................        <10
    Southeast Arkansas College...................................        <10
    Southeast Community College..................................        <10
    Southeast Kentucky Community and Technical College...........        <10
    Southeast Texas Career Institute.............................        <10
    Southeastern Bible College...................................        <10
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    Southeastern Louisiana University............................        <10
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    Southern College.............................................        <10
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    Southern Nazarene University.................................        <10
    Southern New Hampshire University............................        <10
    Southern Oregon University...................................        <10
    Southern State Community College.............................        <10
    Southern University at Shreveport--Bossier City..............        <10
    Southern Vermont College.....................................        <10
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    Southern Vocational Technical Institute......................        <10
    Southern West Virginia Community and Technical College.......        <10
    Southwestern Christian College...............................        <10
    Southwestern College.........................................        <10
    Southwestern Michigan College................................        <10
    Southwestern Professional Institute..........................        <10
    Southwestern University......................................        <10
    Spalding University..........................................        <10
    Sparks College...............................................        <10
    Spartan College of Aeronautics and Technology................        <10
    Spartanburg Community College................................        <10
    Spartanburg Methodist College................................        <10
    Special School District of St. Louis County..................        <10
    Spelman College..............................................        <10
    Spertus College of Judaica...................................        <10
    Spoon River College..........................................        <10
    Spring Arbor University......................................        <10
    Spring Garden College........................................        <10
    St Norbert College...........................................        <10
    St. Catharine College........................................        <10
    St. Clair County Community College...........................        <10
    St. Edward's University......................................        <10
    St. George's University, School of Veterinary Medicine.......        <10
    St. John Fisher University...................................        <10
    St. Lawrence University......................................        <10
    St. Mary's University........................................        <10
    St. Matthew's University School of Medicine..................        <10
    St. Paul's School of Nursing.................................        <10
    Standard Healthcare Services, College of Nursing.............        <10
    Stanford University..........................................        <10
    State College of Florida, Manatee-Sarasota...................        <10
    State Fair Community College.................................        <10
    State University of New York at Albany.......................        <10
    State University of New York at New Paltz....................        <10
    State University of New York at Oneonta......................        <10
    State University of New York at Stony Brook..................        <10
    State University of New York College at Potsdam..............        <10
    State University of New York Polytechnic Institute...........        <10
    Stefans Beauty College.......................................        <10
    Stevens--The Institute of Business & Arts....................        <10
    Stevenson University.........................................        <10
    Stillman College.............................................        <10
    Stockton University..........................................        <10
    Stone Academy................................................        <10
    Stratford University.........................................        <10
    Stylemasters College of Hair Design..........................        <10
    Styletrends Barber and Hairstyling Academy...................        <10
    Suffolk University...........................................        <10
    Sullivan County Community College--SUNY Office of Community          <10
     Colleges....................................................
    SUM Bible College & Theological Seminary.....................        <10
    Summit College...............................................        <10
    Summit Institute.............................................        <10
    Summit Salon Academy--Gainesville............................        <10
    Sumner College...............................................        <10
    SUNY Buffalo State University................................        <10
    SUNY College at Purchase.....................................        <10
    SUNY College of Environment Science & Forestry...............        <10
    SUNY Cortland................................................        <10
    SUNY Fulton-Montgomery Community College.....................        <10
    SUNY Old Westbury............................................        <10
    SUNY Westchester Community College...........................        <10
    Super Shapes College of Cosmetology..........................        <10
    Superior Training Services...................................        <10
    Susquehanna University.......................................        <10
    Sussex County Community College..............................        <10
    Swansea University...........................................        <10
    Sylvain Melloul International Hair Academy...................        <10
    Taft University System (The).................................        <10
    Talladega College............................................        <10
    Teachers College, Columbia University........................        <10
    Technical Career Institutes..................................        <10
    Technical Education Center...................................        <10
    Temple College...............................................        <10
    Temple University............................................        <10
    Tenaj Salon Institute........................................        <10
    Tennessee Career Institute...................................        <10
    Tennessee State University...................................        <10
    Tennessee Temple University..................................        <10
    Texas A&M International University...........................        <10
    Texas A&M University.........................................        <10
    Texas A&M University--Corpus Christi.........................        <10
    Texas Aero Technology........................................        <10
    Texas Barber College.........................................        <10
    Texas Christian University...................................        <10
    Texas College................................................        <10
    Texas Healthtech Institute...................................        <10
    Texas Lutheran University....................................        <10
    Texas Southern University....................................        <10
    Texas Tech University Health Sciences Center.................        <10
    Thaddeus Stevens College of Technology.......................        <10
    Thomas Jefferson School of Law...............................        <10
    Three Rivers Community College...............................        <10
    Tidewater Community College..................................        <10
    Tiffin University............................................        <10
    Toledo Public Schools Adult and Continuing Education.........        <10
    Tompkins Cortland Community College..........................        <10
                                                                  ----------
          Total Transformation Institute of Cosmetology..........        <10
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    Tougaloo College.............................................        <10
    Touro University.............................................        <10
    Towson University............................................        <10
    Trainco Bus School...........................................        <10
    Transformed Barber & Cosmetology Academy.....................        <10
    Travel & Trade Career Institute..............................        <10
    Travel Institute.............................................        <10
    Travel Institute of the Pacific..............................        <10
    Treasure Valley Community College............................        <10
    Trend Barber College.........................................        <10
    Trend Benders Academy........................................        <10
    Trend College................................................        <10
    Trend Setters' Academy of Beauty Culture.....................        <10
    Trend Setters School.........................................        <10
    Trevecca Nazarene University.................................        <10
    Tri-County Technical College.................................        <10
    Trident Technical College....................................        <10
    Trine University.............................................        <10
    Trinidad State College.......................................        <10
    Trinity College of Florida...................................        <10
    Trinity University...........................................        <10
    Troy State University Montgomery.............................        <10
    Troy University..............................................        <10
    Truett McConnell University..................................        <10
    Trumbull Career and Technical Center-Adult Training Center...        <10
    Tufts University.............................................        <10
    Tulsa Welding School.........................................        <10
    U.S. Truck Driver Training School............................        <10
    Ultimate Medical Academy.....................................        <10
    Union College................................................        <10
    Union Institute & University.................................        <10
    United Schools...............................................        <10
    United States Sports Academy.................................        <10
    United Theological Seminary..................................        <10
    Unity Environmental University...............................        <10
    Universal Spa Training Academy...............................        <10
    Universal Technical Institute................................        <10
    Universal Training Institute.................................        <10
    Universidad Ana G. Mendez--Cupey Campus......................        <10
    Universidad Central del Este.................................        <10
    Universidad Politecnica de Puerto Rico.......................        <10
    University of Akron (The)....................................        <10
    University of Alabama at Birmingham..........................        <10
    University of Alaska Anchorage...............................        <10
    University of Arizona (The)..................................        <10
    University of Arkansas.......................................        <10
    University of California, Irvine.............................        <10
    University of California, Los Angeles........................        <10
    University of California, Riverside..........................        <10
    University of California, San Francisco......................        <10
    University of California, Santa Cruz.........................        <10
    University of Central Arkansas...............................        <10
    University of Central Florida................................        <10
    University of Central Missouri...............................        <10
    University of Central Oklahoma...............................        <10
    University of Charleston.....................................        <10
    University of Chicago (The)..................................        <10
    University of Cincinnati.....................................        <10
    University of Colorado Boulder...............................        <10
    University of Colorado Colorado Springs......................        <10
    University of Connecticut....................................        <10
    University of Dallas.........................................        <10
    University of Dayton.........................................        <10
    University of Detroit Mercy..................................        <10
    University of Dubuque........................................        <10
    University of Findlay (The)..................................        <10
    University of Hartford.......................................        <10
    University of Hawaii--West Oahu..............................        <10
    University of Hawaii at Manoa................................        <10
    University of Houston--Victoria..............................        <10
    University of Idaho..........................................        <10
    University of Illinois Chicago...............................        <10
    University of Kansas.........................................        <10
    University of Limerick.......................................        <10
    University of Louisiana at Monroe............................        <10
    University of Louisville.....................................        <10
    University of Lynchburg......................................        <10
    University of Management and Technology (The)................        <10
    University of Mary...........................................        <10
    University of Mary Washington................................        <10
    University of Maryland--Baltimore County.....................        <10
    University of Maryland--Eastern Shore........................        <10
    University of Maryland Global Campus.........................        <10
    University of Massachusetts--Amherst.........................        <10
    University of Massachusetts--Lowell..........................        <10
    University of Massachusetts at Boston........................        <10
    University of Miami..........................................        <10
    University of Minnesota--Twin Cities.........................        <10
    University of Minnesota Duluth...............................        <10
    University of Missouri--Kansas City..........................        <10
    University of Missouri--Saint Louis..........................        <10
    University of Mobile.........................................        <10
    University of Montana Western (The)..........................        <10
    University of Nebraska.......................................        <10
    University of Nebraska--Kearney..............................        <10
    University of New Hampshire School of Law....................        <10
    University of North Carolina--Chapel Hill....................        <10
    University of North Carolina--Charlotte......................        <10
    University of North Carolina Asheville.......................        <10
    University of North Carolina at Pembroke.....................        <10
    University of North Dakota...................................        <10
    University of Northern Colorado..............................        <10
    University of Pennsylvania...................................        <10
    University of Pikeville......................................        <10
    University of Rhode Island...................................        <10
    University of Rio Grande.....................................        <10
    University of Saint Andrews..................................        <10
    University of Saint Francis..................................        <10
    University of Saint Mary.....................................        <10
    University of Scranton.......................................        <10
    University of South Carolina Upstate.........................        <10
    University of South Dakota...................................        <10
    University of Southern California............................        <10
    University of Southern Indiana...............................        <10
    University of Southernmost Florida...........................        <10
    University of Tennessee......................................        <10
    University of Tennessee--Martin..............................        <10
    University of Tennessee Southern.............................        <10
    University of Texas at Arlington.............................        <10
    University of Texas at Austin................................        <10
    University of Texas at Dallas................................        <10
    University of the Arts (The).................................        <10
    University of the Incarnate Word.............................        <10
    University of the Ozarks.....................................        <10
    University of the Southwest..................................        <10
    University of Tulsa (The)....................................        <10
    University of Utah...........................................        <10
    University of Virginia.......................................        <10
    University of Virginia's College at Wise (The)...............        <10
    University of Washington--Seattle............................        <10
    University of West Los Angeles...............................        <10
    University of Wisconsin--Parkside............................        <10
    University of Wisconsin--Stevens Point.......................        <10
    University of Wisconsin--Stout...............................        <10
    University of Wisconsin--Whitewater..........................        <10
    Unlimited Cosmetology School.................................        <10
    Ursuline College.............................................        <10
    Utah State University........................................        <10
    Utica School of Commerce.....................................        <10
    Utica University.............................................        <10
    Valencia College.............................................        <10
    Valley Forge Military College................................        <10
    Vantage College..............................................        <10
    Vaughn College of Aeronautics and Technology.................        <10
    VEEB Nassau County School of Practical Nursing...............        <10
    Ventura College..............................................        <10
    Vernon College...............................................        <10
    Verve College................................................        <10
    Vibe Barber College..........................................        <10
    Vicksburg School of Cosm.....................................        <10
    Victoria College.............................................        <10
    Victory University...........................................        <10
    Video Symphony EnterTraining.................................        <10
    Video Technical Institute....................................        <10
    Vincennes Beauty College.....................................        <10
    Virginia Intermont College...................................        <10
    Virginia Polytechnic Institute & State University............        <10
    Virginia State University....................................        <10
    Virginia Union University....................................        <10
    Virginia University of Lynchburg.............................        <10
    Vista College................................................        <10
    Vogue Beauty and Barber School...............................        <10
    Vogue College School of Hair Design #16......................        <10
    Voorhees University..........................................        <10
    Wade College.................................................        <10
    Wade Gordon Hairdressing Academy.............................        <10
    Wagner College...............................................        <10
    Wake Forest University.......................................        <10
    Walla Walla Community College................................        <10
    Walnut Hill College..........................................        <10
    Walsh College of Accountancy & Business Administration.......        <10
    Walsh University.............................................        <10
    Warner Pacific University....................................        <10
    Warren County Career Center..................................        <10
    Wartburg College.............................................        <10
    Washington Adventist University..............................        <10
    Washington Bible College.....................................        <10
    Washington University in St. Louis...........................        <10
    Watkins College of Art, Design & Film........................        <10
    Wayne State College..........................................        <10
    Wayne State University.......................................        <10
    Waynesburg University........................................        <10
    Waynesville Career Center....................................        <10
    Webb's Barber School of Arts.................................        <10
    Wentworth Institute of Technology............................        <10
    Wesleyan College.............................................        <10
    West Coast University........................................        <10
    West Liberty University......................................        <10
    West Texas A&M University....................................        <10
    West Virginia Business College...............................        <10
    West Virginia University.....................................        <10
    West Virginia University--Parkersburg........................        <10
    Westech College..............................................        <10
    Western Area Career & Technology Center......................        <10
    Western Beauty Institute.....................................        <10
    Western Connecticut State University.........................        <10
    Western Governors University.................................        <10
    Western Nevada College.......................................        <10
    Western Oregon University....................................        <10
    Western Piedmont Community College...........................        <10
    Western Seminary.............................................        <10
    Western University of Health Sciences........................        <10
    Western Washington University................................        <10
    Westfield State University...................................        <10
    WestMed College..............................................        <10
    Westminster University.......................................        <10
    Westmoreland County Community College........................        <10
    Wharton County Junior College................................        <10
    Wichita State University Campus of Applied Sciences and              <10
     Technology..................................................
    Wichita Technical Institute..................................        <10
    Willamette University........................................        <10
    William James College........................................        <10
    William Peace University.....................................        <10
    William Penn University......................................        <10
    Williams Baptist University..................................        <10
    Wilmington College...........................................        <10
    Wingate University...........................................        <10
    Wisconsin Lutheran College...................................        <10
    Wittenberg University........................................        <10
    Wolford College..............................................        <10
    Women's Techl Institute......................................        <10
    Woodbury University..........................................        <10
    Worcester Polytechnic Institute..............................        <10
    Worcester State University...................................        <10
    Xavier University............................................        <10
    Xavier University of Louisiana...............................        <10
    Yakima Valley College........................................        <10
    Yale University..............................................        <10
    Yavapai College..............................................        <10
    Yeshiva University...........................................        <10
    York College of Pennsylvania.................................        <10
    Yorktowne Business Institute.................................        <10
                                                                  ----------
          Grand Total............................................      7,700
    ------------------------------------------------------------------------

                      Total Closed Cases By Primary School
                               As of May 31, 2024
    ------------------------------------------------------------------------
     Case counts and totals are rounded to the nearest ten and redacted for
                              values less than 10.
    -------------------------------------------------------------------------
                                                                      Case
                            Primary School                           Count
    ------------------------------------------------------------------------
    ITT Technical Institute......................................      1,830
    Heald College................................................      1,700
    Altierus Career College......................................      1,530
    Everest College..............................................      1,510
    University of Phoenix........................................        790
    Everest Institute............................................        710
    WyoTech......................................................        630
    DeVry University.............................................        590
    Everest University...........................................        280
    Sanford-Brown College........................................        210
    Altierus Career Education....................................        170
    Argosy University............................................        170
    Purdue University Global.....................................        170
    Marinello School of Beauty...................................        150
    University of Arizona Global Campus (The)....................        150
    Bryman College...............................................        110
    Le Cordon Bleu College of Culinary Arts......................        110
    American InterContinental University.........................        100
    Brightwood College...........................................        100
    Virginia College.............................................        100
    Westwood College--Denver North...............................        100
    Art Institute of Las Vegas (The).............................         90
    Brooks Institute.............................................         90
    South University.............................................         90
    Westwood College--Los Angeles................................         90
    Everest College Phoenix......................................         80
    Walden University............................................         80
    Art Institute of Pittsburgh (The)............................         70
    Capella University...........................................         70
    Colorado Technical University................................         70
    Everest University--Pompano Beach............................         70
    Florida Coastal School of Law................................         70
    Grand Canyon University......................................         70
    Illinois Institute of Art (The)..............................         70
    Keller Graduate School of Management.........................         70
    Art Institute of Atlanta (The)...............................         60
    Ross University, School of Medicine..........................         60
    Anthem College...............................................         50
    Strayer University...........................................         50
    Art Institute of California--Los Angeles (The)...............         40
    Daniel Webster College.......................................         40
    DeVry Institute of Technology................................         40
    Keiser University............................................         40
    Las Vegas College............................................         40
    Lincoln Technical Institute..................................         40
    Miami International University of Art & Design...............         40
    New England Institute of Art (The)...........................         40
    Vatterott College............................................         40
    American Career Institute....................................         30
    Art Institute of California--San Diego.......................         30
    Art Institute of Philadelphia (The)..........................         30
    Art Institutes International Minnesota (The).................         30
    ATI Career Training Center...................................         30
    Bryman School of Arizona (The)...............................         30
    Career Point College.........................................         30
    Carrington College...........................................         30
    Chamberlain University.......................................         30
    Charlotte School of Law......................................         30
    Empire Beauty School.........................................         30
    Fortis College...............................................         30
    Heritage College.............................................         30
    Lincoln College of Technology................................         30
    Medtech College..............................................         30
    Minnesota School of Business.................................         30
    Regency Beauty Institute.....................................         30
    Ross University School of Veterinary Medicine................         30
    Star Career Academy..........................................         30
    Westwood College--O'Hare Airport.............................         30
    Westwood College--South Bay..................................         30
    Wright Career College........................................         30
    American College for Medical Careers.........................         20
    American National University.................................         20
    Art Institute of Colorado (The)..............................         20
    Art Institute of Fort Lauderdale (The).......................         20
    Art Institute of Portland (The)..............................         20
    Art Institute of Seattle (The)...............................         20
    Brightwood Career Institute..................................         20
    Brown Mackie College-Cincinnati..............................         20
    Chicago School of Professional Psychology....................         20
    Concorde Career College......................................         20
    Florida Career College.......................................         20
    Full Sail University.........................................         20
    Globe University.............................................         20
    Harrison College.............................................         20
    Independence University......................................         20
    ITT Technical Institute......................................         20
    Kaplan College...............................................         20
    Le Cordon Bleu College of Culinary Arts in Chicago...........         20
    Liberty University...........................................         20
    Remington College............................................         20
    United Education Institute...................................         20
    Universal Technical Institute................................         20
    American Career College......................................         10
    American Public University System............................         10
    American University of the Caribbean.........................         10
    Anthem Institute.............................................         10
    Arizona Summit Law School....................................         10
    Art Institute of California-Hollywood (The)..................         10
    Art Institute of Houston (The)...............................         10
    Art Institute of New York City (The).........................         10
    Baker College................................................         10
    Berkeley College.............................................         10
    Brooks College...............................................         10
    Brown Mackie College.........................................         10
    Brown Mackie College-South Bend..............................         10
    Centura College..............................................         10
    Collins College..............................................         10
    Dade Medical College.........................................         10
    Daymar College...............................................         10
    Drake College of Business....................................         10
    ECPI University..............................................         10
    Florida Technical College....................................         10
    Hallmark Institute of Photography............................         10
    Harris School of Business....................................         10
    ICDC College.................................................         10
    Kaplan Career Institute......................................         10
    Katharine Gibbs School.......................................         10
    Le Cordon Bleu Institute of Culinary Arts....................         10
    McCann School of Business & Technology.......................         10
    Miller-Motte Technical College...............................         10
    Sanford-Brown Institute......................................         10
    Southern New Hampshire University............................         10
    Ultimate Medical Academy.....................................         10
    Western International University.............................         10
    Westwood College--DuPage.....................................         10
    Wilfred Academy Of Hair & Beauty Culture.....................         10
    A. T. Still University of Health Sciences....................        <10
    Abraham Baldwin Agricultural College.........................        <10
    Academy College..............................................        <10
    Academy for Nursing and Health Occupations...................        <10
    Academy of Art University....................................        <10
    Academy of Business Careers..................................        <10
    Academy of Cosmetology.......................................        <10
    Academy of Court Reporting and Technology....................        <10
    Academy of Esthetics and Cosmetology.........................        <10
    Academy of Stenographic Arts.................................        <10
    ACT College..................................................        <10
    Adams State University.......................................        <10
    Adelphi Business College.....................................        <10
    Adelphi Technical Institute..................................        <10
    Adelphi University...........................................        <10
    Advance Beauty Techs Academy.................................        <10
    Advanced College.............................................        <10
    Advanced Technology Institute................................        <10
    Alabama Agricultural & Mechanical University.................        <10
    Alabama State University.....................................        <10
    Alameda Technical College....................................        <10
    Albany College of Pharmacy and Health Sciences...............        <10
    Albany State University......................................        <10
    Albany Technical College.....................................        <10
    Albert Merrill School........................................        <10
    Albizu University............................................        <10
    Alfred University............................................        <10
    All American Career College..................................        <10
    Allegheny College............................................        <10
    Allen School.................................................        <10
    Alliance University..........................................        <10
    Alliant International University.............................        <10
    Allied American University...................................        <10
    Allied Medical and Technical Institute.......................        <10
    All-State Career.............................................        <10
    Alvareita's College of Cosmetology...........................        <10
    Alverno College..............................................        <10
    American Academy of Art College..............................        <10
    American Academy of Cosmetology..............................        <10
    American Academy of Hair Design..............................        <10
    American Academy of Personal Training........................        <10
    American Bartenders School...................................        <10
    American Beauty Academy......................................        <10
    American Beauty College......................................        <10
    American Business Institute..................................        <10
    American Business Institute (Closed).........................        <10
    American Career Academy......................................        <10
    American Career Training Travel School.......................        <10
    American Center for Technical Arts & Sciences................        <10
    American College.............................................        <10
    American College of Barbering................................        <10
    American College of Education................................        <10
    American College of Hairstyling-Des Moines...................        <10
    American College of Medical Technology.......................        <10
    American Commercial College..................................        <10
    American Health Institute....................................        <10
    American Institute...........................................        <10
    American Institute of Alternative Medicine...................        <10
    American Institute of Trucking...............................        <10
    American International College...............................        <10
    American National College....................................        <10
    American River College.......................................        <10
    American School of Cosmetology...............................        <10
    American School of Technology................................        <10
    American University (The)....................................        <10
    American University of Antigua College of Medicine...........        <10
    American Vocational Center...................................        <10
    Amridge University...........................................        <10
    Ams College Home Study Division..............................        <10
    Anamarc College..............................................        <10
    Anne Arundel Community College...............................        <10
    Antelope Valley College......................................        <10
    Antioch University...........................................        <10
    Antonelli College............................................        <10
    Antonelli Institute..........................................        <10
    Apex Technical School........................................        <10
    Appalachian State University.................................        <10
    Arizona Academy of Beauty....................................        <10
    Arizona Automotive Institute.................................        <10
    Arizona Institute of Electrolysis Div Unif School of AM......        <10
    Arizona State University.....................................        <10
    Arkansas Baptist College.....................................        <10
    Arkansas Beauty College......................................        <10
    Arkansas Tech University.....................................        <10
    Art Institute of Charlotte (The).............................        <10
    Art Institute of Dallas (The)................................        <10
    Art Institute of Tucson (The)................................        <10
    Art Institute of York (The)--Pennsylvania....................        <10
    Art of Beauty College........................................        <10
    Arthur's Beauty College......................................        <10
    Artistic Nails & Beauty Academy..............................        <10
    ASA College..................................................        <10
    Ashland University...........................................        <10
    Aspen University.............................................        <10
    ASPIRA City College..........................................        <10
    Associated Business Careers..................................        <10
    Associated Technical College.................................        <10
    ATA College..................................................        <10
    ATI- Career Training Center..................................        <10
    ATI College of Health........................................        <10
    ATI Technical Training Center................................        <10
    Atlanta Medical Institute....................................        <10
    Atlanta Metropolitan State College...........................        <10
    Atlanta University...........................................        <10
    Atlanta's John Marshall Law School...........................        <10
    Auburn University............................................        <10
    Auburn University Montgomery.................................        <10
    Augusta Technical College....................................        <10
    Aurora University............................................        <10
    Austin Business College......................................        <10
    Austin College...............................................        <10
    Austin Community College.....................................        <10
    Avalon Institute.............................................        <10
    Ave Maria School of Law......................................        <10
    Ave Maria University.........................................        <10
    Aveda Arts & Sciences Institute Covington....................        <10
    Aveda Institute--Fort Myers..................................        <10
    Aveda Institute Boise........................................        <10
    Aviation Institute Of Maintenance............................        <10
    Avtech Institute.............................................        <10
    Bacone College...............................................        <10
    Bailie School of Broadcast...................................        <10
    Bainbridge State College.....................................        <10
    Baker University.............................................        <10
    Baldwin Wallace University...................................        <10
    Ball State University........................................        <10
    Baltimore City Community College.............................        <10
    Barber--Scotia College.......................................        <10
    Barclay Career School........................................        <10
    Barclay College..............................................        <10
    Barnard College..............................................        <10
    Barry University.............................................        <10
    Barstow Community College....................................        <10
    Barton County Community College..............................        <10
    Baton Rouge Community College................................        <10
    Bauder College...............................................        <10
    Bauder College Specializing in Career Education..............        <10
    Bay Area Medical Academy.....................................        <10
    Bay State College............................................        <10
    Baylor University............................................        <10
    Beaufort County Community College............................        <10
    Beauty Institute (The).......................................        <10
    Beauty Institute Schwarzkopf Professional (The)..............        <10
    Beauty Schools of America....................................        <10
    Becker College...............................................        <10
    Beckfield College............................................        <10
    Bel--Rea Institute of Animal Technology......................        <10
    Bellevue College.............................................        <10
    Bellevue University..........................................        <10
    Belmont University...........................................        <10
    Benedict Business Institute..................................        <10
    Bene's Career Academy........................................        <10
    Benjamin Franklin Cummings Institute.........................        <10
    Bentley University...........................................        <10
    Berks Technical Institute....................................        <10
    Bethel University............................................        <10
    Big Bend Community College...................................        <10
    Big Sandy Community and Technical College....................        <10
    BioHealth College............................................        <10
    Black Hills State University.................................        <10
    Blackhawk Technical College..................................        <10
    Blinn College................................................        <10
    Bloomfield College...........................................        <10
    Blue Cliff Career College....................................        <10
    Blue Cliff College...........................................        <10
    Blue Ridge Community and Technical College...................        <10
    Blue Ridge Community College.................................        <10
    Boca Beauty Academy..........................................        <10
    Boise State University.......................................        <10
    Bonnie Joseph Academy of Cosmetology & Barbering.............        <10
    Boricua College..............................................        <10
    Bossier Parish Community College.............................        <10
    Boston College...............................................        <10
    Boston University............................................        <10
    Boulder Valley Region #2 Public School District..............        <10
    Bowie State University.......................................        <10
    Bowling Green State University...............................        <10
    Bradford College.............................................        <10
    Bradford School..............................................        <10
    Bradley University...........................................        <10
    Bramson ORT College..........................................        <10
    Branell Institute............................................        <10
    Branford Hall Career Institute...............................        <10
    Braxton School of Business...................................        <10
    Brazosport Junior College....................................        <10
    Briarcliffe College..........................................        <10
    Brittany Beauty Academy......................................        <10
    Brittany Beauty School.......................................        <10
    Broadview College............................................        <10
    Brookline College............................................        <10
    Brookstone College of Business...............................        <10
    Broward College..............................................        <10
    Brown Mackie College (the -).................................        <10
    Brown Mackie College-Findlay.................................        <10
    Brown Mackie College-Louisville..............................        <10
    Brown Mackie College-Merrillville............................        <10
    Brown Mackie College-North Canton............................        <10
    Bryan College................................................        <10
    Bryan Institute..............................................        <10
    Bryan University.............................................        <10
    Bryant & Stratton Business Institute--Rochester..............        <10
    Bryant & Stratton College....................................        <10
    Bryant and Stratton College..................................        <10
    Bryman School................................................        <10
    Buchanan Beauty College......................................        <10
    Buckner Barber School........................................        <10
    Bunker Hill Community College................................        <10
    Burlington College...........................................        <10
    Business Career Training Institute...........................        <10
    Business Etcetera Institute of Technology....................        <10
    Business Informatics Center..................................        <10
    Butler Business School.......................................        <10
    Butler County Community College..............................        <10
    Cabot College................................................        <10
    CALC, Institute of Technology................................        <10
    Caldwell Community College & Technical Institute.............        <10
    Calhoun Community College....................................        <10
    Caliber Training Institute...................................        <10
    California Aeronautical University...........................        <10
    California Baptist University................................        <10
    California College of the Arts...............................        <10
    California College of Vocational Careers.....................        <10
    California College San Diego.................................        <10
    California Northstate University.............................        <10
    California Polytechnic State University......................        <10
    California School of Court Reporting.........................        <10
    California State University--Sacramento......................        <10
    California State University Channel Islands..................        <10
    California State University, East Bay........................        <10
    California State University, Fresno..........................        <10
    California State University, Long Beach......................        <10
    California State University, Los Angeles.....................        <10
    California State University, Northridge......................        <10
    California State University, San Marcos......................        <10
    Cambria-Rowe Business College................................        <10
    Cambridge College of Healthcare & Technology.................        <10
    Cambridge Techl Inst.........................................        <10
    Cameo College of Essential Beauty............................        <10
    Campbell University..........................................        <10
    Canada College...............................................        <10
    Canisius University of Buffalo, New York.....................        <10
    Cape Fear Community College..................................        <10
    Capitol City Careers.........................................        <10
    Capitol City Junior College..................................        <10
    Capitol City Trade & Technical School........................        <10
    Capri Institute of Hair Design...............................        <10
    Cardinal Stritch University..................................        <10
    Career Academy of Beauty.....................................        <10
    Career Care Institute........................................        <10
    Career Colleges of America...................................        <10
    Career Colleges of Chicago...................................        <10
    Career Institute of Health and Technology....................        <10
    Career Point Business School.................................        <10
    Career Quest Learning Centers................................        <10
    Career Technical College.....................................        <10
    Career Training Academy......................................        <10
    Career Training Center.......................................        <10
    Careercom College of Business................................        <10
    Careers Unlimited............................................        <10
    Carlow University............................................        <10
    Carnegie Career College......................................        <10
    Carnegie Institute...........................................        <10
    Carousel Beauty College......................................        <10
    Carson City Beauty Academy...................................        <10
    Case Western Reserve University..............................        <10
    Cashier Training Institute...................................        <10
    Casper College...............................................        <10
    Cayuga Community College.....................................        <10
    Cazenovia College............................................        <10
    CBM Education Center.........................................        <10
    CCIC Beauty College..........................................        <10
    CDA Technical Institute......................................        <10
    CDE Career Institute.........................................        <10
    CDI Career Development Institute.............................        <10
    Cedar Valley College.........................................        <10
    Center for Employment Training...............................        <10
    Central Alabama Community College............................        <10
    Central Carolina Technical College...........................        <10
    Central Community College....................................        <10
    Central Florida Institute....................................        <10
    Central Georgia Technical College............................        <10
    Central Michigan University..................................        <10
    Central New Mexico Community College.........................        <10
    Central Ohio Technical College...............................        <10
    Central State University.....................................        <10
    Central Texas College District...............................        <10
    Central Washington University................................        <10
    Century College..............................................        <10
    Cerritos Community College...................................        <10
    Chancellor University........................................        <10
    Chapman University...........................................        <10
    Charles A. Jones Career and Education Center.................        <10
    Charles Stewart Mott Community College.......................        <10
    Charmayne Beauty Academy.....................................        <10
    Charter College..............................................        <10
    Chase College................................................        <10
    Chattahoochee Technical College..............................        <10
    Chattanooga College--Medical, Dental and Technical Careers...        <10
    Chemeketa Community College..................................        <10
    Cheseapeake Business Inst of Virginia........................        <10
    Chester Career College.......................................        <10
    Chester College of New England...............................        <10
    Cheyney University of Pennsylvania...........................        <10
    Chicago State University.....................................        <10
    Chowan University............................................        <10
    Chris' Beauty College........................................        <10
    Christine Valmy International School forEsthetics, Skin Care         <10
     & Make-up...................................................
    Cincinnati Metropolitan College..............................        <10
    Cincinnati State Technical & Community College...............        <10
    CIT College of InfoMedical Technology........................        <10
    City College.................................................        <10
    City College of San Francisco................................        <10
    Clark Atlanta University.....................................        <10
    Clark College................................................        <10
    Clark State College..........................................        <10
    Clearwater Christian College.................................        <10
    Cleveland Chiropractic College...............................        <10
    Cleveland Clinic Educational Fndtn Schoolof Radiologic               <10
     Therapy Techlgy.............................................
    Cleveland Institute of Art (The).............................        <10
    Cleveland Institute of Technology............................        <10
    Cleveland University-Kansas City.............................        <10
    Clover Park Technical College................................        <10
    Coast Career Institute.......................................        <10
    Coastal Alabama Community College............................        <10
    Coastal Pines Technical College..............................        <10
    Cobb Beauty College..........................................        <10
    Coconino County Community College............................        <10
    Coleman University...........................................        <10
    College of Court Reporting...................................        <10
    College of Eastern Idaho.....................................        <10
    College of Health Care Professions (The).....................        <10
    College of New Rochelle (The)................................        <10
    College of Office Technology (The)...........................        <10
    College of Saint Mary........................................        <10
    College of Saint Rose........................................        <10
    College of Southern Idaho....................................        <10
    College of Southern Nevada...................................        <10
    College of Staten Island/CUNY................................        <10
    College of the Mainland......................................        <10
    CollegeAmerica--Flagstaff....................................        <10
    CollegeAmerica Denver........................................        <10
    Collin County Community College District.....................        <10
    Colorado Mesa University.....................................        <10
    Colorado State University....................................        <10
    Columbia College.............................................        <10
    Columbia College Chicago.....................................        <10
    Columbia Southern University.................................        <10
    Columbia State Community College.............................        <10
    Columbia University in the City of New York..................        <10
    Columbus College of Art & Design.............................        <10
    Columbus State Community College.............................        <10
    Commercial College of Shreveport.............................        <10
    Commercial Trades Inst.......................................        <10
    Commonwealth International University........................        <10
    Commonwealth University of Pennsylvania......................        <10
    Community College of Baltimore County........................        <10
    Community College of Philadelphia............................        <10
    Compass College of Cinematic Arts............................        <10
    Computer Learning Center.....................................        <10
    Computer Learning Center of Alexandria.......................        <10
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    Computer Learning Centers Chicago............................        <10
    Computer Learning Centers Los Angeles........................        <10
    Computer Systems Institute...................................        <10
    Concho Career Institute......................................        <10
    Concord Law School...........................................        <10
    Concorde Career Institute....................................        <10
    Concordia College Alabama....................................        <10
    Concordia University.........................................        <10
    Concordia University--Saint Paul.............................        <10
    Connelley Technical Institute & Adult Education Center.......        <10
    Consolidated School of Business..............................        <10
    Consumer Electronics Training Center.........................        <10
    Continental School of Beauty Culture.........................        <10
    Cornell College..............................................        <10
    Cornerstone University.......................................        <10
    Cortiva Institute............................................        <10
    Cortiva Institute--Seattle...................................        <10
    Cosumnes River College.......................................        <10
    County Schools Home Study....................................        <10
    Court Reporting Institute of St Louis........................        <10
    Court Reporting Institute,Inc................................        <10
    Covenant College.............................................        <10
    Coyne College................................................        <10
    Crandall Junior College......................................        <10
    Creighton University.........................................        <10
    Crescent City School of Gaming & Bartending..................        <10
    Crowder College..............................................        <10
    Crown College................................................        <10
    Cuesta College...............................................        <10
    Culinary Institute of New Orleans............................        <10
    Cumberland County College....................................        <10
    CUNY Borough of Manhattan Community College..................        <10
    CUNY Bronx Community College.................................        <10
    CUNY Brooklyn College........................................        <10
    CUNY John Jay College of Criminal Justice....................        <10
    CUNY Lehman College..........................................        <10
    CUNY Medgar Evers College....................................        <10
    Curry College................................................        <10
    Cutting Edge Hairstyling Academy.............................        <10
    Cuyahoga Community College...................................        <10
    Dakota State University......................................        <10
    Dalenas College of Beauty....................................        <10
    Dallas Baptist University....................................        <10
    Dallas College...............................................        <10
    Dallas Court Reporting College...............................        <10
    Dallas Institute of Funeral Service..........................        <10
    Dallas Theological Seminary..................................        <10
    Darton State College.........................................        <10
    Davenport University.........................................        <10
    Day Spa Career College.......................................        <10
    Dayton Barber College........................................        <10
    Daytona College..............................................        <10
    Daytona State College........................................        <10
    De Anza Community College....................................        <10
    Debbies School of Beauty Culture.............................        <10
    Decker College...............................................        <10
    Del Mar College..............................................        <10
    Delaware County Community College............................        <10
    Delaware County Institute of Training........................        <10
    Delaware State University....................................        <10
    Delta Career Institute.......................................        <10
    Delta College of Business & Technology.......................        <10
    Delta School of Business and Technology......................        <10
    Delta State University.......................................        <10
    Demarge College..............................................        <10
    Denver Technical College.....................................        <10
    DePaul University............................................        <10
    Des Moines Area Community College............................        <10
    DeSales University...........................................        <10
    Detroit Engineering Institute................................        <10
    Detroit Institute Of Commerce................................        <10
    DeVry College of Technology..................................        <10
    Diablo Valley College........................................        <10
    Diesel Truck Driver Train School.............................        <10
    Divers Academy of the Eastern Seaboard.......................        <10
    Dominican College............................................        <10
    Dominion College.............................................        <10
    Dorsey College...............................................        <10
    Douglas J Aveda Institute....................................        <10
    Dover Business College.......................................        <10
    Dowling College..............................................        <10
    DPT Business School..........................................        <10
    Drake School of Westchester..................................        <10
    Draughon Business College....................................        <10
    Draughons Business College...................................        <10
    Draughons College............................................        <10
    Dret School..................................................        <10
    Drexel University............................................        <10
    Duke University..............................................        <10
    Duluth Business University...................................        <10
    Dunwoody College of Technology...............................        <10
    Durham Beauty Academy........................................        <10
    Durham Technical Community College...........................        <10
    D'Youville University........................................        <10
    East Carolina University.....................................        <10
    East Mississippi Community College...........................        <10
    East Ohio College............................................        <10
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    Education America-Topeka Technical College...................        <10
    Edutek Professional College..................................        <10
    Edutek Professional Colleges.................................        <10
    El Camino College............................................        <10
    Eldorado College.............................................        <10
    Electronic Computer Programming Inst.........................        <10
    Elegance International.......................................        <10
    Elite College of Cosmetology.................................        <10
    Elizabethtown Community and Technical College................        <10
    Elkin's Inst in Dallas.......................................        <10
    Elmira College...............................................        <10
    Elon University..............................................        <10
    Embry-Riddle Aeronautical University.........................        <10
    Emerson College..............................................        <10
    Emory University.............................................        <10
    Empire Beauty Schools........................................        <10
    Empire State University......................................        <10
    Empire Technical School......................................        <10
    Empire Technical School of New Jersey........................        <10
    Erie Community College.......................................        <10
    ESS College Of Business......................................        <10
    Essex Community College......................................        <10
    Estrella Mountain Community College..........................        <10
    ETI Technical College of Niles...............................        <10
    Eugenio Maria De Hostos School of Law........................        <10
    Eureka Institute of Health and Beauty........................        <10
    Everglades University........................................        <10
    Evergreen State College (The)................................        <10
    Excelsior University.........................................        <10
    Expert Solutions Technical College...........................        <10
    Fairfield University.........................................        <10
    Fairleigh Dickinson University...............................        <10
    Faith International University...............................        <10
    Fashion Institute of Design & Merchandising..................        <10
    Fashion Institute of Technology..............................        <10
    FastTrain of Fort Lauderdale.................................        <10
    FastTrain of Miami...........................................        <10
    FastTrain of Tampa...........................................        <10
    Faulkner University..........................................        <10
    Federal Truck Driving School.................................        <10
    Felician University..........................................        <10
    Ferris State University......................................        <10
    Fielding Graduate University.................................        <10
    Finger Lakes School of Massage (The).........................        <10
    First School for Careers.....................................        <10
    Fisher College...............................................        <10
    Five Towns College...........................................        <10
    Flagler College..............................................        <10
    Flamingo Beauty College......................................        <10
    Florence--Darlington Technical College.......................        <10
    Florida Agricultural & Mechanical University.................        <10
    Florida Atlantic University..................................        <10
    Florida College of Careers...................................        <10
    Florida International University.............................        <10
    Florida National University..................................        <10
    Florida SouthWestern State College...........................        <10
    Florida State College at Jacksonville........................        <10
    Forrest College..............................................        <10
    Fort Hays State University...................................        <10
    Fort Scott Community College.................................        <10
    Fortis Institute.............................................        <10
    Fortis Institute--Towson.....................................        <10
    Fosbre Academy of Hair Design................................        <10
    Fountainhead College of Technology...........................        <10
    Four-D College...............................................        <10
    Fox College..................................................        <10
    Framingham State University..................................        <10
    Francis Tuttle Technology Center School District No. 21......        <10
    Franciscan Missionaries of Our Lady University...............        <10
    Franklin College.............................................        <10
    Franklin University..........................................        <10
    Fremont University...........................................        <10
    French Fashion Academy.......................................        <10
    Fresno City College..........................................        <10
    Fresno Technical College.....................................        <10
    Frontier Nursing University..................................        <10
    Frostburg State University...................................        <10
    G Skin & Beauty Institute....................................        <10
    Gaither & Company Beauty College.............................        <10
    Galaxy Medical College.......................................        <10
    Galen Health Institutes......................................        <10
    Galiano Career Academy.......................................        <10
    Gallaudet University.........................................        <10
    GateWay Community College....................................        <10
    Gateway Electronics Inst.....................................        <10
    Gateway Technical College....................................        <10
    Gene Juarez Academy..........................................        <10
    Genesee-Livingston-Steuben-Wyoming BOCES.....................        <10
    Genesis Career College.......................................        <10
    George Mason University......................................        <10
    George Washington University.................................        <10
    Georgia Beauty Academy.......................................        <10
    Georgia Gwinnett College.....................................        <10
    Georgia Military College.....................................        <10
    Georgia Perimeter College....................................        <10
    Georgia Piedmont Technical College...........................        <10
    Georgia School of Bartending.................................        <10
    Georgia Southern University..................................        <10
    Georgia State University.....................................        <10
    Germanna Community College...................................        <10
    Gibbs College................................................        <10
    Gibson's Barber & Beauty College.............................        <10
    Gino Robair Beauty College...................................        <10
    Glendale Career College......................................        <10
    Glenwood Beauty Academy......................................        <10
    Globe Institute of Technology................................        <10
    God's Bible School & College.................................        <10
    Golden State School..........................................        <10
    Goodwin University...........................................        <10
    Governors State University...................................        <10
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    Grand Rapids Community College...............................        <10
    Grand Valley State University................................        <10
    Great Lakes Techl Inst.......................................        <10
    Green River College..........................................        <10
    Greenville Technical College.................................        <10
    Gretna Career College........................................        <10
    Griffin Bellevue Business College............................        <10
    Grossmont College............................................        <10
    Guilford College.............................................        <10
    Guilford Technical Community College.........................        <10
    Gwinnett College.............................................        <10
    Gwinnett College-Sandy Springs...............................        <10
    Gwinnett Technical College...................................        <10
    Hair Design Institute at Livingston Street...................        <10
    Hallmark University..........................................        <10
    Hamilton College.............................................        <10
    Hamline University...........................................        <10
    Hannibal--LaGrange University................................        <10
    Harcum College...............................................        <10
    Hardin-Simmons University....................................        <10
    Harford Community College....................................        <10
    Hargest Vocational Technical College.........................        <10
    Harrington College of Design.................................        <10
    Harris--Stowe State University...............................        <10
    Harrisburg Area Community College............................        <10
    Harrison Career Institute....................................        <10
    Hartford Techl Inst..........................................        <10
    Hartwick College.............................................        <10
    Harvard University...........................................        <10
    Hausman Computer Associates School of Computer Programming...        <10
    Hawkeye Community College....................................        <10
    HCI College..................................................        <10
    Heald Business College.......................................        <10
    Heald College, School of Business............................        <10
    Heald Institute of Technology................................        <10
    Healthy Hair Academy.........................................        <10
    Helene Fuld College of Nursing...............................        <10
    Helms Career Institute.......................................        <10
    Hennepin Technical College...................................        <10
    Henry Ford College...........................................        <10
    Heritage Institute...........................................        <10
    Herkimer County Community College--SUNY Office of Community          <10
     Colleges....................................................
    Herzing University...........................................        <10
    Hill College.................................................        <10
    Hillsborough Community College...............................        <10
    Hinds Community College......................................        <10
    Hofstra University...........................................        <10
    Hollywood Beauty College.....................................        <10
    Hollywood Institute of Beauty Careers........................        <10
    Holyoke Community College....................................        <10
    Hondros College of Nursing...................................        <10
    Honolulu Community College...................................        <10
    Hope International University................................        <10
    Horry--Georgetown Technical College..........................        <10
    Houston Christian University.................................        <10
    Houston Community College....................................        <10
    Houston Training Schools.....................................        <10
    Howard University............................................        <10
    Humphreys University.........................................        <10
    Hunter Business School.......................................        <10
    Hutchinson Community College.................................        <10
    Hypnosis Motivation Institute................................        <10
    IBMC College.................................................        <10
    Idaho State University.......................................        <10
    Idea Career Training.........................................        <10
    Illinois CareerPath Institute................................        <10
    Illinois School of Commerce..................................        <10
    Illinois School of Health Careers............................        <10
    Illinois State University....................................        <10
    Illinois Wesleyan University.................................        <10
    Indian Hills Community College...............................        <10
    Indian River State College...................................        <10
    Indiana Institute of Technology..............................        <10
    Indiana University--Bloomington..............................        <10
    Indiana University--Kokomo...................................        <10
    Indiana University--Northwest................................        <10
    Indiana University--Purdue University Indianapolis...........        <10
    Indiana Wesleyan University..................................        <10
    Institute for Business & Technology..........................        <10
    Institute for Health Education (The).........................        <10
    Institute For Therapeutic Massage............................        <10
    Institute of Allied Medical Professions......................        <10
    Institute of Business & Technology...........................        <10
    Institute of Culinary Education..............................        <10
    Institute of Medical Education...............................        <10
    Institute of Production and Recording (The)..................        <10
    Institute of Technical Arts..................................        <10
    Institute of Technology......................................        <10
    IntelliTec College...........................................        <10
    Inter American University of Puerto Rico--San German Campus..        <10
    Interactive College of Technology............................        <10
    Interboro Institute..........................................        <10
    InterCoast Colleges..........................................        <10
    Interdenominational Theological Center.......................        <10
    Interface College............................................        <10
    International Academy of Design and Technology...............        <10
    International Aviation & Travel Academy......................        <10
    International Beauty School..................................        <10
    International Business College...............................        <10
    International Business College-..............................        <10
    International Culinary Center................................        <10
    International Dealers School.................................        <10
    International Renowned Beauty Academy........................        <10
    International School of Health, Beauty & Technology..........        <10
    International Technical Institute............................        <10
    International Training.......................................        <10
    International Training Center (Closed).......................        <10
    Interstate Techl Inst........................................        <10
    Iowa Central Community College...............................        <10
    Iowa State University of Science & Technology................        <10
    Itawamba Community College...................................        <10
    Iverson Institute............................................        <10
    Ivy Tech Community College of Indiana........................        <10
    Ivy Tech Community College of Indiana--Region 4..............        <10
    Ivy Tech Community College of Indiana--Region 5..............        <10
    Ivy Tech Community College of Indiana--Region 7..............        <10
    Ivy Tech Community College of Indiana--Region 3..............        <10
    J Sargeant Reynolds Community College........................        <10
    Jackson State Community College..............................        <10
    Jackson State University.....................................        <10
    Jacksonville Business and Careers Institute..................        <10
    Jacksonville University......................................        <10
    James Albert School of Cosmetology...........................        <10
    James Madison University.....................................        <10
    Jamestown Community College..................................        <10
    Jarvis Christian University..................................        <10
    Jay Truck Driving Training Center............................        <10
    Jay's Technical Institute....................................        <10
    Jefferson Business College (Closed)..........................        <10
    Jefferson College............................................        <10
    Jefferson Community and Technical College....................        <10
    Jett College of Cosmetology..................................        <10
    John Amico School of Hair Design.............................        <10
    John Carroll University......................................        <10
    John F. Kennedy University...................................        <10
    John Hopkins University......................................        <10
    Johns Hopkins University.....................................        <10
    Johnson C. Smith University..................................        <10
    Johnson County Community College.............................        <10
    Jolie Health and Beauty Academy..............................        <10
    Joliet Junior College........................................        <10
    Jon Louis School of Beauty...................................        <10
    Jones International University...............................        <10
    Kankakee Academy Of Hair Design..............................        <10
    Kansas City Business College.................................        <10
    Kansas City Kansas Community College.........................        <10
    Kasturba Medical College.....................................        <10
    Katherine Gibbs School.......................................        <10
    Kean University..............................................        <10
    Keene Beauty Academy.........................................        <10
    Kelsey--Jenney College.......................................        <10
    Kemper Military School and College...........................        <10
    Kennesaw State University....................................        <10
    Kenneth Shuler School of Cosmetology & Hair Design...........        <10
    Kenny's Academy of Barbering.................................        <10
    Kent State University........................................        <10
    Keuka College................................................        <10
    Keystone Technical Institute.................................        <10
    Kilgore College..............................................        <10
    King University..............................................        <10
    Kings College................................................        <10
    King's College...............................................        <10
    Kingsborough Community College/CUNY..........................        <10
    Knoxville Institute of Hair Design...........................        <10
    Krissler Business Institute..................................        <10
    L T International Beauty School..............................        <10
    LA College International.....................................        <10
    La' James International College..............................        <10
    La' James International College--Des Moines..................        <10
    La Jean's Beauty & Etiquette College.........................        <10
    Lab Paul Mitchell Partner School (The).......................        <10
    Labour College of Healthcare.................................        <10
    L'Academie de Cuisine........................................        <10
    Lackawanna College...........................................        <10
    Lacy Cosmetology School......................................        <10
    Lakes Region Community College...............................        <10
    Lakeside School of Massage Therapy...........................        <10
    Lamar University.............................................        <10
    Lambuth University...........................................        <10
    Lamson College...............................................        <10
    Lander University............................................        <10
    Lane College.................................................        <10
    Lane Community College.......................................        <10
    Langston University..........................................        <10
    Lansing Community College....................................        <10
    Laramie County Community College.............................        <10
    Latin Beauty Academy.........................................        <10
    Lawrence Technological University............................        <10
    Lawton School for Medical and Dental Assistants..............        <10
    Lehigh University............................................        <10
    Lehigh Valley College........................................        <10
    Lenoir-Rhyne University......................................        <10
    Lesley University............................................        <10
    LeTourneau University........................................        <10
    Levittown Beauty Academy.....................................        <10
    Life University..............................................        <10
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    LIM College..................................................        <10
    Limestone University.........................................        <10
    Lincoln College of New England...............................        <10
    Lincoln Technical Institute--Hartford........................        <10
    Lipscomb University..........................................        <10
    Livingstone College..........................................        <10
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    Lone Star College System.....................................        <10
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    Long Island Beauty School....................................        <10
    Long Island University.......................................        <10
    Long Technical College.......................................        <10
    Lorain County Community College..............................        <10
    Los Angeles Business College.................................        <10
    Los Angeles City College.....................................        <10
    Los Angeles Community College District Office................        <10
    Los Angeles Film School (The)................................        <10
    Los Angeles Mission College..................................        <10
    Los Angeles Pacific College..................................        <10
    Los Angeles Pierce College...................................        <10
    Los Angeles Trade-Technical College..........................        <10
    Los Angeles Valley College...................................        <10
    Louisiana Delta Community College............................        <10
    Louisiana State University at Eunice.........................        <10
    Louisiana Technical College--Morgan Smith Campus.............        <10
    Loyola University Chicago....................................        <10
    Loyola University New Orleans................................        <10
    Lu Ross Academy..............................................        <10
    Luzerne County Community College.............................        <10
    Macomb Community College.....................................        <10
    Madison Area Technical College...............................        <10
    Madison Media Institute......................................        <10
    Madison Schools..............................................        <10
    Madisonville Community College...............................        <10
    Manchester Community College.................................        <10
    Mandl School.................................................        <10
    Manhattan Beauty School......................................        <10
    Manhattan School of Music....................................        <10
    Manor College................................................        <10
    Mansfield Business College...................................        <10
    Marian Health Careers Center.................................        <10
    Maric College................................................        <10
    Marinello Schools of Beauty..................................        <10
    MarJon School of Beauty......................................        <10
    Martinsburg College..........................................        <10
    Mary Holmes College..........................................        <10
    Marycrest College............................................        <10
    Marygrove College............................................        <10
    Maryland University of Integrative Health....................        <10
    Marylhurst University........................................        <10
    Marymount Manhattan College..................................        <10
    Marywood University..........................................        <10
    Mason Anthony School of Cosmetology Arts & Sciences..........        <10
    Massage Therapy Institute of Colorado........................        <10
    Massasoit Community College..................................        <10
    Massey Business College......................................        <10
    Masters Institute............................................        <10
    Masters of Cosmetology College...............................        <10
    Mattia College...............................................        <10
    Maurice Charles Academy of Hair Styling......................        <10
    Mayville State University....................................        <10
    MCI Institute of Technology..................................        <10
    McIntosh College.............................................        <10
    McKendree University.........................................        <10
    McLennan Community College...................................        <10
    McNally Smith College of Music...............................        <10
    McNeese State University.....................................        <10
    MCPHS University.............................................        <10
    MDT College of Health Sciences...............................        <10
    Mech Tech College............................................        <10
    Med Help Training School.....................................        <10
    MediaTech Institute..........................................        <10
    Medical Career College.......................................        <10
    Medical Institute of Palm Beach..............................        <10
    Medical University of the Americas...........................        <10
    Memphis Institute of Barbering...............................        <10
    Menlo College................................................        <10
    Mercer University............................................        <10
    Mercy University.............................................        <10
    Meridian Institute of Surgical Assisting.....................        <10
    Merit College................................................        <10
    Merrillville Beauty College..................................        <10
    Mesa Community College.......................................        <10
    Mesabi Range College.........................................        <10
    Methodist University.........................................        <10
    Metro Business College.......................................        <10
    Metropolitan College.........................................        <10
    Metropolitan College of New York.............................        <10
    Metropolitan Community College...............................        <10
    Metropolitan Learning Institute..............................        <10
    Metropolitan State University of Denver......................        <10
    Miami--Jacobs Career College.................................        <10
    Miami Dade College...........................................        <10
    Miami Media School...........................................        <10
    Miami Regional University....................................        <10
    Miami Technical Institute....................................        <10
    Miami University.............................................        <10
    MIAT College of Technology...................................        <10
    Michigan Computer Institute..................................        <10
    Michigan State University....................................        <10
    Michigan Technological University............................        <10
    Micropower Career Institute..................................        <10
    Mid-America Christian University.............................        <10
    MidAmerica Nazarene University...............................        <10
    Mid-Continent University.....................................        <10
    Middle Georgia State University..............................        <10
    Middle Tennessee State University............................        <10
    Middlesex College............................................        <10
    Middlesex Community College..................................        <10
    Middlesex University.........................................        <10
    Midland Career Institute.....................................        <10
    Midland College..............................................        <10
    Midlands Technical College...................................        <10
    Midwest Technical Institute..................................        <10
    Midwestern State University..................................        <10
    Midwestern University........................................        <10
    Milan Institute..............................................        <10
    Milan Institute of Cosmetology...............................        <10
    Miles College................................................        <10
    Miles Community College......................................        <10
    Miller--Motte Technical College..............................        <10
    Miller-Motte College.........................................        <10
    Millersville University of Pennsylvania......................        <10
    Milwaukee Area Technical College.............................        <10
    Mineral Area College.........................................        <10
    Minneapolis Business College.................................        <10
    Minneapolis Community and Technical College..................        <10
    Minnesota State University Moorhead..........................        <10
    Minnesota State University, Mankato..........................        <10
    Mississippi College..........................................        <10
    Mississippi Gulf Coast Community College.....................        <10
    Mississippi State University.................................        <10
    Mississippi Valley State University..........................        <10
    Missouri Baptist University..................................        <10
    Missouri College.............................................        <10
    Missouri School of Barbering & Hairstyling...................        <10
    Missouri Valley College......................................        <10
    Missouri Vocational Center...................................        <10
    Missouri Western State University............................        <10
    Mitchell Technical College...................................        <10
    Mohawk Valley Community College--SUNY Office of Community            <10
     Colleges....................................................
    Moler Beauty College.........................................        <10
    Molloy University............................................        <10
    Monmouth University..........................................        <10
    Monroe College...............................................        <10
    Monroe Community College.....................................        <10
    Montana State University--Billings...........................        <10
    Montclair State University...................................        <10
    Montefiore School of Nursing.................................        <10
    Montgomery College...........................................        <10
    Morehouse College............................................        <10
    Morgan State University......................................        <10
    Morris Brown College.........................................        <10
    Morris College...............................................        <10
    Mount Ida College............................................        <10
    Mount Washington College.....................................        <10
    Mountain State University....................................        <10
    Mountain States Technical Institute..........................        <10
    Mt. Hood Community College...................................        <10
    Mt. Sierra College...........................................        <10
    MTA School, Resident School..................................        <10
    MTI Business College.........................................        <10
    MTI College..................................................        <10
    MTI College of Business and Technology.......................        <10
    Muir Technical College.......................................        <10
    Municipal Training Center....................................        <10
    Murray State College.........................................        <10
    Murray State University......................................        <10
    MyComputerCareer at Indianapolis.............................        <10
    MyComputerCareer at Raleigh..................................        <10
    MyrAngel Beauty Institute....................................        <10
    Nairobi College..............................................        <10
    Nashua Community College.....................................        <10
    Nashville Auto-Diesel College................................        <10
    Nashville Career School......................................        <10
    Nashville College of Medical Careers.........................        <10
    Nashville State Community College............................        <10
    Nassau Community College.....................................        <10
    Nassau Technological Center..................................        <10
    Nasson Institute.............................................        <10
    National Academy For Paralegal Studies.......................        <10
    National Academy of Beauty Arts..............................        <10
    National American University.................................        <10
    National Broadcasting School.................................        <10
    National College.............................................        <10
    National Education Center Bryman Campus......................        <10
    National Education Center Kee Business College Campus........        <10
    National Education Center National Institute of Tech Campus..        <10
    National Education Center National Institute of Technology           <10
     Campus......................................................
    National Education Center Temple School Campus...............        <10
    National Education Center, Bryman Campus.....................        <10
    National Education Center-Bauder College Campus..............        <10
    National Graduate School of Quality Management (The).........        <10
    National Holistic Institute..................................        <10
    National Louis University....................................        <10
    National Park College........................................        <10
    National Polytechnic College.................................        <10
    National School of Health Technology.........................        <10
    National Training............................................        <10
    National Training Systems--Correspondence School.............        <10
    National University..........................................        <10
    National University College-IBC Institute....................        <10
    National University of Health Sciences (The).................        <10
    Naugatuck Valley Community College...........................        <10
    Navarro College..............................................        <10
    Neumont College of Computer Science..........................        <10
    New College of California....................................        <10
    New England College..........................................        <10
    New England College of Business and Finance..................        <10
    New England Institute of Technology..........................        <10
    New England School of Acupuncture............................        <10
    New Jersey City University...................................        <10
    New Life Business Institute..................................        <10
    New Mexico State University..................................        <10
    New School, The..............................................        <10
    New York Career Institute....................................        <10
    New York College of Health Professions.......................        <10
    New York Institute of Massage................................        <10
    New York Institute of Technology.............................        <10
    New York Medical Career Training Center......................        <10
    New York School Of Dog Grooming..............................        <10
    New York University..........................................        <10
    Newberry Schools of Beauty...................................        <10
    Newbridge College............................................        <10
    NHTI--Concord's Community College............................        <10
    Nichols College..............................................        <10
    Norfolk State University.....................................        <10
    North American Trade Schools.................................        <10
    North Carolina Agricultural and Technical State University...        <10
    North Carolina Central University............................        <10
    North Carolina Wesleyan University...........................        <10
    North Central College........................................        <10
    North Central Missouri College...............................        <10
    North Hennepin Community College.............................        <10
    North Iowa Area Community College............................        <10
    North Park University........................................        <10
    Northampton County Area Community College....................        <10
    Northcentral Technical College...............................        <10
    Northcentral University......................................        <10
    Northcoast Medical Training Academy..........................        <10
    Northeast Institute..........................................        <10
    Northeast Iowa Community College.............................        <10
    Northeast Texas Community College............................        <10
    Northeastern Technical College...............................        <10
    Northern Illinois University.................................        <10
    Northern Oklahoma College....................................        <10
    Northern Virginia Community College..........................        <10
    Northwest--Shoals Community College..........................        <10
    NorthWest Arkansas Community College.........................        <10
    North-West College...........................................        <10
    Northwest Hair Academy.......................................        <10
    Northwest Missouri State University..........................        <10
    Northwest Schools............................................        <10
    Northwestern College.........................................        <10
    Northwestern Institute of Health and Technology..............        <10
    Northwestern State University................................        <10
    Northwestern University......................................        <10
    Northwood University.........................................        <10
    Norwich University...........................................        <10
    Notre Dame of Maryland University............................        <10
    Nova Institute of Health Technology..........................        <10
    Nova Southeastern University.................................        <10
    NTMA Training Centers of Southern California.................        <10
    NUC University...............................................        <10
    O/E Learning Center..........................................        <10
    Oakland Community College....................................        <10
    Oakland University...........................................        <10
    Oakwood University...........................................        <10
    Odessa College...............................................        <10
    Ohio Christian University....................................        <10
    Ohio College of Podiatric Medicine...........................        <10
    Ohio Dominican University....................................        <10
    Ohio Media School............................................        <10
    Ohio State University (The)..................................        <10
    Ohio University..............................................        <10
    Oklahoma City Community College..............................        <10
    Old Dominion University......................................        <10
    Olympian Academy of Cosmetology..............................        <10
    Olympic College..............................................        <10
    Omnitech Institute...........................................        <10
    Onondaga Community College...................................        <10
    Onondaga Cortland Madison BOCES..............................        <10
    Orange Coast College.........................................        <10
    Orange County Business College...............................        <10
    Orangeburg--Calhoun Technical College........................        <10
    Oregon Polytechnic Institute.................................        <10
    Orion College................................................        <10
    Orion Technical College......................................        <10
    Our Lady of The Lake University..............................        <10
    Owens Community College......................................        <10
    Ozarks Technical Community College...........................        <10
    PACE UNIV ALL CAMPUSES.......................................        <10
    Pace University..............................................        <10
    Pacific Coast College........................................        <10
    Pacific College of Health and Science........................        <10
    Pacific Oaks College.........................................        <10
    Pacific Travel Trade School..................................        <10
    Paine College................................................        <10
    Palm Beach State College.....................................        <10
    Palomar College..............................................        <10
    Paris Junior College.........................................        <10
    Park Avenue School of Cosmetology............................        <10
    Park University..............................................        <10
    Park West Barber School......................................        <10
    Parkland College.............................................        <10
    Pasadena City College........................................        <10
    Pasco--Hernando State College................................        <10
    Passaic County Community College.............................        <10
    Pat Goins Benton Road Beauty School..........................        <10
    Patsy And Rob's Academy of Beauty............................        <10
    Paul Mitchell the School--Little Rock........................        <10
    Paul Mitchell the School--Louisville.........................        <10
    Paul Mitchell The School Costa Mesa..........................        <10
    Paul Mitchell the School Green Bay...........................        <10
    Paul Mitchell the School Roanoke.............................        <10
    Paul Mitchell The School Tinley Park.........................        <10
    PCCenter.....................................................        <10
    PCI Health Training Center...................................        <10
    Pearl River Community College................................        <10
    Pellissippi State Community College..........................        <10
    Pennco Tech..................................................        <10
    Pennsylvania College of Technology...........................        <10
    Pennsylvania Highlands Community College.....................        <10
    Pennsylvania School Of Business..............................        <10
    Pennsylvania State University (The)..........................        <10
    Pensacola School of Massage Therapy & Health Careers.........        <10
    Pensacola State College......................................        <10
    Pepperdine University........................................        <10
    Phillips Business School.....................................        <10
    Phillips College of Chicago..................................        <10
    Phillips Colleges............................................        <10
    Phillips Junior College......................................        <10
    Phillips Junior College At Birmingham........................        <10
    Phoenix Educational Systems of Pensacola.....................        <10
    Piedmont Technical College...................................        <10
    Piedmont University..........................................        <10
    Pierce College...............................................        <10
    Pierpont Community & Technical College.......................        <10
    Pikes Peak State College.....................................        <10
    Pima County Community College................................        <10
    Pima Medical Institute.......................................        <10
    Pinchot University...........................................        <10
    Pinellas Technical College--Clearwater Campus................        <10
    Pinnacle College.............................................        <10
    Pitt Community College.......................................        <10
    Pittsburgh Career Institute..................................        <10
    Pittsburgh Technical College.................................        <10
    Pivot Point Academy..........................................        <10
    Platt College................................................        <10
    Platt College--San Diego.....................................        <10
    Plaza Beauty School..........................................        <10
    Plaza College................................................        <10
    Plaza Three Academy..........................................        <10
    Point Park University........................................        <10
    Point University.............................................        <10
    Polytechnic Institute........................................        <10
    Pontiac Business Institute...................................        <10
    Porter and Chester Institute.................................        <10
    Porterville College..........................................        <10
    Portland Community College...................................        <10
    Post University..............................................        <10
    Poteau Beauty College........................................        <10
    Prairie View Agricultural & Mechanical University............        <10
    Praxis Institute.............................................        <10
    Presbyterian College.........................................        <10
    Prince George's Community College............................        <10
    Printing Trades School.......................................        <10
    Prism Career Institute.......................................        <10
    Pro Career Center............................................        <10
    Professional Business School.................................        <10
    Professional Career Centers..................................        <10
    Professional Career College..................................        <10
    Professional Careers Institute...............................        <10
    Professional Skills Institute................................        <10
    Prospect Hall School of Business.............................        <10
    PSI Institute................................................        <10
    PSI Institute of Washington..................................        <10
    PTC Career Institue of Washington............................        <10
    PTC Career Institute.........................................        <10
    Pulse Beauty Academy.........................................        <10
    Purdue University............................................        <10
    Purdue University Northwest..................................        <10
    Quincy College...............................................        <10
    Quinebaug Valley Community College...........................        <10
    Quinnipiac University........................................        <10
    Radians College..............................................        <10
    Rancho Arroyo Vocational Technical Institute.................        <10
    Rasmussen College............................................        <10
    Rasmussen University.........................................        <10
    Real Barbers College (The)...................................        <10
    Refrigeration School (The)...................................        <10
    Regency Beauty Institute--Cleveland..........................        <10
    Regent University............................................        <10
    Regina's College of Beauty...................................        <10
    Regis University.............................................        <10
    Remington College--Cleveland Campus..........................        <10
    Remington College--Mobile Campus.............................        <10
    Remington College--New Orleans Campus........................        <10
    Remington College--Tampa Campus..............................        <10
    Reno Junior College of Business..............................        <10
    Revell Training Center.......................................        <10
    Richard Bland College........................................        <10
    Richard J Daley College-City Colleges of Chicago.............        <10
    Ridgewater College...........................................        <10
    Ridley-Lowell Business & Technical Institute.................        <10
    Ridley-Lowell School of Business.............................        <10
    Robert Fiance Hair Design Inst...............................        <10
    Robert Fiance Institute of Florida...........................        <10
    Robert Morris College........................................        <10
    Robert Morris University.....................................        <10
    Robert Morris University Illinois............................        <10
    Roberts Walsh Business School................................        <10
    Rochester Community and Technical College....................        <10
    Rocky Mountain College of Art + Design.......................        <10
    Roger Williams University....................................        <10
    Rogers State University......................................        <10
    Rollins College..............................................        <10
    Roosevelt University.........................................        <10
    Rosedale Technical College...................................        <10
    Ross Medical Education Center................................        <10
    Rosston College..............................................        <10
    Roswell College of Cosmetology...............................        <10
    Rowan University.............................................        <10
    Roxbury Community College....................................        <10
    Roy Jorgensen Associates Truck Driving School................        <10
    Royal Beauty Careers.........................................        <10
    Royale College of Beauty and Barbering.......................        <10
    RTP Hispanic American College................................        <10
    Rutgers, the State University of New Jersey..................        <10
    SABER College................................................        <10
    Saddleback College...........................................        <10
    SAE Expression College.......................................        <10
    SAE Institute of Technology, Los Angeles.....................        <10
    SAE Institute of Technology, New York........................        <10
    Saginaw Valley State University..............................        <10
    Saint Ambrose University.....................................        <10
    Saint Augustine's University.................................        <10
    Saint Elizabeth University...................................        <10
    Saint Francis College........................................        <10
    Saint Gregory's University...................................        <10
    Saint John's University......................................        <10
    Saint Joseph's College.......................................        <10
    Saint Joseph's University....................................        <10
    Saint Leo University.........................................        <10
    Saint Louis Community College................................        <10
    Saint Paul College--A Community & Technical College..........        <10
    Saint Peter's University.....................................        <10
    Saint Thomas University......................................        <10
    Saint Vincent College & Seminary.............................        <10
    Saint Xavier University......................................        <10
    Salem State University.......................................        <10
    Salem University.............................................        <10
    Salon Academy (The)..........................................        <10
    Salon Professional Academy (The).............................        <10
    Salt Lake Community College..................................        <10
    Sam Houston State University.................................        <10
    Samford University...........................................        <10
    San Antonio College..........................................        <10
    San Bernardino Beauty College................................        <10
    San Bernardino Valley College................................        <10
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    San Diego Miramar College....................................        <10
    San Diego State University...................................        <10
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    San Joaquin Valley College...................................        <10
    Santa Ana College............................................        <10
    Santa Barbara Business College...............................        <10
    Santa Barbara City College...................................        <10
    Santa Fe College.............................................        <10
    Santa Fe University of Art and Design........................        <10
    Sanz Secretarial School......................................        <10
    Sarasota School of Massage Therapy...........................        <10
    Savannah College of Art and Design...........................        <10
    Savannah River College.......................................        <10
    Savannah State University....................................        <10
    Savannah Technical College...................................        <10
    Sawyer College at Ponoma.....................................        <10
    Sawyer School................................................        <10
    Sawyer School (The)..........................................        <10
    Sawyer School of Business....................................        <10
    Saybrook University..........................................        <10
    SBI Campus--an affiliate of Sanford-Brown....................        <10
    Schenectady County Community College.........................        <10
    School of Communication Arts of North Carolina...............        <10
    School of Visual Arts........................................        <10
    Schreiner University.........................................        <10
    Scioto County Career Technical Center........................        <10
    SCS Business and Technical Institute.........................        <10
    Seattle Pacific University...................................        <10
    Seminole State College of Florida............................        <10
    Seton Hall University........................................        <10
    Shear Finesse Beauty Academy.................................        <10
    Shepherd University..........................................        <10
    Sierra Valley College of Court Reporting.....................        <10
    Simdex Techl Inst............................................        <10
    Simmons University...........................................        <10
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    Skagit Valley College........................................        <10
    Skelly Beauty Admy...........................................        <10
    Skyline College..............................................        <10
    Skyline College--Richmond....................................        <10
    Smith Chason College.........................................        <10
    Sojourner-Douglass College...................................        <10
    Somerset Community College...................................        <10
    South Bay Trade School.......................................        <10
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    Southeastern Academy.........................................        <10
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    Southern Career Institute....................................        <10
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    Southern Illinois University Edwardsville....................        <10
    Southern Institute of Cosmetology............................        <10
    Southern New Jersey Technical School.........................        <10
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     Baton Rouge.................................................
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    Southern West Virginia Community and Technical College.......        <10
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    Southwest Institute of Healing Arts..........................        <10
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    Southwest University at El Paso..............................        <10
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    Southwestern College of Business.............................        <10
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    Specs Howard School of Media Arts............................        <10
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    Spoon River College..........................................        <10
    Spring Arbor University......................................        <10
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    St. Catharine College........................................        <10
    St. Joseph's University New York.............................        <10
    St. Louis College of Health Careers..........................        <10
    St. Mary's University........................................        <10
    St. Paul's School of Nursing.................................        <10
    St. Petersburg College.......................................        <10
    Stage One The Hair School....................................        <10
    Stanbridge University........................................        <10
    Stanly Community College.....................................        <10
    Star Technical Institute.....................................        <10
    Stark State College..........................................        <10
    State University of New York at Albany.......................        <10
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    State University of New York at Farmingdale..................        <10
    State University of New York at New Paltz....................        <10
    State University of New York at Oswego (SUNY Oswego).........        <10
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    Stautzenberger College.......................................        <10
    Stenotype Institute of Jacksonville..........................        <10
    Stenotype Institute of Springfield...........................        <10
    Stephen F Austin State University............................        <10
    Stevens Henager College All Campuses.........................        <10
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    Stone Academy................................................        <10
    Stratford School.............................................        <10
    Stratford University.........................................        <10
    Suburban Technical School....................................        <10
    Suffolk County Community College.............................        <10
    Sullivan and Cogliano Training Centers.......................        <10
    Sullivan College of Technology and Design....................        <10
    Sullivan University..........................................        <10
    SUM Bible College & Theological Seminary.....................        <10
    Summit Academy Opportunities Industrialization Center........        <10
    Summit Beauty School.........................................        <10
    Summit College...............................................        <10
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    SUNY College at Geneseo......................................        <10
    SUNY College of Agriculture & Technology at Morrisville......        <10
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    Talladega College............................................        <10
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    Tarleton State University....................................        <10
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    Taylor Business Institute....................................        <10
    TDDS Technical Institute.....................................        <10
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    Texas A&M University--Kingsville.............................        <10
    Texas Barber College.........................................        <10
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    Tidewater Community College..................................        <10
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    TIGI Hairdressing Academy Legacy.............................        <10
    Tompkins Cortland Community College..........................        <10
    TONI&GUY Hairdressing Academy................................        <10
    Touro University.............................................        <10
    Trainco Bus School...........................................        <10
    Transwestern Inst............................................        <10
    Treasure Valley Community College............................        <10
    Trebas Institute of Rec Arts.................................        <10
    Trend Beauty College.........................................        <10
    Trend Benders Academy........................................        <10
    Trend College................................................        <10
    Triangle Tech................................................        <10
    Tribeca Flashpoint College...................................        <10
    Tricoci University of Beauty Culture.........................        <10
    Tri-County Technical College.................................        <10
    Trident Technical College....................................        <10
    Trident University International.............................        <10
    Trinity International University.............................        <10
    Tri-State College of Acupuncture.............................        <10
    Tri-State Institute of Hair Design...........................        <10
    Tri-State Semi Driver Training...............................        <10
    Troy University..............................................        <10
    Truckee Meadows Community College............................        <10
    Tucson College...............................................        <10
    Tufts University.............................................        <10
    Tulsa Community College......................................        <10
    Tulsa Welding School.........................................        <10
    Tunxis Community College.....................................        <10
    Tuskegee University..........................................        <10
    Twin City Beauty College.....................................        <10
    Tyler Junior College.........................................        <10
    UEI (United Education Institute).............................        <10
    UEI College..................................................        <10
    Ultissma Beauty Institute (CLOSED)...........................        <10
    Unified Schools of America-Compton Campus....................        <10
    Union Adventist University...................................        <10
    Union Institute & University.................................        <10
    Unitech Training Academy.....................................        <10
    United Career Center.........................................        <10
    United College...............................................        <10
    United College of Business...................................        <10
    United Schools...............................................        <10
    United States International Univ.............................        <10
    Unitek College...............................................        <10
    Universal Career School......................................        <10
    Universidad Ana G. M ndez--Gurabo Campus.....................        <10
    Universidad Ana G. Mendez--Cupey Campus......................        <10
    Universidad Ana G. Mendez--Gurabo Campus.....................        <10
    Universidad del Sagrado Corazon..............................        <10
    University of Advancing Computer Technology..................        <10
    University of Akron (The)....................................        <10
    University of Alabama at Birmingham..........................        <10
    University of Arizona (The)..................................        <10
    University of Arkansas.......................................        <10
    University of Arkansas--Grantham.............................        <10
    University of Arkansas--Pulaski Technical College............        <10
    University of Arkansas at Fort Smith.........................        <10
    University of Arkansas at Monticello.........................        <10
    University of Arkansas for Medical Sciences..................        <10
    University of Bridgeport.....................................        <10
    University of California, Berkeley...........................        <10
    University of California, Irvine.............................        <10
    University of California, Los Angeles........................        <10
    University of California, Riverside..........................        <10
    University of California, San Diego..........................        <10
    University of Central Arkansas...............................        <10
    University of Central Florida................................        <10
    University of Central Missouri...............................        <10
    University of Central Oklahoma...............................        <10
    University of Cincinnati.....................................        <10
    University of Colorado Colorado Springs......................        <10
    University of Colorado Denver................................        <10
    University of Connecticut....................................        <10
    University of Dayton.........................................        <10
    University of Denver.........................................        <10
    University of Detroit Mercy..................................        <10
    University of Florida........................................        <10
    University of Glasgow........................................        <10
    University of Hartford.......................................        <10
    University of Hawaii at Manoa................................        <10
    University of Health Sciences and Pharmacy in St. Louis......        <10
    University of Houston........................................        <10
    University of Houston--Clear Lake............................        <10
    University of Houston--Downtown..............................        <10
    University of Illinois Chicago...............................        <10
    University of Illinois Urbana-Champaign......................        <10
    University of Indianapolis...................................        <10
    University of Iowa...........................................        <10
    University of Kentucky.......................................        <10
    University of La Verne.......................................        <10
    University of Louisiana at Lafayette.........................        <10
    University of Louisiana at Monroe............................        <10
    University of Louisville.....................................        <10
    University of Lynchburg......................................        <10
    University of Maine..........................................        <10
    University of Maine--Farmington..............................        <10
    University of Management and Technology (The)................        <10
    University of Mary Hardin-Baylor.............................        <10
    University of Maryland--Baltimore County.....................        <10
    University of Maryland--Eastern Shore........................        <10
    University of Maryland Global Campus.........................        <10
    University of Maryland, Baltimore............................        <10
    University of Massachusetts--Dartmouth.......................        <10
    University of Massachusetts--Lowell..........................        <10
    University of Massachusetts at Boston........................        <10
    University of Medicine & Dentistry of New Jersey.............        <10
    University of Memphis (The)..................................        <10
    University of Miami..........................................        <10
    University of Michigan.......................................        <10
    University of Michigan--Dearborn.............................        <10
    University of Minnesota--Crookston...........................        <10
    University of Minnesota Duluth...............................        <10
    University of Minnesota--Twin Cities.........................        <10
    University of Mississippi....................................        <10
    University of Missouri--Columbia.............................        <10
    University of Missouri--Kansas City..........................        <10
    University of Missouri--Saint Louis..........................        <10
    University of Mobile.........................................        <10
    University of Montevallo.....................................        <10
    University of Nevada , Reno..................................        <10
    University of New Haven......................................        <10
    University of North Alabama..................................        <10
    University of North Carolina--Charlotte......................        <10
    University of North Florida..................................        <10
    University of North Georgia..................................        <10
    University of North Texas....................................        <10
    University of Northwestern Ohio..............................        <10
    University of Oregon.........................................        <10
    University of Oxford--St Catherine's College.................        <10
    University of Portland.......................................        <10
    University of Rio Grande.....................................        <10
    University of Sarasota.......................................        <10
    University of Scranton.......................................        <10
    University of Silicon Valley.................................        <10
    University of South Alabama..................................        <10
    University of South Carolina--Columbia.......................        <10
    University of South Carolina Upstate.........................        <10
    University of South Dakota...................................        <10
    University of South Florida..................................        <10
    University of Southern California............................        <10
    University of Southern Maine.................................        <10
    University of Southern Mississippi...........................        <10
    University of Southernmost Florida...........................        <10
    University of St. Augustine for Health Sciences..............        <10
    University of Sydney.........................................        <10
    University of Tampa (The)....................................        <10
    University of Tennessee......................................        <10
    University of Tennessee--Martin..............................        <10
    University of Texas at Arlington.............................        <10
    University of Texas at Austin................................        <10
    University of Texas at Tyler.................................        <10
    University of Texas Rio Grande Valley........................        <10
    University of the Cumberlands................................        <10
    University of the District of Columbia.......................        <10
    University of the Incarnate Word.............................        <10
    University of the Pacific....................................        <10
    University of the Rockies....................................        <10
    University of the Virgin Islands.............................        <10
    University of Toledo.........................................        <10
    University of Utah...........................................        <10
    University of Virginia.......................................        <10
    University of Washington--Seattle............................        <10
    University of West Florida (The).............................        <10
    University of West Georgia...................................        <10
    University of Wisconsin--Milwaukee...........................        <10
    University of Wisconsin--River Falls.........................        <10
    University of Wisconsin--Stout...............................        <10
    University of Wisconsin--Whitewater..........................        <10
    University of Wisconsin Colleges.............................        <10
    University of Wyoming........................................        <10
    Unknown-School-Name..........................................        <10
    Urbana University............................................        <10
    USA Training Academy Home Study..............................        <10
    Utica School of Commerce.....................................        <10
    Utica University.............................................        <10
    Valdosta State University....................................        <10
    Valencia College.............................................        <10
    Valley Commercial College....................................        <10
    Valor Christian College......................................        <10
    Vanderbilt University........................................        <10
    Vantage College--San Antonio.................................        <10
    VEEB Nassau County School of Practical Nursing...............        <10
    Velvatex College of Beauty Culture...........................        <10
    Vernon College...............................................        <10
    Verve College................................................        <10
    Vet Tech Institute of Houston................................        <10
    Victory University...........................................        <10
    Video Symphony EnterTraining.................................        <10
    Video Technical Institute....................................        <10
    Villanova University.........................................        <10
    Vincennes University.........................................        <10
    Virginia Institute of Technology.............................        <10
    Virginia Intermont College...................................        <10
    Virginia Polytechnic Institute & State University............        <10
    Virginia State University....................................        <10
    Virginia University of Lynchburg.............................        <10
    Vista College................................................        <10
    Vocational Training Center...................................        <10
    Wake Technical Community College.............................        <10
    Walsh College of Accountancy & Business Administration.......        <10
    Walter Jay M.D. Institute, An Educational Center.............        <10
    Wards Corner Beauty Academy..................................        <10
    Warner Pacific University....................................        <10
    Washington School of Secretaries.............................        <10
    Washington State University..................................        <10
    Washington University in St. Louis...........................        <10
    Washtenaw Community College..................................        <10
    Watterson College Pacific....................................        <10
    Waubonsee Community College..................................        <10
    Wayland Baptist University...................................        <10
    Wayne County Community College District......................        <10
    Wayne State University.......................................        <10
    Webster Career College.......................................        <10
    Webster University...........................................        <10
    Wesleyan College.............................................        <10
    West Chester University of Pennsylvania......................        <10
    West Coast University........................................        <10
    West Virginia Junior College.................................        <10
    West Virginia Northern Community College.....................        <10
    West Virginia University.....................................        <10
    Westech College..............................................        <10
    Western Career College.......................................        <10
    Western Governors University.................................        <10
    Western Illinois University..................................        <10
    Western Michigan University..................................        <10
    Western New Mexico University................................        <10
    Western Oregon University....................................        <10
    Western Piedmont Community College...........................        <10
    Western State University College of Law......................        <10
    Western Suffolk BOCES........................................        <10
    Western Technical College....................................        <10
    Westfield State University...................................        <10
    Wharton County Junior College................................        <10
    Wheeling University..........................................        <10
    White Mountains Community College............................        <10
    Whittier College.............................................        <10
    Widener University...........................................        <10
    Wilberforce University.......................................        <10
    Wilbur Wright College........................................        <10
    Wiley College................................................        <10
    Wilfred Academy..............................................        <10
    Wilfred Academy of Hair and Beauty Culture...................        <10
    Wilfred Academy of Hair Design & Beauty Culture..............        <10
    Willfred's Frederic Hairstyling..............................        <10
    William Paterson University of New Jersey....................        <10
    William Penn University......................................        <10
    William Woods University.....................................        <10
    Williams Beauty Academy......................................        <10
    Willsey Institute............................................        <10
    Wilmington University........................................        <10
    Wilson Community College.....................................        <10
    Wingate University...........................................        <10
    Winthrop University..........................................        <10
    Wolford College..............................................        <10
    Wood Tobe--Coburn School.....................................        <10
    Woodbridge Business Institute................................        <10
    Wooster Business College.....................................        <10
    Worcester State University...................................        <10
    Wright State University......................................        <10
    Wyoming County Career and Technical Center...................        <10
    Wytheville Community College.................................        <10
    Xavier University of Louisiana...............................        <10
    Yakima Valley College........................................        <10
    York Institute...............................................        <10
    York St John University......................................        <10
    York Technical College.......................................        <10
    Yorktowne Business Institute.................................        <10
    Youngstown State University..................................        <10
    YTI Career Institute--Altoona................................        <10
    (blank)......................................................      3,660
                                                                  ----------
          Grand Total............................................     20,840
    ------------------------------------------------------------------------

        Question. Please provide the top five reasons that borrower defense
    claims are placed in ``total denied,'' ``total ineligible,'' and
    ``total closed.'' Please also provide the number and corresponding
    percentage for borrower defense claims placed in each category.
        Answer.
        As of May 31, 2024, the top five reasons applications have been
    closed were as follows (numbers have been rounded to the nearest 5):

      --No Loans Pre-Adjudication (e.g., no federal loans; loans paid in
            full; no loans at the applicable school) (14,475 applications
            or 69%);
      --No Response from Customer (2,275 applications or 11%);
      --Borrower Received an Automatic Closed School Discharge (965
            applications or 5%);
      --Borrower Requested Case Closure (785 applications or 4%).
      --Incomplete Application (685 applications or 3%)

        As of May 31, 2024, the top five reasons applications were denied/
    deemed ineligible were as follows (numbers have been rounded to the
    nearest 5):

      --Post-Class Denial* (5,765 applications or 75%);
      --Sweet Initial Denial** (1,925 applications or 25%);
      --Sweet Resubmit Denial*** (<10 applications or <1%)

        Note:

        Post Class Denial*--Have been reviewed and do not meet the
    regulatory standard for approval under the 2016 regulation.

        Sweet Initial Denial**--Sweet class members whose application when
    through the streamline adjudication process as defined in the Sweet
    settlement, received a revise and resubmit notice, but failed to revise
    and resubmit within the 6 month period.

        Sweet Resubmit Denial***--Sweet class members who filed a revise
    and resubmit application, but did not meet the streamline standard as
    defined by the Sweet settlement.
        Question. The for-profit college industry drastically increased its
    enrollment during the Great Recession. In many cases, low-value
    colleges preyed on out-of-work adults, promising them an education that
    would lead to well-paying jobs--only to leave those students with a
    mountain of debt and no credential of value. Enrollment peaked in 2011
    at more than three million students in the for-profit sector. The
    Harkin investigation, which was conducted by the Senate Committee on
    Health, Education, Labor, and Pensions, showed that students were
    ``churned'' through these schools, with more than 50 percent of for-
    profit students leaving within 4 months. Schools like Westwood,
    Corinthian, and ITT Tech lied to prospective students about their
    employment outcomes and took their money, only to shutter
    precipitously, leaving those students without good options to complete
    their degrees. The Biden Administration has taken some important steps
    to right those wrongs, discharging student loans for borrowers who were
    not able to graduate. I particularly appreciate that the students from
    Westwood, which closed in 2016, finally have been granted relief.
    However, many other borrowers from many other institutions that
    similarly closed after taking advantage of students have not seen the
    relief they deserve, even when there have been investigations of those
    schools that have found widespread predatory conduct.
        When can borrowers who attended but could not graduate from
    colleges like Charlotte School of Law, Vatterott, schools run by the
    Center for Excellence in Higher Education, schools run by the Dream
    Center, and schools run by Education Corporation of America expect to
    receive the same group relief as students from Westwood?
        Answer. The Department continues to review evidence available to it
    to determine whether additional group discharges are appropriate and
    unfortunately cannot provide additional detail at this time. The
    Department is evaluating evidence while also prioritizing work to
    timely adjudicate the applications as is required by the Sweet
    settlement.
        Question. The Department granted borrower defense discharges for
    borrowers who attended Westwood in August 2022, more than 7 years after
    Westwood precipitously shuttered its doors. While I applaud the
    Department's actions to provide this deserved relief to former Westwood
    students, the notices to Westwood borrowers were not sent out until the
    end of March 2023, 7 months after the Department initially made its
    announcement. As of March 2024--19 months after the announcement--the
    Department reports having processed about 80 percent of those
    discharges.
        Please describe the steps the Department is taking to complete the
    discharges for remaining Westwood borrowers.
        Answer. Federal Student Aid (FSA) provided a list of approved
    borrowers and loans to servicers related to the Westwood group
    discharge with instructions to discharge, refund any payments, and
    delete credit tradelines for approved loans. FSA is working with the
    servicers to complete the remaining Westwood discharges, among other
    approved discharge populations. FSA is also working to reconcile any
    outstanding borrowers to ensure all borrowers receive full relief.
        Question. Please describe any steps the Department has taken to
    communicate with borrowers who have been promised, but have not yet
    received, a loan discharge.
        Answer. Federal Student Aid has not provided any additional
    communications to borrowers beyond the original approval notice sent
    under the group approval for Westwood.
        Question. Please provide an estimated date by which you expect
    these discharges to be completed.
        Answer. Federal Student Aid does not currently have an estimated
    date when we expect remaining discharges to be completed, but we are
    monitoring the situation closely with the loan servicers. Borrowers'
    eligible loans will remain in forbearance until the discharges are
    completed.
        Question. Last month, a court in San Francisco held a hearing on
    the delayed resolution of borrower defense to repayment claims under
    the Department's settlement under Sweet v. Cardona. Under this
    agreement, nearly 300,000 defrauded borrowers are entitled to student
    debt relief because they were defrauded by predatory institutions like
    for-profit colleges.
        Please provide the Department's efforts to use all available legal
    authorities to come into compliance with the Sweet settlement.
        Answer. We believe the declaration provided by Richard Cordray in
    that hearing lays out in significant detail our efforts to ensure that
    borrowers receive the relief to which we have committed. A copy of that
    declaration can be found here.
        Question. In 2021, the Department announced the re-establishment of
    the Office of Enforcement within Office of Federal Student Aid, which
    had been deprioritized under the previous Administration. Over the last
    several months, the Department has been in the process of reorganizing
    the Office of Enforcement and the Office of the Ombudsman to ensure
    adequate oversight of student loan servicers and enforcement of
    borrower rights.
        What is the status of these reorganization efforts? Please provide
    detailed plans of when the Department plans to finalize these efforts.
        Answer. The Department is working to finalize the pending Federal
    Student Aid reorganization as quickly as possible.
        Question. Please provide a list of all institutions for which the
    Department currently holds a letter of credit or other surety and the
    amount of such letter of credit or other surety.
        Answer. A list of financial protections held as of December 31,
    2023, is attached. [The Department provided the attachment to the
    Committee.]
        Question. In March 2022, the Department announced that it would
    begin requiring some private institutions to require signatures from
    their corporate owners on their Program Participation Agreements (PPAs)
    with the Department, particularly for institutions that have a
    demonstrated financial risk. The signatures would ensure that the owner
    remains on the hook for potential taxpayer liabilities, even if the
    institution itself is shuttered. In March 2023, the Department
    broadened the requirement to individual owners of private institutions.
        Has the Department exercised its authority as described in either
    of these electronic announcements (GEN-22-16 and GEN-23-11)? If so, has
    it exercised the authority with respect to any institution that
    shuttered after obtaining the signatures? Were liabilities assessed
    against the individual or corporate owner in any such case?
        Answer. Since issuing electronic announcements GEN-22-16 and GEN-
    23-11, the Department has exercised its authority pursuant to 20 U.S.C.
    1099c(e) to require the assumption of liability by owners of
    institutions to protect the financial interest of the United States.
    Because the Department has only recently begun requesting additional
    signatures in new participation agreements, it is not currently aware
    of any recent closures where additional parties signed the agreement
    and for which there are unpaid liabilities.
        Question. Has the Department produced a list of institutions that
    are exempt pursuant to the statute (i.e., private institutions that
    have not been subjected to a limitation, suspension, or termination
    action; have not had an audit finding resulting in a liability of more
    than 5 percent of Title IV program funds in the two most recent audits;
    that meet and have met for the preceding 5 years the Department's
    financial responsibility requirements under Subpart L; and that have
    not been cited for failure to submit timely audits in the preceding 5
    years)? If so, please provide the list to the Committee.
        Answer. The Department has not produced a list of institutions for
    which 20 U.S.C. 1099(e)(4) prohibits it from seeking the assumption of
    liability or financial guarantees from owners as authorized by 20
    U.S.C. 1099c(e)(1). The Department's March 23, 2022, electronic
    announcement on signature requirements for entities exercising
    substantial control over non-public institutions noted that ``the
    Department may require additional signatures on an institution's PPA
    when an institution seeks initial certification or recertification, or
    when it undergoes a change of ownership under 34 CFR Sec. 600.31(a).''
    It is at these events that the Department, as part of its analysis of
    whether an additional signature should be required, would evaluate the
    institution against the criteria contained in 20 U.S.C. 1099c(e)(4). On
    March 1, 2023, the Department provided additional guidance related to
    establishing personal liability requirements. That announcement notes
    that ``the Department will consider, on a case-by-case, individualized
    basis, a variety of factors in evaluating whether requiring an
    individual exercising substantial control over an institution to assume
    personal liability is necessary to protect the financial interest of
    the United States.'' Likewise, as part of that analysis, the Department
    would evaluate the institution against the criteria contained in 20
    U.S.C. 1099c(e)(4).
        Question. The Department issued new gainful employment regulations
    in October 2023. While those were scheduled to take effect on July 1,
    2024, the Department noted that it would delay reporting requirements
    until October 1, 2024, due to the challenges with the Free Application
    for Federal Student Aid (FAFSA) form; that date is likely to slip
    further. In the meantime, the Department has been working on
    implementation by publishing FAQs and issuing an information collection
    request of the data elements it will require to be reported, but it has
    yet to stand up the new data reporting, leaving institutions further
    behind. Please provide a detailed implementation timeline for the
    gainful employment and financial value transparency regulations,
    including the timelines for: expected reporting; updates to the
    Department's data systems; the establishment of an agreement to produce
    earnings data with a Federal agency with earnings data; the production
    of completer lists; the production of debt-to-earnings rate and the
    earnings premium metric; and the launch of the disclosure website.
        Answer. As noted in the electronic announcement, institutions will
    have the ability to Start reporting as soon as July 1, 2024, but they
    must complete all reporting by October 1, 2024. Updates to the National
    Student Loan Data System are being made prior to July 1 so that
    functionality is ready. We anticipate sharing the data reported by
    institutions with the Federal agency after October 1, 2024, with the
    earnings data returned to the Department a few weeks later. We
    anticipate the first publication of rates in January 2025. The launch
    of the disclosure website is not scheduled until July 1, 2026.
        The Department is in the process of negotiating a memorandum of
    understanding that we anticipate finalizing early this summer.
        Question. The Department is required to review and, if appropriate,
    approve the changes in ownership of institutions for those institutions
    to continue receiving Federal student aid. A recent Government
    Accountability Office investigation into the Department's and Internal
    Revenue Service's processes, especially for conversions from for-profit
    to nonprofit tax status and new regulations finalized in Fall 2022, set
    the stage for a more robust process than the Department has previously
    used. However, the extent to which the Department is prepared to place
    conditions on, or even deny, conversions for for-profit colleges is
    unclear. One example already underway is the University of Arizona
    Global Campus (UAGC, formerly Ashford University), which was acquired
    by the public University of Arizona (UA) but has since apparently
    become a major source of taxpayer liabilities.
        Answer. The Department agrees that under section 498(i)(1) and (4)
    of the Higher Education Act of 1965, as amended (HEA) and implementing
    Federal regulations, an eligible institution of higher education that
    has had a change in ownership resulting in a change of control shall
    not qualify to participate the Title IV programs after the change in
    control unless the institution establishes that it meets the
    requirements of section 102 of the HEA. The Department may
    provisionally certify an institution seeking to continue its Title IV
    participation following a change in ownership based on the preliminary
    review of a materially complete application that is received by the
    Department within 10 business days of the change in ownership
    transaction, and the Department may extend the temporary provisional
    certification on a month to month basis until a final decision is
    issued on the institution's application for continued participation.
    See 20 U.S.C. Sec. 1099c(i), and 34 C.F.R. Sec. Sec. 600.20(g),
    600.20(h), and 668.14(g)(1).
        The Department has denied nonprofit conversions for for-profit
    institutions, including two denials of Grand Canyon University's
    (GCU's) nonprofit requests and the denial of the American Academy of
    Art College's nonprofit conversions request that were issued during the
    prior administration. The current administration has defended the
    Department's GCU decision in U.S. district court and in the appellate
    circuit.
        Question. Has the Department applied any conditions to the Title IV
    participation of the University of Arizona Global Campus?
        Answer. Yes. The Department currently allows UAGC to participate
    under a Temporary Provisional Program Participation Agreement (TPPPA)
    that was executed on July 31, 2023, and an Addendum to the TPPPA that
    was executed on July 31, 2023, after the public institution UA became
    the 100% owner of UAGC upon acquiring UAGC's educational assets from
    the nonprofit UA Foundation in a June 30, 2023, change in ownership
    transaction. The nonprofit UA Foundation acquired the assets of UAGC
    (f/k/a Ashford University) from Zovio Inc. (f/k/a Bridgepoint
    Education, Inc.) in an earlier change in ownership transaction. Copies
    of UAGC's current TPPPA and TPPPA Addendum, and the December 20, 2021,
    letter referenced in UAGC's current TPPPA's conditions are provided
    with this response. UAGC's current TPPPA includes the following
    conditions:
      --UAGC's financial statements must be submitted at the UA level and,
            upon notification, in accordance with a ``school group'' to be
            established by the Department in the Department's records for
            the receipt of annual audit reports covering UA and UAGC;
      --Growth restrictions (new programs, new locations, increase level of
            offering, change length of programs);
      --Biweekly cash balances and monthly reporting of cash budget vs.
            actual as well as significant events;
      --Monthly student roster submissions;
      --Required reporting of any class action, accreditation or government
            actions/investigations;
      --Student complaint reporting;
      --Heightened Cash Monitoring 1 (HCM1) condition; and,
      --The notification condition as specified in the Department's
            December 20, 2021 letter.

        Question. Has the Department formally assessed liabilities against
    UAGC, and if so, at what amount?
        Answer. No, the Department has not formally assessed liabilities
    against UAGC.
        Question. Does the Department anticipate future liabilities against
    UAGC?
        Answer. The Department does not comment on potential future
    oversight actions nor on open oversight actions until the results have
    been formally communicated to the participating entity.
        Question. What is the total of Title IV dollars held by borrowers
    who have filed a claim for borrower defense to repayment against
    Ashford University?
        Answer. As of June 2024, 13,000 borrowers have filed a claim for
    borrower defense to repayment against Ashford University and still have
    open loans for Ashford University or open consolidation loans
    associated with an Ashford University loan. These borrowers' loans have
    been disbursed for $459 million. Loans which have been discharged,
    forgiven, or paid in full have been excluded. This includes loans from
    any time frame, including loans before March 2009 or after April 2020.
        Question. What is the total of Title IV dollars (not already
    discharged or repaid in full) held by borrowers who attended Ashford
    University between March 2009 and April 2020?
        Answer. As of June 2024, 291,000 borrowers have open loans for
    Ashford University or open consolidation loans associated with an
    Ashford University loan. These borrowers' loans have been disbursed for
    $4.99 billion. Loans which have been discharged, forgiven, or paid in
    full have been excluded. This only includes loans from March 1, 2009
    through April 30, 2020.
        The following four OPE ID were used to respond to this data
    request.

    ------------------------------------------------------------------------
                    OPE ID                    SCHOOL NAME      BRANCH NAME
    ------------------------------------------------------------------------
    00188100..............................  University of    University of
                                             Arizona Global   Arizona Global
                                             Campus (The)     Campus (The)
    00188101..............................  University of    University of
                                             Arizona Global   Arizona Global
                                             Campus (The)     Campus--Sauk
                                                              Valley
                                                              Community
                                                              College
    00188102..............................  University of    Ashford
                                             Arizona Global   University--Ma
                                             Campus (The)     in Campus
    00188103..............................  University of    Ashford
                                             Arizona Global   University--Cl
                                             Campus (The)     inton Campus &
                                                              Online Center
    ------------------------------------------------------------------------

        Question. This year, the Department is anticipating starting new
    contracts with student loan companies under the new Unified Servicing
    and Data Solution (USDS) system. I am concerned that this transition
    could lead to the transfer of student loans and errors on student loan
    borrower accounts. What steps is the Department taking to ensure that
    servicer accountability remains a priority and that borrowers can
    smoothly resume making payments and access relief programs enacted by
    Congress?
        Answer. One of the major goals of the Unified Servicing and Data
    Solution (USDS) contract with loan servicers is to increase servicer
    accountability and improve the borrower experience. Under the new
    accountability framework, there are detailed mechanisms known as
    service level agreements to hold servicers accountable for their
    portfolio performance and incentivize more support for borrowers at
    risk of delinquency and default. Poor servicer performance under USDS
    will result in corrective actions and, when appropriate, financial
    penalties. The contract also empowers the Department to reward
    servicers who serve borrowers well, especially those borrowers that are
    at-risk. The USDS servicers began work under the new contract on April
    1, 2024.
        Question. This month, the Department and MOHELA began notifying
    borrowers that MOHELA will no longer be the sole servicer charged with
    administering the Public Service Loan Forgiveness Program (PSLF) and
    TEACH Grant programs and that administration of such programs will be
    handled by the Department directly. This is misleading and has caused
    borrower confusion since the Department's correspondence also says that
    borrowers ``will remain with their existing servicer.'' Further, MOHELA
    has notified borrowers that it will no longer be saving their records
    or keeping track of payments and encouraged borrowers to take
    ``screenshots'' of their accounts prior to April 30 to keep track of
    their progress in anticipation of potential errors.
        Answer. The transition of PSLF and TEACH Grant processing from
    specialty servicers to Federal Student Aid (FSA) is designed to reduce
    processing time, increase FSA's oversight, and improve the borrower
    experience. It is accurate that nearly every borrower will stay with
    their existing loan servicer in USDS, which will handle their day-to-
    day loan servicing needs (e.g., making student loan payments). What is
    changing is that the PSLF and TEACH Grant programs and their management
    are being transitioned to FSA's systems and day-to-day control, meaning
    borrowers interested in or participating in these programs will
    interact directly with StudentAid.gov and 1-800-4-FEDAID, not their
    loan servicer. This is no different from other loan processes that
    borrowers perform on StudentAid.gov, like signing promissory notes and
    applying for income-driven repayment plans and consolidation loans. As
    part of this transition, prior to the processing pause FSA recommended
    borrowers save screenshots and correspondence from the MOHELA website
    for their personal records, as that information would no longer be
    available after April 30, 2024. We encouraged borrowers to do so so
    that they could validate that the information they saw on MOHELA's
    website prior to the processing pause conformed with information on
    StudentAid.gov after the pause, as it is important to us for borrowers
    to have appropriate documentation if there are any discrepancies that
    need to be resolved. As of July 1, 2024, the PSLF program has
    successfully transitioned from MOHELA and now is fully managed by the
    Department on StudentAid.gov. We have resumed processing of PSLF forms
    and are currently working to update PSLF payment counts. With the
    updates to our systems and processes, borrowers can now manage their
    progress toward forgiveness under PSLF on StudentAid.gov from start to
    finish, which includes submitting a PSLF form, monitoring the status of
    their PSLF form on the My Activity section of their StudentAid.gov
    account, retrieving correspondence relating to their PSLF form, and
    accessing their payment counts and approved certified employment.
        Question. What is the Department doing to ensure that borrowers are
    made whole if errors are made on their accounts over the course of the
    PSLF processing pause and transfer to the new USDS system?
        Answer. As stated in the previous response, MOHELA transferred
    borrowers' PSLF records to Federal Student Aid (FSA) during the
    processing pause. FSA will retain all these records in their original
    format and convert these records into our systems. FSA also is
    conducting several data simulation exercises to ensure data integrity.
    If there are errors, MOHELA will be required to work closely with FSA
    to research the root cause of any issues uncovered and support any
    necessary corrections or mitigations. Finally, if a borrower disagrees
    with their status now that the pause has ended, they can contact FSA at
    1-800-4-FEDAID or file a complaint in our feedback system on
    StudentAid.gov.
        Question. How will MOHELA handle borrower records over the course
    of the PSLF processing transfer and pause?
        Answer. MOHELA transferred borrowers' PSLF records to Federal
    Student Aid (FSA) during the processing pause. This includes all data
    and images necessary for FSA's systems to populate borrower payment
    counts and resume processing now that the pause has ended. FSA will
    retain these records in their original format and will also convert
    these records into FSA's systems. New applications and supporting
    documents received but not processed by MOHELA during the pause were
    forwarded to FSA for processing following the end of the pause.
        Question. When a borrower disagrees with a qualifying payment
    count, how will they be able to address this disagreement?
        Answer. If a borrower disagrees with their payment counts, they can
    upload a Reconsideration request on StudentAid.gov. They can also
    upload a dispute (in a separate section) on StudentAid.gov.
        Question. How will the Department hold MOHELA accountable for any
    errors that take place during the transfer?
        Answer. As part of the data migration process, Federal Student Aid
    (FSA) conducted multiple production simulation exercises using actual
    data migrated from MOHELA to catch any data quality or processing
    errors introduced by MOHELA. MOHELA is under contract to work closely
    with FSA to research the root cause of any issues uncovered and to
    support any necessary corrections or mitigations.
        Question. Will the unprocessed PSLF applications currently on file
    with MOHELA be transferred to the Department?
        Answer. Federal Student Aid (FSA) continued to collect e-sign and
    e-submit Forms through the PSLF Help Tool on StudentAid.gov throughout
    the pause. Any forms received by MOHELA during the pause were forwarded
    to FSA for processing following the end of the pause.
        Question. Our children are facing a literacy crisis, which is
    worsened by skyrocketing chronic absenteeism. In the 2021-2022 school
    year, 31 percent of students were chronically absent. In Illinois, 28.3
    percent of students were chronically absent in the 2022-2023 school
    year, compared to 17.5 percent in the last full school year prior to
    the pandemic.
        According to the Illinois Policy Institute, ``this rate is 10
    percentage points higher among Illinois' low-income students: 38
    percent missed at least 10 percent of their school days in 2023.'' This
    is deeply concerning as chronic absenteeism is connected to lower
    academic performance in math and reading, negative effects on social
    and emotional development, and lower graduation rates. Research shows
    that chronic absenteeism is most detrimental for our nation's most
    vulnerable students--students of color, students from low-income
    families, students with disabilities, English learners, and homeless
    and foster and youth. I am encouraged by the Department's agenda to
    increase student attendance. Under the Every Student Succeeds Act
    (ESSA), 37 states measure chronic absenteeism as part of their
    accountability systems to reflect school quality and student success.
        How does the Department monitor how states are using this data to
    inform intervention strategies to create supportive learning
    environments that foster a sense of belonging? How are states using
    this data to inform school improvement efforts under ESSA state plans
    to address chronic absenteeism and improve student outcomes?
        Answer. The Department conducts a comprehensive review of an SEA's
    implementation of Title I as part of our ESEA consolidated monitoring
    process. This review evaluates State compliance with all of the
    requirements in Title I, including:
      --Implementation of accountability systems (including the School
            Quality or Student Success (SQSS) indicators, which includes
            chronic absenteeism in a majority of States);
      --State and local report cards, including reporting on the SQSS
            indicators;
      --State oversight and approval of support and improvement plans for
            schools identified for comprehensive support and improvement
            (CSI), including State oversight of the requirement for each
            CSI school to conduct a needs assessment, review all indicator
            data, and identify evidence-based interventions;
      --State oversight of LEA review, approval, and monitoring processes
            of plans for schools identified for targeted support and
            improvement (TSI) and additional targeted support and
            improvement (ATSI);
      --Use of ESEA section 1003 school improvement funds; and
      --General monitoring and technical assistance for LEAs and schools.
        In addition, in summer 2024, the Department is conducting a Title I
    targeted monitoring activity focused on the implementation of ESEA
    section 1003 school improvement funding requirements in five SEAs. This
    includes how the SEA is awarding funds to LEAs to support identified
    schools, how it is reviewing LEA applications, and how the SEA is
    ensuring that ESEA section 1003 funds are used to support evidence-
    based interventions. As part of this review, the Department is asking
    States to identify effective evidence-based interventions that LEAs
    have implemented using section 1003 funds. Several States have provided
    interventions to address chronic absenteeism. For example, Alabama
    implemented a Building Assets, Reducing Risks (BARR) program, which is
    a schoolwide system of strategies focused on building relationships,
    utilizing real-time data, and enabling schools to improve student
    outcomes. Schools implementing BARR reported an increase in student
    attendance and decrease in student misbehavior. Illinois indicated that
    several schools used 1003 school improvement funds to hire attendance
    staff to monitor attendance and liaise with families to address chronic
    absenteeism.
                                     ______

                 Questions Submitted by Senator Jeanne Shaheen
        Question. Free Application for Federal Student Aid (FAFSA): I am
    extremely concerned about the impact of this year's FAFSA errors and
    delays on students and their families, as well as on colleges and
    universities.
        What is the Department doing to address the alarmingly low rates of
    FAFSA completion caused by the Department's catastrophic handling of
    this situation, and what is the Department's plan to ensure that
    students in this year's graduating high school class do not permanently
    lose out on educational opportunities?
        Answer. The Department has already received over 12.22 million
    FAFSA forms, 11.68 million of which have been processed as of July 9,
    2024. The Department has made significant progress in closing the gap
    in FAFSA submissions to 5.7 percent as of July 9 compared to this time
    last year, down from nearly 40 percent in March. Submissions from high
    school seniors are currently less than 12 percent behind last year, as
    of July 2, 2024.
        In addition to ED's existing messaging and media, the Department
    launched the Student Support Strategy in May to distribute $50M to
    organizations on the ground supporting current cycle FAFSA completion
    efforts, specifically targeting this year's high school senior class.
    Organizations receiving funding are paying for additional summer
    staffing, developing supportive resources, and working directly with
    students and families.
        This spring and summer the Department is taking significant action
    to get FAFSA completions at the levels of previous cycles. Over the
    summer months the Department is implementing four primary strategies to
    close completion gaps:
          1. Updating key messaging and asks by stakeholder group for the
            summer months.
          2. Maximizing first-time FAFSA submissions and completions
            through a community college specific campaign, adult learner
            campaign, and territories-specific support.
          3. Converting students who have started but not submitted the
            FAFSA to completed status through direct emails and text
            campaigns from FSA, as well as other initiatives like
            additional trainings for counselors.
          4. Ensuring that all returning students have completed the FAFSA
            through tactics focused on students who may have stopped out of
            higher education and/or who may be transfer students.
        Finally, the Department has launched a Summer Resources campaign to
    new stakeholder groups who oversee locations that students frequent
    over the summer. These groups will provide a folder of promotional
    materials and resources to remind students to complete the FAFSA and
    offer support. The campaign includes more than 30 new stakeholder
    groups including: public recreation centers, gyms, movie theaters,
    libraries, supermarkets, one-stop centers, food pantries, malls, summer
    sports orgs, volunteer sites, etc.
        Question. Why am I still hearing from NH colleges and universities
    that have yet to receive all the information they need from the
    Department?
        Answer. Since rolling out the Better FAFSA, and as of July 9, 2024,
    the Department has received 12.22 million FAFSA forms. The Department
    has addressed nearly all known issues with the form and has made
    significant progress in closing the gap in FAFSA submissions to 5.7
    percent as of July 9 compared to this time last year, down from nearly
    40 percent in March. Nearly all four-year colleges and universities are
    packaging aid offers for students who are now making enrollment
    decisions.
        Throughout the launch of the new FAFSA, a top priority of the
    Department has been providing support to colleges and universities to
    make sure they have the resources they need to process student records
    as efficiently as possible, make aid offers to students, and encourage
    enrollment in higher education. Through the College Support Strategy,
    we have provided support to every college or university that has
    reached out to us for help, and last month we launched a new $50
    million program--the Student Support Strategy--to help drive FAFSA
    completion and increase college enrollment across the country.
        The Department will continue to leave no stone unturned in pursuit
    of our goal of ensuring that every student has the help they need to
    access the life-changing potential of higher education. We are happy to
    meet with your office or institutions in your state to provide
    additional information or support.
        Question. With ongoing FAFSA data errors impacting so many students
    and institutions, how will the Department ensure that students do not
    have funding clawed back from them if their financial aid packages may
    have been issued incorrectly as a result of these errors?
        Will there be a process for students to submit claims, should they
    be awarded erroneous amounts of grants and loans due to errors and
    problems with the FAFSA rollout?
        Answer. The Department will continue to assess ways to provide
    guidance to institutions regarding awards made under the 24-25 FAFSA
    while maintaining the appropriate improper payment safeguards.
        Question. How will the Department hold itself accountable for the
    harm it has caused institutions, students, families and taxpayers?
        Answer. Implementing the FUTURE Act and FAFSA Simplification Act
    required completely overhauling the entire FAFSA ecosystem. This
    included updating over 20 systems, some of which were over 50 years
    old. It required changes to the form itself, the underlying formula,
    data management and security procedures and working to ensure that
    institutions, states, and vendors could implement the changes. The
    Department acknowledges that the expansive scope and timeline of the
    changes for the 2024-25 FAFSA has been challenging for students,
    families, institutions, states, and organizations that support them.
        Executive leadership at the Department has been working closely
    with the Office of Postsecondary Education and other offices within ED
    since fall of 2022 to set priorities, oversee project planning and
    implementation, and ensure accountability for the development and
    launch of the 2024-25 FAFSA. This detailed and frequent oversight will
    continue leading up to and through the 2025-26 FAFSA implementation.
        The Department recently outlined comprehensive steps it is taking
    to improve Federal Student Aid (FSA) for students, families, borrowers,
    and schools. These efforts will ensure FSA works better and addresses
    ongoing management and operational challenges. Specifically, the
    Department has or is taking the following steps:
      --Searching for a new Chief Operating Officer (COO) for FSA.
      --Conducting a full-scale review of FSA's current and historical
            organization, management, staffing, workflow structures,
            business processes, and operations to continue bringing the
            Federal financial aid system into to the 21st century.
      --Hired an independent consulting firm to make recommendations to the
            COO and the Secretary on ways to improve the design, structure,
            and processes within FSA, with a focus on building an updated
            organizational structure and workflow.
      --Reviewing contracts and acquisition procedures to ensure contracts
            are appropriately structured to hold vendors accountable for
            meeting key deadlines, achieving desired outcomes, and
            providing the best value to the agency and protecting
            taxpayers' resources.
      --Restructuring senior leader reporting protocols to increase
            accountability and make sure we provide the best value to the
            agency and protect taxpayers' resources.
      --Creating a new IT innovation team empowered to lead information
            technology design to support the digital transformation of the
            organization. This new team will oversee recruitment of top
            engineers, project managers, and designers who will bring
            critical information technology expertise and experience to
            strengthen FSA's work in this area.
      --Seeking input from the Office of the Inspector General (OIG) and
            engaging Members of Congress, whose constituents receive
            services from FSA.
      --Continuing our robust outreach efforts to parents, students,
            colleges, and community organizations, and conduct listening
            sessions with them this summer.
        Question. Student Loan Repayment: Secretary Cardona, at several
    previous hearings before this Committee, I asked you repeatedly about
    the transition back to repayment, and you assured me that the
    Department was committed to providing clarity for borrowers and
    facilitating a successful resumption of payments. At last year's
    hearing, you assured me explicitly that the Department would ``work
    with its contractors and outside partners to ensure that borrowers have
    the most up-to-date, accurate information on the status of their
    loans.''
        Why, then, have borrowers had to deal with incorrect information
    and confusion as they attempt to make the payments they owe?
        Answer. The Department has worked closely with its loan servicers
    throughout the return to repayment process. This was a herculean task
    to bring approximately 28 million borrowers back to repayment last
    October, which is five times more than in an entire typical year.
    Federal Student Aid has been burdened with flat funding and higher
    costs, leaving servicers with significantly fewer call center
    representatives per borrower than they had in 2020. FSA provided
    updated versions of a communications playbook to servicers to provide
    smooth communications to borrowers.
        Question. How is the Department working to better support borrowers
    and ensure they have the accurate information they need to successfully
    make their required payments?
        Answer. The Department has changed the way we communicate with
    borrowers and made it easier for borrowers to reach us through our call
    centers. The return to repayment was the first time the Department has
    been able to do direct outreach to borrowers. We emailed and texted
    millions of borrowers with information about repayment options and
    directed them to affordable repayment plans and the opportunity to
    enroll in auto-debit. The Department initiated a one-of-a-kind program
    developed with academic researchers call the Targeted Early Delinquency
    Intervention campaign that tested communication models for borrowers
    who missed payments to get them back on track.
        Question. Educator Shortage: Schools in New Hampshire are facing
    significant challenges with hiring and retaining teachers, staff and
    school administrators.
        How is the Department working to address the educator shortage
    facing schools across the country?
        Answer. The Department is working to help states and districts in
    their efforts to eliminate educator shortages through programs that
    expand access to high-quality and affordable educator preparation
    programs, promote career advancement and leadership opportunities for
    educators, provide high-quality new teacher induction and professional
    development throughout educators' careers, and address teacher
    compensation. The Department has partnered with the Department of Labor
    to bring Registered Teacher Apprenticeships to 37 states, DC, and PR in
    an effort to address educator shortages and invest in teacher
    preparation programs. Registered Apprenticeships are a key strategy in
    the Administration's plan to raise the bar in education and improve
    learning conditions in schools by ending the educator shortage and
    providing all students with great teachers prepared to succeed in the
    classroom. Additionally, the Administration's FY 2025 Budget requested
    significant increases for competitive programs that will strengthen and
    diversify the teacher pipeline by helping states and districts build
    high-quality pathways into the profession to recruit and prepare
    educators. The budget request includes:
          1. Increase of $25 million for Teacher Quality Partnerships, to
            prepare educators through effective programs including teacher
            residencies and grow-your-own programs.
          2. Increase of $15 million for the Augustus F. Hawkins Centers of
            Excellence Program, to support a diverse and well-prepared
            pipeline of effective educators by expanding and strengthening
            teacher education programs at Historically Black Colleges or
            Universities (HBCUs), Hispanic-serving Institutions, Tribally
            Controlled Colleges or Universities (TCCUs), and other
            Minority-Serving Institutions (MSIs).
          3. Increase of $10 million for the Personnel Preparation Program,
            an investment designed to bolster the special education
            educator pipeline.
          4. Level support is requested for the State Personnel Development
            Program, an investment designed to help State educational
            agencies (SEAs) reform and improve their systems for personnel
            preparation and professional development of individuals
            providing early intervention, educational, and transition
            services to improve results for children with disabilities.
        Question. How is the Department supporting school districts in
    their efforts to recruit and retain teachers, school leaders and staff?
        Answer. In addition to the request for increased funding for
    teacher preparation programs, the Administration has requested an
    increase in funding for competitive grant programs that support
    educators and school leaders to develop, prepare and retain teachers
    throughout the pipeline. The budget request includes:
          1. Increase of $5 million for Graduate Fellowships, to support
            the training of more higher education faculty with the
            knowledge and skills to train the next generation of teachers.
          2. $90 million for the Supporting effective educator development
            to prepare, develop, and retain an effective and diverse
            teacher and school leader workforce, that can meet the social,
            emotional, mental health and academic needs of their students.
          3. $173 million for the Teacher and School Leader Incentive
            grants, to support school-based models of distributed
            leadership that give teachers the opportunity to lead beyond
            the classroom, and be compensated for this work, improving
            teacher retention.
        Question. Pandemic Relief Funds: I am hearing concern from schools
    across my state about the upcoming expiration of Elementary and
    Secondary School Emergency Relief (ESSER) funds. I appreciate the
    guidance the Department has provided for states and school districts
    that may need additional time to continue liquidating funds, and I
    continue to urge the Department to work to ensure this process is
    feasible and not burdensome for school districts to navigate.
        Given that some school districts may be interested in submitting
    their late liquidation applications as soon as possible, whereas others
    may not be ready until closer to the deadline, can you confirm that
    states will have multiple opportunities to request late liquidation
    flexibility on behalf of their school districts?
        Answer. A State, as the Department's pandemic-relief grantee,
    determines both its timeline and process for requesting a late
    liquidation extension on behalf of itself and its school districts. The
    Department does, however, require that the submission of a State's
    request for a liquidation extension include the forecasted amount of
    funds to be liquidated during the period of extension for both the
    State and all of its districts. The Department does not review
    incomplete requests, meaning those requests that do not accurately
    project the anticipated needs of a grantee and all of the school
    districts for which the State will extend the liquidation period when
    its extension is approved. States may amend requests as better State
    and local fiscal data becomes available. This process ensures that the
    Department has the necessary fiscal data to provide adequate oversight
    for the continued implementation of ARP funds during the extended
    liquidation period.
        Question. How is the Department ensuring that districts are aware
    that they can extend time for contracted services through the late
    liquidation time period to ensure that tutoring services, mental health
    services and other effective programs can continue past the obligation
    deadline?
        Answer. The Department has held multiple office hours for grantees,
    including State education agencies and Governors, to ensure that the
    timeline and process for seeking an extension is clear. During these
    sessions, the Department has communicated that activities may continue
    past the obligation deadline under certain circumstances, namely, if
    allowable under State and local procurement laws. These office hours
    are recorded and available on the Department's website. Further, the
    Department held monthly check-in calls with each State throughout the
    spring. These calls focused on ensuring that grantees are regularly
    communicating their timelines and processes for requesting liquidation
    extensions to their subrecipients within the State. States have also
    received individual technical assistance to support the State to submit
    a complete and accurate request as soon as possible.
        Question. How is the Department's proposal for new ESSER spending
    data collection requirements, which the Department expects will require
    an additional four million personnel hours for school districts to
    comply with, different from existing data collection requirements on
    states and school districts, and why are these new requirements needed
    in addition to the information already provided through state and
    district plans?
        Answer. New ESSER spending data collection requirements include
    detailed sub-categories for the use of funds (e.g., meals for students,
    tutoring, additional staffing/activities to support social and
    emotional well-being, community schools, etc.). This will provide the
    public with more detailed information on ESSER expenditures compared to
    the broad categories we previously required, which offered little
    detail through general accounting code categories. States were notified
    of this change in 2022, with initial collection of the expanded data
    set beginning in 2024.
        Question. How is the Department working to support school districts
    facing upcoming budgetary challenges as a result of the expiration of
    pandemic relief funds?
        Answer. The Strategic Planning for Continued Recovery (SPCR), is an
    ED-funded initiative that began during the summer of 2023, which aims
    to support insular areas as well as state educational agencies (SEAs)
    as they work with local educational agencies (LEAs) to sustain
    effective investments funded by ESSER (Elementary and Secondary School
    Emergency Relief) and ESF (Education Stabilization Fund). To best
    support the field, ED complied a cross-office SPCR Project Team and
    Advisory Board, with representatives from: the Office of Assistant
    Secretary, Office of Formula Grants, Program and Grantee Support
    Services, Office of State and Grantee Relations, Office of School
    Support and Accountability, Rural Insular and Native Achievement
    Programs, and the Office of Special Education and Rehabilitative
    Services.
        The SPCR focuses on supporting SEAs (and, by extension, LEAs) to
    implement six strategies: (1) Determine impact of investments; (2)
    Prioritize efforts for ongoing recovery & transformation; (3) Achieve
    sustainability through financial planning; (4) Ensure access &
    opportunity for all; (5) Communicate impact of investments; and (6)
    Support/sustain systemic capacity building. Within those strategies,
    SEAs have engaged LEAs by using five levers: 1) Grantmaking; 2)
    Monitoring; 3) Policies; 4) Technical Assistance; and 5) Partnerships.
        Through the SPCR, SEAs have participated in a variety of activities
    over the last year, including: attending live or watching a recording
    of strategy-specific webinars, learning from and sharing with other
    SEAs through cross-SEA collaboration sessions, and accessing
    individualized consultations with SPCR initiative content experts. The
    SPCR also has a robust resource inventory, including the SPCR SEA
    Sustainability Planning Template. The initiative regularly amplifies
    materials from SEAs and LEAs--such as North Carolina's ESSER Funding
    Cliff Toolkit--to support ED stakeholders with the sustainability of
    effective ESSER and ESF investments.
        Finally, at the start of June 2024, the SPCR team launched three
    short-term communities of practice. All SEAs and IAs were invited to
    join. These COPs, focused on return on investment [Participants: DC,
    Guam, IN, NE, NV, NJ, NY, NC], evaluating trade-offs [Participants: WA,
    AL, USVI], and planning sustainability of effective internal processes
    and technical assistance supports provided to LEAs [Participants: CNMI,
    OK, KS, American Samoa, CA], are convening SEA teams to learn from one
    another and to receive free coaching from SPCR subject matter experts.
    All COP participants will meet in Dallas, TX in July 2024 for an in-
    person institute and in August 2024 for a cross-SEA share-out of
    lessons learned and best practices as they plan for the expiration of
    pandemic relief funds.
        Question. Given that school districts will be looking for
    alternative sources of funds to replace pandemic relief funding, how is
    the Department working to notify school districts about funding
    opportunities, such as new competitive grant opportunities, that can
    enable them to sustain personnel and services?
        Answer. When the Department opens new grant competitions it
    publishes a Notice Inviting Applications (NIA) in the Federal Register,
    which includes information on program purpose, eligible applicants,
    selection criteria, and award information. The Department promotes
    these new funding opportunities publicly and shares with relevant
    stakeholders (e.g., States, districts, professional groups, advocacy
    groups and others). Information on current open grant competitions, can
    be found here.
        The Department released a factsheet, Sustaining Investments in
    Teachers Beyond the American Rescue Plan, highlighting additional
    Federal resources available to sustain ARP investments in key
    strategies focused on attracting, preparing, supporting, and retaining
    a diverse teacher workforce and address teacher shortages for the long-
    term. In addition, the Department has released two policy briefs, which
    discuss specific grants that can be used to support educators.
        Finally, the Department's Raise The Bar pages include information
    about grants and resources that States and districts can leverage to
    support an array of needs.
        Question. Mental Health: I continue to be concerned about the
    mental health crisis facing school communities.
        How is the Department using appropriated funds to help increase
    access to mental health services in schools?
        Answer. The Department has long supported increasing access to
    school-based mental health services to make it easier for any student
    struggling with these challenges to get the help they need. It is
    critical that we recognize psychological distress and ensure access to
    the support and services needed to diagnose and treat mental illness.
    The Bipartisan Safer Communities Act (BSCA) authorized $2 billion in
    funding for the Department to expand school-based mental health
    services and to provide additional support for States and districts to
    support initiatives to promote safe and healthy learning environments
    for students and school staff.
        Through BSCA and School Safety National Activities funding, the
    Department has awarded a total of 264 grants under the School-Based
    Mental Health Services (SBMH) grant program and the Mental Health
    Service Professional (MSHP) Demonstration grant program to date. The
    purpose of SBMH is to increase the number of credentialed school-based
    mental health service providers delivering school-based mental health
    services to students. Funding for MHSP is used to train school-based
    mental health services providers for employment in schools and local
    educational agencies. In FY 2024, we plan to make additional awards
    under both programs with funding from the School Safety National
    Activities funding.
        In addition, under BSCA, the Stronger Connections grant program
    provided $1 billion in funding for State educational agencies to award
    competitive grants to high-need LEAs to broadly support safe and
    healthy learning environments, in accordance with section 4108 of the
    ESEA. This could include additional supports for school-based mental
    health services.
        The FY 2025 budget request builds on these investments through
    funding under the following programs:
      --The School Safety National Activities request would provide
            approximately $39.8 million under for new awards under SBMH and
            MHSP programs.
      --Funding under Student Support and Academic Enrichment program can
            be used to support safe and healthy students and provide
            school-based mental health services, including through
            partnerships with mental health or healthcare entities. The
            request for this program aims to increase access to school-
            based health services, including mental health services, for
            students enrolled in Medicaid and the Children's Health
            Insurance Program (CHIP). The Department is considering using a
            portion of the FY 2025 funds reserved for technical assistance
            and capacity building to further assist States and LEAs to
            implement and expand school-based physical and mental health
            services. Working in close coordination with the newly launched
            technical assistance center for school-based Medicaid run by
            the Centers for Medicare and Medicaid Services, the Department
            would continue to provide technical assistance and resources
            for States and LEAs to address physical and mental health needs
            of students.
      --The request for Full-Service Community Schools would support
            efforts to increase access to school-based health services,
            including mental health services, for students enrolled in
            Medicaid and CHIP. Community schools, which often offer mental
            and physical healthcare services to students, may be well
            positioned to leverage Medicaid and CHIP funding to expand the
            school-based services offered to students.
        Question. What does the Department see as the primary challenges
    facing efforts to increase the numbers of school-based mental health
    professionals?
        Answer. Funding and access to licensed mental health professionals
    appear to be significant challenges to providing school-based mental
    health services according to results from the NCES School Pulse Survey
    for the 2023-2024 school year reported in March of 2024. Data from that
    survey indicated that only 48 percent of public schools agree that they
    are able to effectively provide mental health services to all students
    in need. Inadequate funding was identified as a limiting factor for 57
    percent of public schools, and inadequate access to licensed mental
    health professionals was identified as a limiting factor for 53 percent
    of public schools. A 2022 GAO report documented financial, educational,
    and workplace challenges for recruiting and retaining behavioral health
    providers that are relevant to school settings. These challenges
    include (1) low reimbursement rates and compensation for behavioral
    services; (2) a lack of a pipeline for recruitment for underserved
    populations to enter the workforce because many programs designed to
    recruit diverse behavioral health providers only benefit individuals
    already studying in a behavioral health field; and (3) a workload for
    behavioral health providers that is often high, which can lead to
    providers burning out and leaving the field.
        Question. Education Research: I appreciate that the Department is
    looking to diversify the types of institutions that receive funding
    from the Institute of Education Sciences (IES).
        What is the Department of Education planning to do in FY 2025 to
    ensure more funding goes out to research institutions that have not
    traditionally received IES funding?
        Answer. The Research Centers at IES (National Center for Education
    Research (NCER) and National Center for Special Education Research
    (NCSER)) are also implementing broad outreach strategies to research
    institutions across the nation. We are working collaboratively with our
    colleagues in other parts of the Department to ensure that our funding
    opportunities are shared broadly. In addition, we have announced our
    primary competitions with sufficient time so that our program officers
    can provide technical assistance to new applicants.
        Under its Research Training in the Education Sciences grant program
    (84.305B), NCER has developed opportunities for early career
    researchers from any research institution to submit applications for
    smaller grants. These efforts have resulted in NCER providing research
    grants to two MSIs and one research institution for the first time.
    NCER continues to reach out to potential early career applicants at
    institutions that traditionally have not been grantees.
        The Research Training in the Education Sciences grant competition
    also supports our Pathways to the Education Sciences program (https://
    ies.ed.gov/ncer/projects/program.asp?ProgID=95) which are awarded to
    awarded to minority-serving institutions (MSIs) and their partners. To
    date, IES has made twelve awards to seven MSIs. IES intends to invite
    applicants to this program in FY 2025.
        NCER has also launched several programs intended to increase the
    number of applications we receive from a different and wider range of
    applicants. For example, both our Transformative Research in the
    Education Sciences and our Using Longitudinal Data to Support State
    Education Policymaking programs require partnerships with industry (the
    Transformative program) and with state and local education agencies.
        Question. How are you working to facilitate innovative education
    research at IES?
        Answer. IES recently established the Accelerate, Transform, Scale
    (ATS) Initiative, which supports advanced education research and
    development (R&D) to create scalable solutions to improve education
    outcomes for all learners and eliminate persistent achievement and
    attainment gaps. The ATS Initiative is inspired by the advanced
    research projects agencies (ARPAs) found throughout the Federal
    government. ARPAs leverage insights from basic and applied research to
    develop and scale breakthrough solutions and capabilities in focused
    areas that research and industry do not traditionally support.
        Through this initiative, IES is investing in bold, innovative ideas
    that come from interdisciplinary, diverse teams that have the potential
    to make dramatic advances towards solving seemingly intractable
    problems and challenges in the education field. A central part of IES's
    innovative education research investments is incentivizing partnerships
    between research institutions and other important education
    stakeholders. For example, the California Policy Lab (based at UC
    Berkely and UCLA) partnered with the California Community College
    Chancellor's Office, the University of California Office of the
    President, the California Department of Social Services, and the
    California Student Aid Commission. By combining data from these
    organizations, the researchers can estimate both the number of CA
    college students eligible for SNAP benefits and the number receiving
    them. The research is likely to lead to innovations in how the program
    is provided and disseminated in response to the finding of a wide gap
    between eligibility and receipt, and differences in how students are
    treated based on the type of college they attend. (Note: the report
    will be released tomorrow if we want to link to it).
        In the Transformative Research in the Education Sciences program,
    IES requires teams to include a partnership between a research
    organization, product development organization, and education agency.
    Awardees must also establish a cost sharing partner by the start of the
    second year of their grant to ensure that there is another entity with
    a vested interest in the sustainability of the project.
        Through its Statistical and Research Methods in Education grant
    program, IES is supporting the development of research methods that
    allow researchers to do new types of analyses and design new or
    improved research projects.
                                     ______

                  Questions Submitted by Senator Jeff Merkley
    TRIO and FAFSA
        Question. The rollout of the new FAFSA has been difficult for
    students and colleges across the country. One such population that has
    been negatively impacted by the new FAFSA is students who might be
    eligible for TRIO.
        TRIO law stipulates that to qualify for the program, students must
    demonstrate that their family's taxable income did not exceed 150% of
    the Federal poverty level. However, under the new FAFSA, TRIO programs
    are unable to automatically access information about whether a student
    qualifies for TRIO (their family's taxable income).
        Now, to obtain the information needed to determine students'
    eligibility, TRIO programs must ask students to submit a waiver to
    their financial aid offices consenting to the release of their Federal
    tax information. The student must then return to the TRIO office with
    this information, which the program will then use to determine program
    eligibility. This is a very cumbersome process that adds additional
    barriers to students' participation in TRIO.
        Secretary Cardona, is the Department of Education doing anything to
    address this problem or does Congress need to pass legislative language
    to fix this issues?
        Answer. The Department continues to prioritize our work in rolling
    out the new FAFSA. Specific to TRIO eligibility, we agree that the
    current definition of low-income in TRIO statute is overly restrictive
    and creates barriers for TRIO grantees seeking to enroll otherwise
    eligible students that meet commonsense definitions of low-income. For
    that reason, the Administration proposed appropriations language in the
    FY 2025 President's budget that would broaden the definition of low-
    income to provide TRIO grantees with greater flexibility in determining
    whether a potential TRIO participant qualifies as a low-income
    individual. The proposed language would allow TRIO grantees to, when
    determining whether a potential participant is a low-income individual,
    consider whether the potential participant or their immediate family
    has participated in the past year in certain Federal assistance
    programs, in addition to the existing criteria set forth in the HEA. We
    believe that this proposed language would reduce barriers for
    recruiting and enrolling eligible participants, thereby ensuring that
    TRIO grantees are able to serve the students with the greatest need.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
    Student Debt Forgiveness
        Question. Our national debt continues to grow and recently exceeded
    $34 trillion. This Administration's new student loan cancellation
    proposal is estimated to cost as much as $750 billion. We simply cannot
    afford to add another $750 billion to the national debt.
        There are already more than 50 student loan repayment and
    forgiveness programs that aim to attract individuals to vital service
    jobs, such as teachers, healthcare workers, and public servants. This
    Administration's student debt cancellation programs undermine these
    programs and force hard-working taxpayers who already paid off their
    loans or did not go to college to shoulder the cost. Instead, we should
    be focusing on bipartisan student debt reforms that take commonsense
    steps to fill the gaps in our workforce.
        That is why I introduced the bipartisan SMARTER Debt Act. This bill
    would establish an interactive, online dashboard at the Department of
    Education to improve public access to information about these existing
    student loan programs that aim to attract borrowers to public service
    and highly needed professions.
        Will you support my commonsense proposal to promote student loan
    forgiveness programs that aim to fill the gaps in our workforce
    shortages?
        Answer. We would be happy to discuss with your office the best ways
    to make sure that borrowers are aware of the forgiveness opportunities
    available to them.
        Question. Can the Department commit to promoting these existing
    programs to further incentive students to enter into public service,
    teaching, and healthcare?
        Answer. The Department believes that programs that provide relief
    for public service, particularly the Public Service Loan Forgiveness
    Program, are critical for ensuring that students are able to work in
    public service professions. We have and will continue to promote PSLF.
    If there are other Federal programs that we should consider, we would
    be happy to have a conversation with your office.
    FAFSA and Homeless Youth
        Question. While we are all aware of the many of the challenges
    surrounding the launch of the new Free Application for Federal Student
    Aid (FAFSA), the application delays have been particularly burdensome
    for students in foster care and students experiencing homelessness. The
    West Virginia Department of Education identified more than 13,530
    students who experienced homelessness last school year.
        For anyone to move out of poverty and live a healthy life, it's
    helpful to have some sort of postsecondary education or skills
    training. One of the most significant barriers to access is financial
    aid. Without it, they cannot transition to and complete their college
    education--leaving them at a higher risk of continued homelessness and
    hardship as adults.
        The FAFSA Simplification Act included provisions to remove barriers
    that are commonly faced by youth experiencing homelessness--
    specifically all of the documentation they needed to ``prove'' that
    they have no home. However, I am disappointed to hear about the ongoing
    challenges that these students are facing during the Department's
    rollout of the FAFSA.
        Can you share how the Department plans to resolve the documentation
    challenges that youth experiencing homelessness are facing and how the
    Department plans to provide assistance to these students?
        Answer. The Department has published via Electronic Announcement
    (GEN-23-06) and the FSA Handbook clear guidance outlining the
    responsibilities of the Financial Aid Administrator in implementing the
    provision of the FAFSA Simplification Act as it related to
    Unaccompanied Youth and Homeless determinations. We will continue to
    emphasize this guidance with the financial aid community.
    FAFSA Completion Concerns
        Question. West Virginia's high school FAFSA completion rates are
    down nearly 40 percent, despite holding over 200 FAFSA workshops across
    the state. Students and parents have become increasingly frustrated
    when they receive errors and have to wait for the Department to
    reprocess them.
        Every student and their family deserve to know the full cost of
    going to college before they make such an important decision. Students
    should have all of the facts necessary to learn the best way to finance
    a college education, and these persistent FAFSA changes and delays are
    ultimately affecting these students' ability to pursue a college degree
    and will harm those most in need of aid.
        How is the Department assisting states, like my home state of West
    Virginia, who are experiencing lower than average FAFSA completion
    numbers?
        Answer. The Department is keeping careful track of the states who
    have lower than average FAFSA completion numbers this cycle and is
    implementing a variety of tactics to provide support, including
    dedicated outreach to make state officials aware of the Student Support
    Strategy--which provides funds for FAFSA completion efforts over the
    summer months, dedicated weekly office hours for state personnel to
    join with senior ED and FSA leaders to get information, share best
    practices, and ask questions, and importantly, sharing data through
    weekly emails to state, district, and local leadership about submission
    and completion data and metrics by state and district. Further, ED is
    working with national non-profit and college access organizations to
    direct surge capacity over the summer months to states needing support,
    is providing targeted direct messaging through existing communication
    channels and promotional campaigns, and is collecting state-specific
    data via survey about student completion portals and LEA utilization
    rates in order to provide and/or direct technical, operational, and
    philanthropic support over the summer months.
    FAFSA Impacts on Schools
        Question. While colleges and universities are already extending
    their decision deadlines to give prospective students enough time to
    weigh their admissions offers, schools are now experiencing delays in
    even being able to send their financial aid packages out as the
    Department continues to find errors and reprocess FAFSA applications.
        These continuous delays and the Department's frequently changing
    guidance are creating uncertainty around college decisions for
    institutions, students, and their families. Not being able to provide
    financial aid information prevents students and their families from
    being able to make timely and informed financial decisions. This puts
    additional financial strain on families which in turn can be
    detrimental to institutions of higher education who have experienced
    declining enrollment since the COVID-19 pandemic.
        With these ongoing FAFSA issues, colleges are reporting significant
    declines in undergraduate deposits, potentially forecasting another
    decline in enrollments this fall.
        When does the Department plan to publish the draft FAFSA form for
    the 2025-2026 school year?
        Can the Department commit to making the form for school year 2025-
    2026 available to complete online by October 1, 2024?
        Answer. The Department has already received and processed over
    12.22 million FAFSA forms, 11.68 million of which have been processed
    as of July 9, 2024. The Department has made significant progress in
    closing the gap in FAFSA submissions to 5.7 percent as of July 9
    compared to this time last year, down from nearly 40 percent in March.
    Nearly all four-year colleges and universities are packaging aid offers
    for students who are now making enrollment decisions.
        We have heard from students, families, institutions, states, and
    those that support them that it is important for the FAFSA form to
    launch on October 1. The Department is working toward this goal.
        To ensure a consistent and smooth user experience during the
    upcoming FAFSA cycle, the 2025-26 FAFSA will remain consistent with the
    2024-25 form. As a result, and similar to previous years when we have
    not had major shifts in functionality, the 2025-26 form will not be
    made available for public comment. However, we will continue to focus
    our efforts on improving the user experience for students, families,
    and our partners and will collect feedback to inform our efforts
    through a series of listening sessions and a Request for Information
    (RFI) this summer to solicit feedback from those not able to attend the
    sessions.
        The Department will request specific feedback on ways to improve
    the help text on the form, student tip sheets, or other direct
    communication to students to ensure students can successfully complete
    and submit the form. The Department will also request feedback from
    financial aid administrators, counselors and others on ways the
    Department can provide additional support to them in their work.
        The listening sessions and RFI will also lead to the development of
    a new Better FAFSA Better Future Roadmap--to be released in late
    summer--that will outline new tools the Department is making available,
    such as additional trainings, webinars, counselor guides, and student
    tip sheets.
    Homeless Youth
        Question. During the height of the COVID-19 pandemic, I was proud
    to secure additional funding for the education of homeless children and
    youth in the response to evidence that children and youth experiencing
    homelessness were disproportionately impacted by school closures, yet
    were largely overlooked in the first two COVID-19 packages. Those
    funds, the American Rescue Plan--Homeless Children and Youth (ARP-HCY)
    funds must be obligated by September 30th of this year.
        Unfortunately, youth homelessness has worsened since the pandemic,
    and in the last year there has been a 16% increase in the number of
    families in homeless shelters. In 2023, the West Virginia Department of
    Education has identified more than 13,530 students who experienced
    homelessness. With the increase in student homelessness, I was pleased
    that the President's budget requested $129 million for McKinney-Vento
    education dollars.
        Given the increase in student homelessness, the incredible impact
    of the ARP- HCY funds for which I advocated, and the fact that current
    funding level only allows 1 out of 5 school districts to receive
    targeted support, can you share what the Department is doing to support
    and address the rise of homeless youth in West Virginia and across the
    country?
        Answer. The ARP-HCY funds presented unprecedented opportunities for
    SEAs and LEAs to enhance their ability to assist children and youth
    experiencing homelessness. While the ongoing McKinney-Vento Education
    for Homeless Children and Youths (EHCY) program typically focuses on
    educationally related support service needs, the ARP-HCY funds allow
    SEAs and LEAs to collaborate with other agencies and organizations to
    form a comprehensive support system for addressing various needs for
    students in the form of wrap-around services. The Department required
    States to allocate at least 75 percent of the ARP-HCY funding to LEAs
    via subgrants, which allowed SEAs to offer subgrants to LEAs that had
    not previously had an EHCY subgrant to improve their capacity to
    identify and support the needs of students experiencing homelessness.
    The remaining funds were available for State-level activities to
    support training, technical assistance, capacity-building, and
    engagement at the State and LEA levels.
        In addition, the Department's National Center for Homeless
    Education (NCHE) provides support to help States and LEAs maximize
    their ARP-HCY funds. The Department has offered regular webinars,
    office hours, and other presentations at national conferences on
    supporting implementation of the EHCY and ARP-HCY programs, including
    strategies for maximizing the obligation of funds and building
    sustainable impact (given that the ARP-HCY funds are a one-time
    investment). NCHE offers a range of products and services for homeless
    education staff and stakeholders in both States and LEAs, such as
    topical reports and briefs, including program practice spotlights from
    around the country, topical ad hoc workgroups of SEA staff, and
    regularly maintaining a hotline and website.
        Each SEA receives customized technical assistance by NCHE to meet
    their specific needs. This includes support with how to analyze its LEA
    data on students experiencing homelessness and strategies for
    obligating funds in collaboration with community-based organizations
    who also serve these students and their families. Department staff
    continue to regularly engage with SEA staff to provide support and help
    them maximize the reach and value of the ARP-HCY funds to meet the
    needs of homeless children and youth by the obligation deadline of
    September 30, 2024.
        Question. 52% of students experiencing homelessness were
    chronically absent during the 2021-2022 school year. Students
    experiencing homelessness face unique barriers to school attendance,
    including frequent moves that make transportation difficult, lack of
    basic needs like clothes and hygiene products, and more. Within the
    Department's efforts to reduce chronic absenteeism, what specific
    actions are being taken to address the high chronic absence rates of
    students experiencing homelessness?
        Answer. Chronic absenteeism is one of the performance measures for
    the EHCY program, so the Department tracks year-to-year performance
    nationally and by State. Furthermore, information is made public
    annually on ED Data Express and through the Department's National
    Center for Homeless Education. Both the Department and NCHE highlight
    this topic and data on chronic absenteeism among students experiencing
    homelessness and strategies for addressing this issue in presentations,
    webinars and other communications. In Dear Colleague Letters on the
    ARP-HCY program and various webinars and other communications, the
    Department has addressed allowable uses of funds that address chronic
    absenteeism from transportation and health barriers to strategies to
    engage and support students experiencing homelessness. For example,
    wraparound services, even provision of clothing and food, extra-
    curricular activities, can be tied to reducing chronic absenteeism.
    Finally, in its approaches to addressing the increase in chronic
    absenteeism among public school students in general, the Department has
    focused on the needs of special populations such as students
    experiencing homelessness.
        Question. Will the Department issue public guidance affirming that
    the allowable uses of ARP-HCY funds, as explained in the September 2023
    Dear Colleague Letter to Chief State School Officers, are also
    allowable under Education for Children and Youth funds, including
    short-term motel stays when reasonable and necessary and used as a last
    resort when no other options are available?
        Answer. The Department does not have plans to issue guidance
    specific to this particular use of funds under the EHCY program.
    However, please note that in the September 2023 DCL, this particular
    use of funds had a footnote with the following explanation:
        ``The ARP-HCY statute provides additional emergency funding to SEAs
    and LEAs to enable homeless children and youth to attend and fully
    participate in school and to provide these children and youth with
    wraparound services given the COVID-19 pandemic. As an emergency
    program, the Department has determined that using ARP-HCY funds for
    short-term emergency housing is consistent with the purpose of the ARP-
    HCY statute and could be allowable as a wraparound service made
    necessary by circumstances precipitated by or related to the COVID-19
    emergency, provided the cost of the housing is reasonable and necessary
    and all other requirements are met. This use of funds would not,
    however, be allowable under the regular EHCY program.''
        In our webinar on May 28, 2024, on ``Maximizing Unobligated ARP-HCY
    Funds,'' the Department clarified that it is possible for SEAs and LEAs
    to use ARP-HCY funds to extend the provision of this service as late as
    March 2026, if the SEA applies for liquidation extension for this
    period of time and the SEA or LEA contracts with a community-based
    organization to provide short-term temporary housing to students
    experiencing homelessness.
        Question. Will the Department provide sample language that States
    can utilize in their late liquidation applications for ARP-HCY to ease
    the burden on them and streamline the process for the Department?
        Answer. Yes. The Department has established a template to
    streamline State's applications for late liquidation and has provided a
    number of technical assistance opportunities to clarify the process for
    SEAs. For example, the Department held two webinars and a presentation
    on this topic and will be holding monthly office hours on ARP-HCY
    liquidation extension, starting in June 2024, to discuss the process
    and examples of how submit complete requests. This will build on the
    substantial work already in place, including the technical assistance
    webinars following the release of the CARES Act funding liquidation
    extension request template in October and November 2022 and the work to
    provide late liquidation for the ESSER and GEER programs.
    Communications to grantees detailing the ARP-HCY liquidation extension
    process are available on the Department's ARP-HCY webpage under
    ``Fiscal Information'' (https://oese.ed.gov/offices/american-rescue-
    plan/american-rescue-plan-elementary-secondary-school-emergency-relief-
    homeless-children-youth-arp-hcy/fiscal-information/). Our policy for
    requesting an ARP-HCY liquidation extension is not new for SEAs; it is
    consistent with the templates for ESSER I-III and EANS.
        Question. Title I, Part A requires that LEAs receiving such funds
    set aside such sums as may be necessary to provide educationally
    related support services to assist students experiencing homelessness.
    What efforts have been made by the Department to encourage LEAs
    receiving Title I, Part A funds that have not identified students
    experiencing homelessness to use their set aside funds for
    identification purposes?
        Answer. The Department does not interpret the revised statutory
    language for the Title I, Part A LEA homeless reservation as requiring
    a set-aside of all LEAs receiving Title I, Part A funds if the LEA does
    not have any identified students experiencing homelessness enrolled in
    the LEA. Having said that, the Department is committed to supporting
    meaningful implementation of the Title I, Part A reservation for
    students experiencing homelessness. In our recent technical assistance
    and monitoring we have encouraged SEAs and LEAs to use recent trend
    data on homeless student enrollment and achievement gaps to determine a
    necessary and reasonable amount that is sufficient to address the
    unique needs of students experiencing homelessness.
        This topic has also been a significant part of the Department's
    monitoring efforts. The Department recently revised our monitoring
    protocol for McKinney-Vento to include questions about the Title I,
    Part A homeless set-aside and have had findings in several States that
    require the SEA to issue joint Title I and McKinney-Vento guidance to
    LEAs concerning how to determine a sufficient LEA homeless reservation.
    As a result, three SEAs monitored in recent years have already posted
    new guidance on their websites (i.e., South Carolina, Arkansas and
    Michigan). Other states are in the process of resolving corrective
    action on this matter by summer 2024 (e.g., Minnesota and Illinois).
    The Department has focused on this finding in our technical assistance
    and webinars with all SEAs, including both at conferences of State
    Title I coordinators and our annual conference of McKinney-Vento
    Education for Homeless Children and Youth program State Coordinators.
    We focused on the need by the SEA to provide this kind of oversight and
    guidance or technical assistance to all LEAs enrolling students
    experiencing homelessness. An LEA without an enrolled student
    experiencing homelessness may also use local or trend data to set-aside
    an amount to improve the identification of such students and connecting
    them to educationally related support services.
        As a further step for ensuring accountability on this issue, we
    have taken steps to improve transparency of SEA data. In February 2024,
    States submitted, for the first time, data on LEA reservations of Title
    I-A funds that includes the initially reserved amount to serve students
    experiencing homelessness. The Department is currently reviewing these
    data. Having these data will allow the Department compare the Title I
    homeless set-aside to the homeless student count. This analysis will
    show the number of LEAs that have not set-aside funds to address
    student homelessness and will inform our monitoring and technical
    assistance activities in FY 2025.
        Finally, the Department's National Center for Homeless Education
    (NCHE) has supported implementation of the Title I, Part A set-aside
    requirements through general technical assistance and targeted
    assistance to grantees. For example, NCHE published a training module
    entitled ``Title I, Part A Reservation of Funds for Students
    Experiencing Homelessness'' in April 2023 (https://nche.ed.gov/title-i-
    pre-recorded-webinar/). NCHE has also updated its LEA Needs Assessment
    Tool (https://nche.ed.gov/needs-assessment/), which includes a section
    specific to the Title I, Part A reservation.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
    FAFSA Implementation
        Question. I'm concerned that the Department used time, resources,
    and personnel to advance its priorities around canceling student debt
    that otherwise would have been directed towards implementing the FUTURE
    Act and the FAFSA Simplification Act.
        How many staff at the Department worked exclusively on
    implementation of the FAFSA Simplification Act and the FUTURE Act?
        How many staff at the Department have spent any portion of their
    time working on debt cancellation or forgiveness efforts?
        Answer. Offices across the entire Federal Student Aid enterprise
    have and continue to support the 2024-25 FAFSA development and
    implementation in various capacities. This includes the Office of
    Student Experience and Aid Delivery, the Office of Partner
    Participation and Oversight, the Policy Implementation and Oversight
    Directorate, the Enterprise Technology Directorate and others. Many of
    these offices and others, such as the Partner Enforcement and Consumer
    Protection Directorate, are involved in ensuring that students receive
    access to student loan forgiveness programs for which they are
    eligible.
        Other offices across the Department also support the implementation
    of FAFSA Simplification Act and FUTURE Act including: Office of the
    Secretary, Office of the Deputy Secretary, Office of the Under
    Secretary, Office of Communications and Outreach, Office of Legislation
    and Congressional Affairs, Office of the General Counsel, Office of
    Postsecondary Education, and the Office of Planning, Evaluation and
    Policy Development.
        Question. The Department is facing a crisis of credibility and
    trust with financial aid offices, students, families, counselors, and
    the general public as a result of the continued delays and errors
    surrounding the 2024-25 FAFSA. This not only creates issues during the
    award year, but could result in effects that spill over into next
    year's cycle.
        What efforts are being made to restore trust with students,
    families, institutions, and the public?
        Answer. The Department recently outlined comprehensive steps it is
    taking to improve Federal Student Aid (FSA) for students, families,
    borrowers, and schools. These efforts will ensure FSA works better and
    addresses ongoing management and operational challenges. Specifically,
    the Department has or is taking the following steps:
      --Searching for a new Chief Operating Officer (COO) for FSA.
      --Conducting a full-scale review of FSA's current and historical
            organization, management, staffing, workflow structures,
            business processes, and operations to continue bringing the
            Federal financial aid system into to the 21st century.
      --Hired an independent consulting firm to make recommendations to the
            COO and the Secretary on ways to improve the design, structure,
            and processes within FSA, with a focus on building an updated
            organizational structure and workflow.
      --Reviewing contracts and acquisition procedures to ensure contracts
            are appropriately structured to hold vendors accountable for
            meeting key deadlines, achieving desired outcomes, and
            providing the best value to the agency and protecting
            taxpayers' resources.
      --Restructuring senior leader reporting protocols to increase
            accountability and make sure we provide the best value to the
            agency and protect taxpayers' resources.
      --Creating a new IT innovation team empowered to lead information
            technology design to support the digital transformation of the
            organization. This new team will oversee recruitment of top
            engineers, project managers, and designers who will bring
            critical information technology expertise and experience to
            strengthen FSA's work in this area.
      --Seeking input from the Office of the Inspector General (OIG) and
            engaging Members of Congress, whose constituents receive
            services from FSA.
      --Continuing our robust outreach efforts to parents, students,
            colleges, and community organizations, and conduct listening
            sessions with them this summer.
        In addition, the Department announced Jeremy Singer as FAFSA
    Executive Advisor in FSA to lead the FAFSA overall strategy and
    accelerate technology innovation to further enhance FSA's technical and
    operational capabilities.
        We have heard from students, families, institutions, states, and
    those that support them that it is important for the FAFSA form to
    launch on October 1. The Department is working toward this goal and
    toward launching other functionality to ensure students receive timely
    aid offers for the 2025-26 award year as quickly as possible.
        As part of the effort to launch the 2025-26 form, the Department
    will also request feedback from financial aid administrators,
    counselors and others on ways the Department can provide additional
    support to them in their work.
        Question. Even though the Department is still in the midst of
    dealing with issues for this current FAFSA cycle, staff should also be
    focusing on the development of the 2025-26 FAFSA. The Department has
    not yet released any information on whether the 2025-26 FAFSA is on
    track, or whether additional delays should be expected. What we do know
    is that in a typical year, the draft FAFSA is released for public
    comment by late February, and to date, the 2025-26 draft FAFSA has not
    yet been released.
        Where does the FAFSA development cycle for the 2025-26 award year
    currently stand?
        What are you doing to ensure that the delays and errors that
    plagued this FAFSA cycle are not repeated?
        Can you commit that the 2025-26 FAFSA will be available and fully
    functional by October 1, 2024?
        Answer. We have heard from students, families, institutions,
    states, and those that support them that it is important for the FAFSA
    form to launch on October 1. The Department is working toward this goal
    and launching other functionality to ensure students receive timely aid
    offers for the 2025-26 award year as quickly as possible.
        The Department has announced Jeremy Singer, president of the
    College Board, as a new FAFSA Executive Advisor. He will lead FSA's
    overall strategy on the 2025-26 FAFSA form, working closely with the
    Department's leadership and the FAFSA implementation team to strengthen
    internal systems and processes, bolster technical capabilities, and
    drive innovation to help ensure optimal performance leading to the
    launch of the 2025-26 FAFSA form.
        Senior leadership at the Department will continue to work closely
    with career staff to ensure the 2025-26 FAFSA is launched and ready for
    students to submit applications on an expected timeline of October 1,
    2024.
        To ensure a smooth user experience during the upcoming FAFSA cycle,
    the 2025- 26 FAFSA form will remain consistent with the 2024-25 form.
    As a result, and similar to previous years when we have not had major
    shifts in functionality, the 2025-26 form will not be made available
    for public comment. However, we will continue to focus our efforts on
    improving the user experience for students, families, and our partners
    and will collect feedback to inform our efforts through a series of
    listening sessions and a Request for Information (RFI) this summer to
    solicit feedback from those not able to attend the sessions.
        The Department will request specific feedback on ways to improve
    the help text on the form, student tip sheets, or other direct
    communication to students to ensure students can successfully complete
    and submit the form. The Department will also request feedback from
    financial aid administrators, counselors and others on ways the
    Department can provide additional support to them in their work.
        The listening sessions and RFI will also lead to the development of
    a new Better FAFSA Better Future Roadmap--to be released in late
    summer--that will outline new tools the Department is making available,
    such as additional trainings, webinars, counselor guides, and student
    tip sheets.
        Question. Beyond a properly working FAFSA, there are several
    additional milestones that are critical to ensuring a smooth
    application experience for students, including the delivery of
    applicant data to institutions, the ability for students and schools to
    make corrections, and the processing of paper FAFSAs.
        When will ED make available a roadmap of resources and key delivery
    dates for these deliverables in the 2025-26 FAFSA cycle?
        Can the Department ensure that for the 2025-26 award year, ISIR
    processing timelines, availability of student, parent, and
    institutional corrections, and processing of paper FAFSAs will return
    to the usual schedule of being available when the 25-26 FAFSA goes
    live?
        Answer. We have heard from students, families, institutions,
    states, and those that support them that it is important for the FAFSA
    form to launch on October 1. The Department is working toward this goal
    and toward launching other functionality to ensure students receive
    timely aid offers for the 2025-26 award year as quickly as possible.
        The Department has announced Jeremy Singer, president of the
    College Board, as a new FAFSA Executive Advisor. He will lead FSA's
    overall strategy on the 2025-26 FAFSA form, working closely with the
    Department's leadership and the FAFSA implementation team to strengthen
    internal systems and processes, bolster technical capabilities, and
    drive innovation to help ensure optimal performance leading to the
    launch of the 2025-26 FAFSA form.
        Senior leadership at the Department will continue to work closely
    with career staff to ensure the 2025-26 FAFSA is launched and ready for
    students to submit applications on an expected timeline of October 1,
    2024.
        To ensure a smooth user experience during the upcoming FAFSA cycle,
    the 2025-26 FAFSA form will remain consistent with the 2024-25 form. As
    a result, and similar to previous years when we have not had major
    shifts in functionality, the 2025-26 form will not be made available
    for public comment. However, we will continue to focus our efforts on
    improving the user experience for students, families, and our partners
    and will collect feedback to inform our efforts through a series of
    listening sessions and a Request for Information (RFI) this summer to
    solicit feedback from those not able to attend the sessions.
        The Department will request specific feedback on ways to improve
    the help text on the form, student tip sheets, or other direct
    communication to students to ensure students can successfully complete
    and submit the form. The Department will also request feedback from
    financial aid administrators, counselors and others on ways the
    Department can provide additional support to them in their work.
        The listening sessions and RFI will also lead to the development of
    a new Better FAFSA Better Future Roadmap--to be released in late
    summer--that will outline new tools the Department is making available,
    such as additional trainings, webinars, counselor guides, and student
    tip sheets.
    Return to the Office
        Question. The COVID national emergency has been over for almost a
    year now and, last August, the White House Chief of Staff encouraged
    agencies to bring back in-person work policies. What is the Department
    of Education's in-person work requirement?
        Answer.
      --Currently, non-bargaining unit employees on a telework agreement
            are required to come into the office 5 days a pay period.
      --Upon completion of our bargaining obligations, the agency
            anticipates increased in- person presence for bargaining unit
            employees of 5 days a pay period.
        Question. Approximately what percentage of the ED workforce is back
    in the office five days a week?
        Answer. Out of the employees required to be in the office five days
    a week, 51% are back in the office.
    Student Loan Forgiveness
        Question. Earlier this month, the Department of Education published
    a draft regulation governing the President's ``Plan B'' student loan
    forgiveness program that is estimated to cost over $147 billion.
    However, the draft is actually only part of the proposed program. The
    Department's press release said an additional rule will be published
    ``over the course of the coming months'' for borrowers who experience
    financial hardship. That rule is expected to be so broad that it would
    very likely result in forgiveness even more costly than the program
    struck down by the Supreme Court last summer. Just like the last
    illegal forgiveness plan, both the current and expected draft rules are
    far outside the scope of what Congress intended in the law.
        Do you think Congress intended for the Department of Education to
    make up rules to forgive hundreds of billions of dollars of student
    loans when it wrote the Higher Education Act?
        Answer. We believe the regulations being proposed provide important
    clarifications and transparency into longstanding authority granted to
    the U.S. Secretary of Education under the Higher Education Act.
        Question. Will the Department commit that all forthcoming
    forgiveness rules will have at least thirty days between final
    publication and effective date, as required by the Administrative
    Procedures Act?
        Answer. Generally, regulations promulgated under title IV of the
    HEA are Subject to a master calendar requirement in which regulations
    finalized before November 1 of a given year take effect the following
    year. That same statute provides authority to exercise early
    implementation of provisions at the discretion of the Secretary. We
    believe that authority dictates the timing of regulations related to
    Federal financial aid.
    Communities in Schools
        Question. The Department's FY 2025 budget would dedicate a
    significant amount of funding to provide support for planning and
    capacity building of services--such as integrated student supports--for
    traditionally underserved students in the Full Service Community
    Schools program. CIS and community schools have had tremendous impact
    in West Virginia, including serving over 114,000 students with the
    supports needed to succeed in school and life across 272 schools in 55
    counties. 89% of these students graduated or got a GED, 82% improved
    academics, and over 99% stayed in school. The planning and capacity
    building grants proposed by ED could provide early support for new and
    less experienced grantees to focus on one of the four pillars of
    community schools, like evidence-based integrated student supports,
    designed to meet the urgent needs of local communities, while they
    decide if they will apply for a full grant.
        What does the Department feel will be the benefits of planning
    grants as part of this program? What went into the choice to make this
    request in looking at past applicants and grantees? Are there
    improvements needed in the program?
        Answer. Efforts to increase investments in the planning stage will
    allow for new and less experienced grantees to develop community
    schools designed to meet the greatest needs of local communities. The
    planning and capacity building grants provide a critical on-ramp for
    local communities to eventually run full-service community schools.
        Question. Does ED feel it needs additional authority to operate
    planning grants in the program, or can you run them on your own under
    the existing program?
        Answer. Yes. ESEA section 4625(c) authorizes grantees to use not
    more than 10 percent of the total amount of grant funds for planning
    purposes during the first year of the grant. To allow grantees to spend
    their entire award on planning activities, the Department would need
    additional authorization.
        Question. If so, will you work with Congress to make sure the goals
    of the planning grants are fulfilled, Congressional ideas and intent
    will be considered, and new and lower capacity organizations will
    receive the planning grants to improve services to students?
        Answer. Yes, the Department will work with Congress to ensure the
    goals of the planning grants are fulfilled and lower capacity
    organizations will receive planning grants.
    Inclusive Access
        Question. The Department is attempting to significantly alter a
    program that allows college students to receive their course materials
    at below market prices and before the first day of class. In the decade
    since this program took effect, data from the College Board has
    demonstrated that student spending on course materials has decreased by
    over 40 percent, which indicates that these affordable access programs
    are working. My understanding is that the Department has completely
    dismissed concerns from a wide range of colleges and universities,
    students, faculty, and other stakeholders that the Department's
    proposed regulations would undermine these affordable access programs.
        Has the Department conducted any studies to determine if its
    proposed changes are sustainable, and in particular whether students
    would still receive the same price discounts and automatic first-day-
    of-class access under the Department's proposed ``opt-in'' framework?
        If not, will you commit to doing so before promulgating these
    regulations?
        Answer. The Department's current regulations permit schools to
    automatically charge students for books and supplies as part of tuition
    and fees, without student authorization, even when the materials can be
    obtained from a source other than the Institution. The regulations
    permit these charges if the school has a contract with a third-party
    publisher or retailer, offers the books ``below competitive market
    rates,'' and gives students a way to opt out, so long as the student
    can obtain the books and supplies by the seventh day of the payment
    period.
        As the Department explained in the first issue paper for the
    negotiated rulemaking committee, the Department has proposed additional
    rulemaking to address this policy issue due to a concern ``that lack of
    disclosure and transparency limits students' ability to find less
    expensive materials or assess if their school is offering the most
    affordable arrangement.'' In feedback received in negotiated rulemaking
    and the Department's review of the issue, we have seen that some ``opt-
    out'' provisions are hidden or unclear and that costs are not truly
    below competitive market rates, with students repeatedly reporting that
    they can obtain books and supplies at a more affordable price. After
    consideration of information received from non-Federal negotiators and
    the public during the negotiated rulemaking sessions, the Department
    plans to release proposed language in a Notice of Proposed Rulemaking
    where it will seek additional public comment on the impact of the
    proposal.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. Secretary Cardona, at last year's budget hearing, I
    questioned you about the level funding the Charter School Program has
    received since Fiscal Year 2019, despite the increase in demand and
    growing student waiting lists across the country. You said that your
    department would continue to support charter schools, however, you are
    now asking for a $40 million decrease for Fiscal Year 2025. This is
    almost a 10 percent cut.
        How is the Department of Education continuing to support charter
    schools as an option for students when you propose cutting a large
    percentage of these effective and beneficial funds?
        Answer. The Administration's FY 2025 budget request reflects tough
    decision- making for a number of Department programs due to tight
    discretionary spending caps. For Charter Schools Grants, the request
    also reflects declines in demand for funding since 2019, 2 years prior
    to this Administration, (including lower demand for continuation
    funding than initially requested by current grantees in their
    applications) under State Entity, Developer, and CMO grants, which is
    consistent with the slowed growth in the number of charter schools
    operating across the country. Historical program performance data show,
    for example, that the number of charter schools in operation increased
    by an average of 167 schools per year between 2016 and 2022 (from 6,859
    schools to 7,860 schools), compared with an average annual increase of
    311 schools between 2010 and 2016 (from 4,991 schools to 6,859
    schools).
        While reflecting a lower request level than in prior years, the
    Department believes the request would be able to meet demand for new
    and continuation awards and help ensure that program funds can be fully
    and appropriately expended without the need for excessive frontloading
    of out-year costs or the possibility of funds reverting to Treasury.
    Between fiscal years 2019 and 2023, for example, 10 annual State Entity
    continuation grant awards were cumulatively reduced by approximately
    $66 million, generally due to lower demand for subgrants to open or
    expand schools than grantees projected in their applications.
        In addition, between fiscal years 2019 and 2022, nine existing CMO
    grantees voluntarily terminated their projects or had their funding
    discontinued by the Department, and 30 annual CMO continuation grant
    awards were reduced by an amount totaling nearly $57 million, generally
    as a result of grantees' inability to replicate or expand the number of
    schools planned in their applications.
        With grantees needing less funding to support fewer school openings
    and expansions than anticipated, the Department has had to rely
    increasingly on frontloading grantees' out-year project costs, make
    supplemental awards, or reprogram funds to other programs in the
    Innovation and Improvement account to avoid lapsing funds.
        Question. A Bachelor's Degree, though valuable, is not the only
    path toward success for students. Many forego the traditional four-year
    university to attend community college for an Associate Degree or to
    enroll in short-term training courses--choosing which path best fits
    their personal goals. In many cases, these students are able to join
    the workforce quickly to contribute to the local and national economy.
        Do you agree that the extension of the use of Pell Grants for job
    training programs would be a good way to lead people, who are not
    interested in a traditional four-year college, into satisfying careers?
        Answer. Any policy that extends the use of Pell Grants should
    include strong guardrails to protect students and taxpayers, as not all
    short-term job training programs are high-quality and lead to good
    jobs. The existing short-term job training programs that are already
    eligible for Federal loans have shown low wage outcomes and high costs,
    particularly among for-profit programs. Any effort to expand Pell
    Grants should preclude for-profits from being eligible entities,
    increase data transparency, improve oversight, and remove Federal
    student aid eligibility for failing programs.
        Question. The rollout of the new FAFSA continues to have harmful
    effects on schools and students. Because of delays and calculation
    errors, the college admissions cycle has been absolutely destabilized.
    It is shocking to see just how badly this process is going, despite
    having years to prepare, as well as an extension.
        When did work on the new FAFSA begin, and was it a priority for the
    department?
        Answer. Implementing FAFSA Simplification Act and FUTURE Act have
    always been a top priority for the Department.
        Testing for the new FAFSA began in early 2022, and executive
    leadership at the Department has been working closely with Federal
    Student Aid and other offices within ED since fall 2022 to set
    priorities, oversee project planning and implementation, and ensure
    accountability for the development and launch of the 2024-25 FAFSA.
    This detailed and frequent oversight will continue leading up to and
    through the 2025-26 FAFSA.
        Question. Why did it take a year and a half for a contract to be
    made in June of 2022 to modernize the system?
        Answer. The Award Eligibility Determination (AED) solution replaced
    the 45- year-old Central Processing System (CPS) and modernized the
    processing of Free Application for Federal Student Aid (FAFSA) forms.
    FSA conducted extensive market research to determine the most
    appropriate acquisition strategy to support its implementation; and FSA
    leveraged the results from this market research to ensure that all the
    appropriate tasks and legal review timeframes were built into the
    acquisition schedule to mitigate a pre- and post-award protest. For
    example, the review timeframes included extensive feedback
    opportunities for the FSA Contract Examiner, FSA Contract Review Panel,
    and the Department's Office of the General Counsel. Additionally, the
    schedule included the requisite timeframes to allow for contractors who
    offered a proposal to submit a pre- or post-award protest. With due
    diligence, the robust acquisitions schedule resulted in a solicitation
    award that did not result in any protests.
        Question. Secretary Cardona, when your confirmation was being
    considered by the Senate, you refused to take a position on Department
    of Education regulations protecting religious student groups, 34 CFR
    Sec. Sec. 75.500(d) and 76.500(d). These rules prohibit public college
    administrators from discriminating against student groups because of
    their sincerely held religious beliefs, speech, and leadership
    standards as a material condition of Department grants. However, your
    Department has proposed striking these protections in a Notice of
    Proposed Rulemaking (RIN 1840-AD72).
        When do you anticipate issuing a final rule for RIN 1840-AD72?
        Is the Department reconsidering its proposed rule pursuant to
    Fellowship of Christian Athletes v. San Jose Unified School District,
    the recent en banc decision from the Ninth Circuit Court of Appeals
    requiring a California school district to end its discrimination
    against a religious student group?
        If you still plan on rescinding these protections for religious
    groups to choose leaders that affirm their faith, please explain how
    doing so is consistent with the promise you made during your
    confirmation process to ``adher[e] to the U.S. Constitution and Federal
    law as interpreted by the Courts.''
        Answer. On February 22, 2023, the Department published a Notice of
    Proposed Rulemaking, RIN 1840-AD72, ``Direct Grant Programs, State-
    Administered Formula Grant Programs,'' and requested written comments
    via the Federal eRulemaking Portal at regulations.gov as outlined in
    the February Federal Register Notice.\3\ The due date for submitting
    comments was March 24, 2023. We are carefully reviewing all comments we
    received in developing a final rule, which we expect to issue this
    fall. The Department also monitors relevant court decisions in
    consideration of its rules throughout the rulemaking process and will
    take them into consideration as appropriate.
    ---------------------------------------------------------------------------
        \3\ See U.S. Dep't of Educ., Notice of Proposed Rulemaking on
    Direct Grant Programs, State-Administered Formula Grant Programs, 88 FR
    10857 (Feb. 22, 2023), https://www.Federalregister.gov/documents/2023/
    02/22/2023-03670/direct- grant-programs-state-administered-formula-
    grant-programs.
    ---------------------------------------------------------------------------
        Question. On April 29, 2024, your Department issued the final Title
    IX regulation, expanding the definition of ``sex'' to include sexual
    orientation and gender identity. Is it correct that under this new
    regulation, sororities and fraternities remain exempted, as they have
    always been, and may continue to make membership and leadership
    selections based on sex, including biological sex?
        Answer. On April 29, 2024, the Department published in the Federal
    Register a Notice of Final Rule (2024 Final Rule), which amends the
    Department's Title IX regulations effective August 1, 2024. The 2024
    Title IX Final Rule includes a provision, to be codified at 34 C.F.R.
    Sec. 106.10, that Title IX's prohibition on sex discrimination includes
    discrimination based on sexual orientation and gender identity.
        Title IX includes several exceptions to its broad prohibition on
    sex discrimination in federally funded education programs and
    activities. One of those exceptions specifies that Title IX does not
    apply to membership practices of ``a social fraternity or social
    sorority which is exempt from taxation under section 501(a) of title
    26, the active membership of which consists primarily of students in
    attendance at an institution of higher education.'' 20 U.S.C.
    Sec. 1681(a)(6)(A). The Department did not propose any amendments to
    the corresponding regulation at 34 C.F.R. Sec. 106.14(a) and that
    provision remains unchanged. Social fraternities and social sororities
    are therefore permitted under Title IX to set their own membership
    practices regarding any sex-based restrictions on their membership.
    Nothing in Title IX or its implementing regulations prohibits a
    fraternity from admitting transgender men or a sorority from admitting
    transgender women if it so chooses.
        The 2024 Final Rule includes a provision, to be codified at 34
    C.F.R. Sec. 106.31(a)(2), which recognizes that in the limited
    circumstances in which recipients are permitted to separate or
    differentiate on the basis of sex, recipients must carry out such
    separation consistent with the statute's nondiscrimination mandate, 20
    U.S.C. 1681, except when the statute itself allows otherwise. Section
    106.31(a)(2) identifies the statutory and regulatory provisions
    regarding the membership practices of social fraternities and social
    sororities as one such exception when the statute itself allows
    otherwise.
        Question. Is it your position that Title IX requires religious
    student groups operating as recognized student organizations on public
    school campuses to be bound by Title IX, and may not receive an
    exemption based on sincerely held religious beliefs?
        Answer. Since 1972, Title IX has provided that its prohibition on
    sex discrimination ``shall not apply to an educational institution
    which is controlled by a religious organization if the application of
    this subsection would not be consistent with the religious tenets of
    such organization.'' 20 U.S.C. 1681(a)(3). The 2024 Final Rule explains
    that educational institutions controlled by a religious organization
    can invoke Title IX's religious exemption, but, consistent with the
    statutory language, Title IX's religious exemption ``does not exempt
    student organizations, individual employees or students, or educational
    institutions not controlled by religious organizations.'' 89 Fed. Reg.
    33838.
        Question. If yes, how do you justify binding religious student
    groups by the nondiscrimination requirements of Title IX and refusing
    them the Title IX religious exemption?
        Answer. See response to above.
        Question. If no, what will you do to ensure that public schools do
    not attempt to impose Title IX's nondiscrimination provisions beyond
    their bounds?
        Answer. The Department is committed to enforcing Title IX
    consistent with all applicable free speech and religious liberty
    protections.
        Consistent with Sec. 106.6(d)(1), nothing in the Title IX
    regulations requires or authorizes a recipient to infringe on
    individuals' First Amendment or other constitutional rights. OCR,
    likewise, must act in accordance with the U.S. Constitution and OCR
    considers constitutional rights when it evaluates a recipient's
    compliance with Title IX. See 89 Fed. Reg. 33823.
        Question. Is it the Department of Education's position that the
    First Amendment's ministerial exception doctrine does not apply to
    Title IX claims?
        Answer. The 2024 Final Rule explains that ``[t]he Department
    recognizes the importance of religious freedoms, including the right
    for religious organizations to congregate and freely exercise their
    faith, as well as the doctrine of ministerial exception that precludes
    application of Title VII and other employment discrimination laws to
    the employment relationship between a religious institution and its
    ministers.'' 89 Fed. Reg. 33535. The 2024 Final Rule further ``notes
    that it is unclear the extent to which the First Amendment's
    ministerial exception doctrine applies to student religious
    organizations and Title IX, as the U.S. Supreme Court has not ruled on
    this question and some courts have declined to extend this exception
    beyond an employment law context. To the extent that a future court
    would find that the doctrine applies to Title IX, Sec. 106.6(d)
    instructs a recipient not to take action in violation of the First
    Amendment, which would include such an exception.'' 89 Fed. Reg. 33535-
    36.
                                     ______

                   Questions Submitted by Senator Marco Rubio
        Question. During your testimony before the subcommittee, you stated
    that you were very concerned about antisemitism and that the harassment
    Jewish students are currently facing is unacceptable. You said that
    that you have spoken with Jewish students who fear going to class due
    to the harassment they are facing on campus--students who have had to
    take different routes to class, and whose parents do not feel safe
    sending them to school. You specifically committed to remove Federal
    dollars if a college or university refuses to comply with Title VI. It
    is also true that individual students receive Federal support through
    several avenues, particularly through the administration's student debt
    cancellation plan, income-driven repayment plan, cancellation of
    interest on student loans, and other actions.
        To date, have any students who have been arrested, or convicted, of
    any Federal or state offense related to a protest over the Israel--
    Hamas war at an institution of higher education received student debt
    relief under the administration's debt relief programs?
        If so, how much and to how many of the students?
        Going forward, will the administration take into account a
    student's actions at these protests when determining debt relief?
        Do students who espouse sentiments of ``Death to America'' deserve
    debt relief?
        Answer. Students currently enrolled at an institution of higher
    education are not eligible for debt relief. Nonetheless, calls to
    violence are absolutely abhorrent. If anyone creates a hostile learning
    environment for students, institutions of higher education have an
    obligation to act. Their primary obligation is to ensure students are
    safe. If investigations conclude that a student has incited violence
    against others, they may pursue disciplinary action that could result
    in suspension or expulsion.
        Question. The department's Office for Civil Rights (OCR) has the
    discretion to conduct compliance reviews to find and remedy
    discrimination at institutes of higher education that has not been
    identified through the traditional complaint process.
        How many Title VI compliance reviews has OCR, under your direction,
    initiated at universities that have failed to protect Jewish students
    against discrimination and harassment since October 7, 2023?
        Answer. Since October 7, 2023, OCR has received an influx of
    complaints filed at an unprecedented rate, challenging discrimination
    against Jewish students. We are working hard to open and investigate
    these cases at an unprecedented speed. In their 4 years, the previous
    Administration launched two nationwide initiatives of compliance
    reviews (neither of which were based on shared ancestry) and 27 total
    complaint investigations based on allegations of shared ancestry
    discrimination in all 4 years. Between October 1, 2023, and June 10,
    2024, OCR opened 118 cases of alleged shared ancestry discrimination,
    all based on complaints, and so far in this Administration OCR has
    already secured resolution agreements redressing investigations
    involving discrimination against Jewish students in more cases than the
    previous Administration secured in all 4 years.
        Question. To what degree has OCR increased these compliance reviews
    to find and remedy discrimination that was not identified through the
    compliant process?
        Answer. OCR continues to devote all resources to address alleged
    discrimination.
        Question. What is the department doing to raise awareness of
    students' option to file a discrimination complaint to OCR?
        Answer. OCR continues to emphasize in all of our public guidance
    documents as well as through outreach that anyone who believes that an
    entity that receives Federal financial assistance from the Department
    has discriminated against someone on the basis of race, color, national
    origin, sex, disability, or age may file a complaint with OCR. OCR has
    also initiated a technical assistance training initiative, informing
    school communities specifically about how the law applies to shared
    ancestry discrimination and the process to file a complaint with OCR.
    Under this initiative, OCR has held 24 trainings, engaging well over
    1,000 participants.
        Question. On November 6, 2023, Hillel International, the Anti-
    Defamation League, the Louis D. Brandeis Center for Human Rights Under
    Law, and Gibson, Dunn & Crutcher LLP launched the Campus Antisemitism
    Legal Line (CALL), a free legal protection helpline for students who
    have experienced antisemitism. CALL was developed to allow any student,
    family, faculty, or staff member to report incidents of antisemitic
    discrimination, intimidation, harassment, vandalism, or violence on
    campus that might require legal action. Lawyers assess reports of
    antisemitic discrimination and hate, conduct in-depth information-
    gathering interviews, and provide pro bono representation for victims
    who choose to move forward with specific cases. In the weeks following,
    CALL received more than 400 unique requests for assistance--showing
    that there is substantial need.
        As part of its Antisemitism Awareness Campaign, the department has
    committed to spotlighting and disseminating information about notable
    efforts by communities to prevent and address antisemitism. Has the
    department shared or distributed information about CALL, or other
    similar resources to provide free legal protection for Jewish students?
    If not, why?
        Answer. OCR vigorously enforces Title VI of the Civil Rights Act of
    1964, including prohibiting discrimination on the basis of shared
    ancestry or ethnic characteristics. OCR has opened and resolved more
    cases on these topics in this Administration than in any prior
    administration, with over 145 open shared ancestry cases under
    Investigation as of July 2024. In comparison, the average number of
    open shared ancestry cases over the last 10 years is 25.
        Because public service is a public trust and government office
    cannot be used for private gain, see 5 C.F.R. Part 2365, the Department
    does not endorse any particular provider of legal services or direct
    students to any specific providers. However, OCR has provided
    guidance--more than in any prior Administration--to every federally
    funded school in the country reminding them of their Federal legal
    obligation to protect students' civil rights in this area. The Office
    has updated its complaint form and continues to provide technical
    assistance so that students know their rights and school leaders know
    their obligations. We encourage any student who has experienced
    discrimination at school to file a complaint.
        The Department is pairing OCR enforcement with more education,
    outreach, training, and resources than ever to build capacity for PK-12
    schools, universities, and community stakeholders. At ED.gov you can
    find a comprehensive overview of actions taken by the Department to
    counter antisemitic, anti-Muslim, and anti-Arab hate since October 7,
    2023. These include practical resources for teachers and school leaders
    including materials on countering antisemitism in PK-12 schools and
    universities reviewed and disseminated by the Department-funded
    National Center for Safe Supportive Learning Environments. And, in the
    coming weeks, the Department will release new materials and amplify
    effective strategies for supporting all students as the dynamics
    continue to evolve ahead of the fall semester. Also, we have and will
    continue to work closely with community leaders on countering
    antisemitism, including by offering them trainings on how to file Title
    VI complaints and meeting with them frequently to hear their feedback
    and suggestions.
        Question. I drafted report language that was included in the FY24
    appropriations legislation that requires the department to report on
    the presence and influence of Confucius Institutes in U.S. educational
    institutions and any steps it has taken to address undue influence
    within institutions of higher education.
        Will you commit to complete this report expeditiously and share
    updates with my office?
        Answer. According to a GAO report issued in October 2023 on the
    topic, the number of Confucius Institutes at U.S. universities has
    significantly declined since 2019, from nearly 100 to fewer than five.
    That same report also documented several steps that universities
    implemented to mitigate concerns or risks associated with hosting a
    Confucius Institute: (1) ensuring that exchange visitors had no
    decisionmaking authority on campus; (2) creating accountability for the
    U.S. director of the Institute to senior officials at the school; and
    (3) maintaining full control over Chinese language courses by the
    schools' academic departments or other appropriate units.
        With nearly all Confucius Institutes closed at this point, the
    higher education community is focused on identifying new and emerging
    threats, in partnership with all relevant national security agencies.
    For example, to help ensure that agencies responsible for protecting
    against foreign malign influence in higher education have the
    information they need, the Department finalized an information-sharing
    agreement with the Federal Bureau of Investigation's National
    Counterintelligence Taskforce. This agreement will better enable the
    Federal government to help institutions identify and protect against
    the risks of foreign malign influence. Additionally, colleges and
    universities can also apply the steps that GAO's report documented to
    mitigate risks from other international partnerships.
        Question. Will you commit to investigate the link between foreign
    gifts to institutes of higher education and the rise in campus
    antisemitism?
        Answer. The Department remains committed to ensuring robust
    compliance with section 117. Under section 117, institutions of higher
    education must file a disclosure report with the Secretary of Education
    on January 31, or July 31, whichever is sooner, whenever any
    institution is owned or controlled by a statutorily defined source, or
    whenever an institution receives a gift from or enters into a contract
    with a foreign source, the value of which is $250,000 or more,
    considered alone or in combination with all other gifts from or
    contracts with that foreign source within a calendar year.\4\
    ---------------------------------------------------------------------------
        \4\ See 20 U.S.C. Sec. 1011f.
    ---------------------------------------------------------------------------
        This disclosure requirement is an important measure in ensuring
    transparency and identifying possible foreign influence in U.S. higher
    education. More information about section 117 can be found on Federal
    Student Aid's webpage, available at https://fsapartners.ed.gov/
    knowledge-center/topics/section-117-foreign-gift-and-contract-
    reporting. Section 117 is a transparency statute, and the Department's
    responsibilities under section 117 are focused on ensuring compliance
    with reporting requirements.
        The Department is concerned about the rise of antisemitic incidents
    at our nation's colleges and universities, as well as in PreK-12
    schools and remains committed to protecting the civil rights of all
    students, including Jewish students. The Department's Office for Civil
    Rights (OCR) works every day to ensure that the civil rights of all
    students are protected. The Department has committed substantial
    efforts to preventing and addressing antisemitic discrimination in
    school communities, both before and since October 7, 2023. In January
    2023, OCR released a fact sheet, Protecting Students from
    Discrimination Based on Shared Ancestry or Ethnic Characteristics and
    in May 2023, OCR issued a Dear Colleague Letter as part of the
    Department's Antisemitism Awareness Campaign, in conjuncture with the
    release of the White House-led U.S. Strategy to Counter Antisemitism.
    In August 2023, OCR released a Dear Colleague Letter addressing race
    and school programming that specifically included examples related to
    antisemitism as well as to the creation of a hostile environment
    resulting from inflammatory campus speech that endorses violence.
        Since the proliferation of hate incidents reported in school
    communities following October 7, OCR has taken further steps to ensure
    full compliance with the Title VI obligations in schools. On November
    7, 2023, OCR released a Dear Colleague Letter, which once again
    reminded schools of their legal obligation under Title VI to address
    allegations of prohibited discrimination, including harassment. OCR
    also updated its complaint form to specific for the first time that
    Title VI's protection from discrimination based on race, color, or
    national origin, including shared ancestry or ethnic characteristics,
    extends to students who are perceived to be Jewish, Muslim, Arab,
    Hindu, or Sikh.
                                     ______

                Questions Submitted by Senator Susan M. Collins
        Question. Institutions of higher education are still awaiting
    direction regarding the processing of FAFSA forms for the 2024-2025
    school year.
        When will the Department begin to process paper FAFSAs?
        Answer. The Department will begin processing 2024-25 paper FAFSA
    forms in July.
        Question. When will the Department provide direction and timeline
    for financial aid administrators to provide corrections to ISIRs in
    cases where students would like to use tax information from 2023 or
    projected earnings from 2024 due to an event that significantly changes
    their family's income?
        Answer. The Department released the FAFSA Partner Portal (FPP) in
    early July that can be used by schools to submit corrections
    electronically.
        Question. The majority of Maine's schools and school districts are
    small and rural, which means they are often at a disadvantage when it
    comes to applying for competitive Federal funds. In 2002, I co-authored
    the Rural Education Achievement Program (REAP). In a tough fiscal year
    with limited program increases, the FY2024 Labor-HHS bill increased
    REAP by $5 million, so I was disappointed to see that the budget
    suggested returning the program to FY2023 levels. This key formula
    grant program is designed to help rural districts, like many in Maine,
    that may lack the personnel and resources to effectively compete for
    Federal competitive grants.
        What is the Department doing to lighten the burden on rural schools
    so that they can compete for competitive grants?
        Answer. The Department is including competition priorities or other
    means of advantage in grant competitions for rural applicants in
    several competitions in FY 2024. Additionally, the Department is
    revising the Education Department General Administrative Regulations by
    proposing to include a priority for rural applicants, codifying the
    Rural Applicants priority from the Department's Administrative
    Priorities that would allow the Secretary to establish a separate
    competition for, or provide competitive preference to, applicants that
    propose to serve rural locations. As a clarification, funding amounts
    for the President's Budget were finalized prior to final congressional
    action on FY 2024 appropriations, which provided an increase for REAP.

                              SUBCOMMITTEE RECESS

        Senator Baldwin. And our committee will now stand in
    recess.
        [Whereupon, at 11:18 a.m., Tuesday, April 30, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2025

                                  ----------

                             THURSDAY, MAY 9, 2024

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m., in room SD-138, Dirksen
    Senate Office Building, Hon. Tammy Baldwin (chair) presiding.
        Present: Senators Baldwin, Murray, Reed, Shaheen, Schatz,
    Manchin, Capito, Kennedy, Hyde-Smith, Boozman, Britt, and
    Collins.

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    STATEMENT OF HON. JULIE SU, ACTING SECRETARY

                   OPENING STATEMENT OF SENATOR TAMMY BALDWIN

        Senator Baldwin. The Senate Appropriations Subcommittee on
    Labor, Health and Human Services, Education, and Related
    Agencies will please come to order.
        Good morning. Today we are having a hearing on the Biden
    administration's fiscal year 2025 budget request for the
    Department of Labor, and I'm happy to welcome Acting Secretary
    Su to our subcommittee.
        As we did last year in the Senate, I'm looking forward to
    working in a bipartisan manner again this year with Senator
    Capito to develop a Labor HHS (Health and Human Services) bill
    that can pass the Senate, pass the House, and be signed into
    law by the President. That means looking for the common ground
    instead of pursuing partisan policy riders and draconian cuts
    to workforce development and worker protection programs.
        When a small minority is able to derail the appropriations
    process, like House Republicans did last year, repeatedly
    threatening government shutdowns, it hurts our constituents,
    our communities intended to be served by our Federal programs.
    It causes Federal agencies to waste time and money, instead of
    working to make sure every dollar is used effectively as
    intended by the laws we pass here in the Congress.
        We need to do better. And Acting Secretary, I think this
    budget is a good first step.
        Acting Secretary Su, you join us today to talk about the
    President's fiscal year 2025 budget for the Department of
    Labor. We have had 27 months in a row of unemployment below 4
    percent, the longest stretch in 50 years. But I know that we
    still have more work to do to give Americans the economic
    security that they need and deserve.
        Over the last few years, Democrats and Republicans came
    together to pass landmark legislation that invests in
    manufacturing, helps us compete against China, invests in our
    aging infrastructure, and importantly, invests in our workers.

                    INVESTING IN WORKFORCE TRAINING PROGRAMS

        And just this week, we are seeing the dividends. In my home
    State of Wisconsin, Microsoft announced that they will be
    investing $3.3 billion for an artificial intelligence data
    center complex, creating thousands of good-paying union jobs,
    and investing in education and job training programs for the
    next generation.
        This budget builds on this progress that we have made, and
    will help continue to build a strong economy that works for
    workers. It proposes investments necessary for training the
    workforce that we need today, and the evolving needs of
    employers.
        The budget also requests resources to maintain critical
    investments in our Nation's core workforce training programs.
    These programs help support workers and their families by
    providing them with access to high quality training programs as
    they seek to grow their careers.
        This includes programs to improve our Nation's public
    workforce system, boost our community college system, help ex-
    offenders land on their feet, and address the employment and
    training needs of Native Americans, migrant and seasonal
    workers, and other workers.
        High quality workforce training programs are a proven path
    to accessing a job that pays a good wage and has good benefits.
    And I am pleased that this budget continues to support these
    important programs.

                       REGISTERED APPRENTICESHIP PROGRAM

        The budget also includes a request, a proposed increase in
    funding for the Registered Apprenticeship Program. I have been
    proud to lead the effort to reauthorize the National
    Apprenticeship Act with my colleague, Senator Lisa Murkowski,
    and I am pleased that the Department is proposing to expand
    apprenticeships and increase opportunities for individuals who
    have historically not had access to apprenticeships programs,
    including women, people of color, and underrepresented groups.
        Apprenticeship programs provide technical instruction and
    on-the-job learning experiences to ensure that workers are well
    prepared for jobs. According to the Wisconsin Department of
    Workforce Development, employers in Wisconsin train around
    10,000 registered apprenticeships in nearly 200 occupations
    every year. Supporting the Federal Registered Apprenticeship
    Program will help Wisconsin and other States continue to
    strengthen and grow their apprenticeship programs.

                      WORKFORCE TRAINING SERVICES FOR VETS

        The budget includes funds for the Department of Veterans'
    Employment and Training Service, which provides workforce
    training services for our Nation's veterans and separating
    service members. These resources help ensure that our service
    members can transfer the skills that they learned serving our
    country to land a family-supporting job and help them
    successfully transition into the workforce. The Department's
    VETS (Veterans' Employment and Training Service) office
    provides critical services to military spouses as they make the
    transition to civilian life, and I look forward to hearing more
    about how the President's budget request would support the
    workforce and training needs of veterans and their families.

                             WAGE AND HOUR DIVISION

        Acting Secretary Su, I'm also pleased to see the increased
    investment in the Wage and Hour Division. The proposed $35
    million increase is needed to recover the hard-earned wages
    owed to workers stolen by their employers.
        Last year, Wage and Hour was able to recover more than $156
    million in Federal minimum wage and overtime owed to more than
    135,000 workers. In Wisconsin, Wage and Hour investigations
    last year identified more than $3 million in back wages owed to
    over 1,400 workers.
        This funding is also critical to enforcing child labor
    laws, and ensuring that when youth are working, they are doing
    so safely and appropriately. There has been extensive recent
    reporting of egregious incidences of child labor violations. As
    long as corporations think that they can ignore Federal child
    labor laws, kids will continue to be put at risk, including 13-
    year-olds working overnight shifts in slaughterhouses and
    meatpacking facilities.
        Wage and Hour staffing has fallen to historic lows, and I
    believe we must provide an increase for the agency's important
    work.

                 OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION

        The budget request also includes an additional $23 million
    for the vital work of the Occupational Safety and Health
    Administration. We've just marked Workers' Memorial Day on
    April 28, remembering workers who've died or been injured while
    on the job.
        Our latest fatality statistics indicate that there were
    5,486 fatal workplace injuries in 2022, up nearly 6 percent
    from the prior year. That's 5,486 too many. We must do better
    for workers, and I believe the proposed increase would move us
    in the right direction.

                   EMPLOYEE BENEFITS SECURITY ADMINISTRATION

        The proposed $15 million increase for the Employee Benefits
    Security Administration would help secure workplace-based
    benefits workers and their families are owed.
        I'm also pleased to see the increased investment of $46
    million for the Bureau of International Labor Affairs. That
    would help strengthen implementation of labor commitments of
    our trading partners and combat international forced labor,
    including in China. We can and must strengthen the economic
    security of our communities at home by our government working
    to eliminate labor abuses abroad.
        Acting Secretary Su, thank you for being here today to talk
    about the Department of Labor's important work.
        In a moment, I'm going to turn it over to Ranking Member
    Capito for her opening remarks. And following her opening
    remarks, we will hear directly from you, Acting Secretary Su.
    And after that, Senators will each have 5 minutes for a round
    of questions.
        Senator Capito.

                   STATEMENT OF SENATOR SHELLEY MOORE CAPITO

        Senator Capito. Thank you, Chair Baldwin. And thank you for
    having the hearing. This is the first Labor budget hearing that
    we've actually had since we took over the reins of the Labor
    HHS subcommittee.
        So Acting Secretary Su, thank you for coming. You did not
    appear last year, in part because the budget came out right as
    Secretary Walsh was leaving the department. So thank you for
    being here today to describe the fiscal year 2025 budget
    priorities for the Department of Labor.

               NEW RULES IMPACTING INDEPENDENT CONTRACTOR STATUS

        First of all, I will say I have had some concerns with the
    Department. There seems to be an agenda to push new regulations
    that impose layers of red tape and in some cases hurt worker
    choice. West Virginia needs fewer inefficient and expensive
    regulations and more job creation.
        To be clear, not all regulations are bad. I applaud efforts
    to curb child labor violations that the Chair was talking
    about, and to keep hard working West Virginians, including our
    minors, safe. So thank you for your efforts there.
        But the Department of Labor should be focused on workforce
    training and creating new jobs, not mandating new burdens that
    take away worker choice and flexibility.
        For example, the Wage and Hour Division earlier this year
    changed the rules governing who qualifies as an independent
    contractor. This new rule imposes a complicated six-factor test
    that allows bureaucrats to decide who is and is not an
    independent contractor, jeopardizing the ability of 27 million
    Americans to work in a way that best fits their needs and
    schedules.
        This regulation takes away the freedom for West Virginia
    real estate agents, truck drivers, freelance workers, and other
    self-employed workers to choose their own hours and work around
    other life priorities, such as going back to school or taking
    care of your children--raising the children.

                              ESG INVESTMENT RULE

        Another regulation that creates more complexity and
    undermines workers' livelihood is the so called ESG Investment
    Rule. This rule allows and even pressures retirement fund
    fiduciaries to consider environmental, social, and governance
    factors in their investment decisions involving workers' hard-
    earned life savings.
        West Virginians who work today and save for tomorrow need
    to be able to optimize their returns to afford life in
    retirement. But this rule pressures financial experts to shift
    potential gains away from American retirees, and into the White
    House's radical climate agenda.
        And just last month, your Department further curbed worker
    flexibility and imposed sweeping new costs on businesses by
    drastically increasing the overtime salary threshold.
        Starting July 1, West Virginia businesses of all sizes,
    including nonprofits and small businesses, will have to figure
    out how to absorb this mandate. This costly change is likely to
    result in fewer hours worked and more restrictions for
    employees, and in some cases, even layoffs.
        Instead of doubling down on this agenda, the Department of
    Labor should focus instead on job creation in areas of
    bipartisan support.

                            APPRENTICESHIP PROGRAMS

        One area, and the Chair also talked about this, where I
    hope we can find some room for agreement is with the
    apprenticeship programs. This budget requests an increase of
    $50 million over fiscal year 2024 for the apprenticeship grant
    program.
        While I'm concerned that your budget would use this
    apprenticeship grant funding to support a green jobs agenda, I
    remain committed to increasing opportunities for West
    Virginians to succeed, and know apprenticeships can play a key
    role in that mission.
        I support Registered Apprenticeship programs, which is why
    I'm also concerned about the Department's proposal released
    late last year to completely overhaul the regulations governing
    the Registered Apprenticeship program. These proposed changes
    will make an already complex system even more difficult for
    employers to navigate, and I think it could reduce Registered
    Apprenticeship opportunities for workers across the country.
        There are a lot of worthy apprenticeship opportunities that
    don't fit the current Registered Apprenticeship model. I'd like
    to see the innovation to expand those apprenticeship
    opportunities to new programs and fields.
        In 2022, I secured funding for Marshall University to
    establish an apprenticeship initiative through Apprenticeships
    Works to train West Virginians to compete for good-paying,
    long-term jobs across the State.
        I've also been a longtime champion of expanding and
    strengthening the early childhood education workforce through
    apprenticeships. Giving our educators a clear path to
    successful careers opens the doors to higher quality and better
    coverage of care, helping both families and child care workers
    in our State.
        The Department of Labor should be focused on strengthening
    workforce development strategies that help all Americans get
    the skills they need to succeed.
        Acting Secretary Su, I hope you will work with this
    congress on that goal as we work through the fiscal year 2025
    process. And thank you again for being here.
        Senator Baldwin. Thank you, Senator Capito. Our witness
    today is Julie Su, the acting Secretary of the Department of
    Labor.
        Acting Secretary Su, thank you for joining us. You will
    have 5 minutes for your opening remarks, and you may begin.

                       SUMMARY STATEMENT OF HON. JULIE SU

        Ms. Su. Thank you so much. Chairwoman Baldwin, Ranking
    Member Capito, and members of the subcommittee, thank you for
    the opportunity to testify in support of President Biden's
    fiscal year 2025 budget request for the Department of Labor.
        As the acting Secretary of Labor, I get to travel the
    country to meet with workers. Workers like Mariah, a single mom
    who was living paycheck to paycheck, worried every day about
    how she would have enough to get by.
        She went to her local Social Services office to apply for
    SNAP (Supplemental Nutrition Assistance Program) and Medicaid
    benefits, and that's where she noticed a flyer for a job
    training program in the pipe trades. Today, Mariah is in a good
    union job, and she has quadrupled her income.
        What struck me about Mariah was not just how much a good
    income meant to her. It was the pride she felt in putting in a
    hard day's work and getting rewarded for it, and the pride she
    saw in her children's eyes.
        It's undeniable. Good jobs change lives. This $13.9 billion
    request will help more people like Mariah get good jobs that
    can support families, lift up communities, and bring the
    dignity and pride that are core to the American dream.
        I want to frame our request under two priority areas.
        First, pathways to good jobs for all of America's workers.
    I've met with thousands of workers like Mariah who are in
    programs that work, programs that exist because we've invested
    in them.
        That's why we're requesting investments to develop and
    expand proven models, as Chairwoman Baldwin said, to connect
    workers to the good jobs they want and need, and employers to
    the workers that they want and need.
        For example, we're requesting $8 billion for the Career
    Training Fund. That investment would help as many as 750,000
    people who do not see 4-year college as their path enroll in
    evidence-based, high quality training programs for actual jobs
    in their communities. Workers who complete high quality
    programs don't end up with a job search, they end up with a
    good job.
        We also seek $335 million for apprenticeship programs.
    Registered Apprenticeships provide training for the actual
    skills that employers need. They allow workers to earn while
    they learn, and they increase job pathways for underrepresented
    groups including women, people of color, veterans, and
    individuals with disabilities.
        When I talk to business owners, many tell me that their top
    concern is recruiting and retaining workers. Well, the
    investments in our budget request are how Congress and the
    Department of Labor can tap into the talents and skills of all
    of America's workers, and make sure that the supply of skilled
    workers meets the demand, right now and well into the future.

                           ENFORCING CHILD LABOR LAWS

        The second priority I'd like to highlight is the Department
    of Labor's mission to protect workers including, and
    especially, those most vulnerable to exploitation. Too often,
    employers who hire 13-year-olds to work in hazardous conditions
    fail to pay workers overtime for 60-hour work weeks, or who put
    workers at risk of losing their limbs or even their lives on
    the job, do it because they believe they'll get away with it--
    that no one will stop them, that they can operate in blatant
    disregard of the laws that Congress has passed.
        Not on our watch. That's why we're requesting modest but
    important increases for the Department's worker protection
    agencies. Because we can't do this vital work without dedicated
    public servants. The Wage and Hour investigators who combat
    child labor, the team that ensures workplaces are free from
    safety hazards, the benefits advisors who answer the phone when
    panicked patients have been denied coverage for mental health
    services by their health insurance company.
        We're asking for $7.5 million for additional staff to
    combat wage theft and child labor; an additional $23 million to
    investigate high hazard workplaces, protect whistleblowers, and
    give employers compliance assistance; and an additional $10.7
    million for my solicitor's office, which has been essentially
    flat-funded for more than a decade.

                              WORKFORCE PROTECTION

        The President's request would also help us advance worker
    rights and promote a level playing field internationally for
    U.S. workers and businesses. And, it would better support
    implementation of Congress's Secure 2.0 Act, the Mental Health
    Parity and Addiction Equity Act, and the No Surprises Act.
    Because when Congress passes laws, we should make them real.
        In all, this budget request will help make sure that
    workers can come home safe and healthy at the end of the
    workday and get high quality jobs with the power to truly
    change lives.
        Again, I thank the subcommittee, and I look forward to your
    questions.
        [The statement follows:]
                         Prepared Statement of Julie Su
        Chairwoman Baldwin, Ranking Member Capito, and members of the
    Subcommittee, thank you for the invitation to testify today. I am
    pleased to appear before this Subcommittee to highlight the investments
    that President Biden's Fiscal Year (FY) 2025 Budget makes in the
    Department of Labor (DOL or Department).
        President Biden knows that good jobs change lives. The $13.9
    billion FY 2025 Budget for the Department continues to build on the
    Biden-Harris Administration's principles for growing a worker-centered
    economy from the bottom up and the middle out by creating pathways to
    good jobs and expanding equitable opportunities, while empowering and
    protecting workers and their families. The President's Budget does so
    in a cost-effective manner by proposing some shifts to prioritize
    critically important programs while remaining within the discretionary
    budget caps set by the Fiscal Responsibility Act.
    Promoting job quality and pathways to good jobs for all workers,
            especially historically underserved workers.
        The FY 2025 Budget expands workforce training that provides
    pathways to good jobs. It advances the President's historic legislative
    accomplishments rebuilding the Nation's infrastructure, supporting
    clean energy, and boosting American manufacturing that have and will
    create millions of good, high-quality jobs. In support of this effort,
    the Budget invests in effective, evidence-based training models to
    ensure that all workers, including women, workers of color, those
    living in rural areas, and workers with disabilities, have the skills
    they need to compete for and fill these and other jobs. This includes
    major new investments through the $8 billion mandatory Career Training
    Fund and a new $50 million investment in the Sectoral Employment
    through Career Training for Occupational Readiness program, both of
    which will support the development and expansion of public-private
    partnerships between employers, education and training providers, and
    community-based groups to equitably deliver high-quality training
    focused on growing industries. The Career Training Fund, as proposed in
    the budget, would provide full funding for 750,000 individuals to
    enroll in evidence-based, high-quality training programs that are
    proven to deliver sustained earnings increases.
        The Budget also invests $335 million in apprenticeship programs,
    increasing access for underrepresented groups, including women, people
    of color, and individuals with a disability, and diversifying the
    industry sectors involved. The Department continues making progress on
    the President's goal to serve at least one million apprentices annually
    within 10 years, advancing racial and gender equity, and supporting
    historically underserved and marginalized communities. Within the
    request is a $50 million increase to expand existing Registered
    Apprenticeship programs in clean energy and climate-related
    occupations. This investment will support successful implementation of
    the Inflation Reduction Act, prepare workers for the in-demand jobs of
    the present and future, and help build a thriving clean energy economy.
    Apprenticeship funds will also enhance the Department's support for
    pre-apprenticeships, youth apprenticeships, and degreed apprenticeships
    to ensure that more people have access to career pathways.
        Similarly, the Department's request includes $5 million for the
    Women in Apprenticeship and Non-Traditional Occupations (WANTO) grant
    program. The Department's Women's Bureau will leverage proven pre-
    apprenticeship training and Registered Apprenticeship retention models
    across the Nation, so that more women can enter and succeed in high-
    quality jobs in a variety of in-demand, nontraditional occupations.
        While pursuing career paths, women disproportionately are impacted
    by the high cost of childcare, which, in turn, impacts their ability to
    work. The National Database of Childcare Prices shows that childcare
    prices are untenable for families across all care types, age groups,
    and county population sizes. Ninety-four percent of all childcare
    workers in the U.S. are women, and childcare workers receive among the
    lowest wages of any occupation. As a country and as a government, we
    must do more to prioritize workers and their families.
        The Biden-Harris Administration has invested in the Nation's
    economy, creating millions of jobs over the past 3 years. Further,
    through the Good Jobs Initiative, we have embedded key principles
    regarding job quality, equity, and worker empowerment in Federal
    funding to ensure that the jobs that are created are good jobs that
    provide stability and security for workers and their families. In
    total, the Department has entered into agreements with six other
    Federal agencies, resulting in $239.6 billion of Investing In America
    (IIA) funds with equity and job quality incentives included in 141 IIA
    Funding Opportunity Announcements. To build on this work, this Budget
    requests an additional $2 million to provide training and technical
    assistance to other Federal agencies as they work to embed and promote
    the Good Jobs Principles in procurement, loans, grants, and other
    Federal financial assistance; and provide a centralized location for
    information and services on workers' rights. Good jobs accessible to
    all workers, including workers from underserved communities, are the
    foundation of an equitable economy, and by supporting workers, we make
    families and economies more competitive globally.
    Protecting the rights, wages, health and safety, and benefits of all
            workers, but especially the most vulnerable.
        One of the Department of Labor's primary roles is to protect
    workers' wages, benefits, and working conditions. And it is the
    dedicated public servants at the Department who do that critical work.
    This is why the FY 2025 Budget requests modest but important increases
    for the Department's worker protection agencies, particularly funding
    to maintain enforcement staff.
        This includes wage and hour investigators who help ensure children
    are not working in dangerous occupations. While positive and safe first
    work experiences can allow young people to develop skills, earn money,
    and learn what it means to be part of the labor force, a job should not
    jeopardize a child's well-being or their educational opportunities. And
    yet, every year, the Department's Wage and Hour Division (WHD) is
    finding thousands of young workers employed in violation of the law.
    The Department's request for WHD includes $7.5 million to support 50
    additional enforcement staff to protect our country's most vulnerable
    workers and combat exploitative child labor. The increased resources
    will allow WHD to maintain its progress in rebuilding enforcement staff
    responsible for carrying out mission-critical, evidence-based
    strategies and delivering on high-impact cases. In addition, the
    Department requests an additional $3.8 million for 19 staff in the
    Office of the Solicitor of Labor (SOL) for legal services to combat
    exploitative child labor, ensuring that WHD's work has the teeth of
    legal enforcement. The Department is committed to combatting all forms
    of illegal child labor because we cannot build our economy on the backs
    of children.
        The Department's work continues by protecting the health and safety
    of workers in high- risk occupations.
        The FY 2025 Budget provides an increase of more than $23 million
    over the FY 2024 enacted level for the Occupational Safety and Health
    Administration (OSHA) to help the agency maintain its enforcement
    presence, particularly in vulnerable and underserved communities.
        This includes staff to investigate high-hazard workplaces,
    enhancing OSHA's enforcement presence; prioritizing outreach and
    training in vulnerable and underserved communities; and improving
    workplace safety and health across the country. Additionally, the
    agency will continue to carry out critical enforcement and
    whistleblower programs, standard- setting activities, and compliance
    assistance programs.
        In addition to OSHA, the Mine Safety and Health Administration
    (MSHA) focuses its worker protection efforts on the more than 322,000
    people who work directly in the mining industry at more than 12,600
    mines nationwide. The request includes increases of over $18 million to
    support MSHA staff, allowing the agency to complete statutorily
    mandated inspections and investigations and expand efforts to work with
    the mining community to reduce fatalities, injuries, and illnesses.
        The Department further levels the playing field for all employers
    by holding scofflaw employers accountable and protecting workers from
    retaliation for enforcing their rights. Companies that choose to ignore
    the law and endanger or underpay their employees are undercutting other
    employers who comply with the law. This is why additional resources for
    SOL are so critical.
        The President's Budget requests an additional $10.7 million for SOL
    to help mitigate the effects of over a decade of near-flat funding and
    the depletion of supplemental appropriated funding from the American
    Rescue Plan Act. Without additional resources, SOL will have to
    significantly reduce its workforce, triggering a reduction in cases
    litigated, reducing pre-litigation advice and assistance, and lessening
    support for the worker protection agencies in developing and pursuing
    litigation-worthy cases. Meeting the demand for legal services at all
    steps in the enforcement process is a critical part of protecting
    workers' pay, benefits, safety and health, and rights.
        The Budget also addresses the Department's international work. The
    Bureau of International Labor Affairs (ILAB) advances worker rights and
    promotes a fair global playing field by enforcing trade commitments,
    strengthening compliance with labor standards, and combating
    international child labor, forced labor, and human trafficking. The
    Budget includes a program increase of $45 million for technical
    assistance funding related to the U.S.-Mexico-Canada Act (USMCA)
    following the expiration of the supplemental appropriation in December
    2023. This program increase will allow the Department to continue
    Mexico-specific technical assistance through awards of grants,
    contracts, and cooperative agreements, primarily to nongovernmental
    organizations whose projects and activities support USMCA
    implementation, including building capacity to legislate and implement
    new labor protections, improve working conditions, stabilize labor
    relations, and increase public awareness and engagement. ILAB will also
    continue its enforcement and monitoring of the labor provisions of the
    USMCA, including use of the facility-specific Rapid Response Mechanism
    and labor attaches stationed in Mexico to ensure compliance.
        Finally, the Department of Labor protects workers beyond the
    workplace and into retirement by ensuring that their hard-earned and
    promised benefits are available.
        The Department requests $4.7 million for the Employee Benefits
    Security Administration (EBSA) to implement provisions of the SECURE
    2.0 Act, which was enacted under the Consolidated Appropriations Act,
    2023. Although EBSA's reach is extraordinarily broad, with additional
    responsibilities added by Congress, its budget has not increased
    proportionally with the increased responsibilities. With the requested
    resources, EBSA will implement a wide range of retirement-focused
    provisions and numerous new requirements established under the SECURE
    2.0 Act, which includes amendments to existing law as well as new
    provisions focused on increasing retirement savings, improving rules
    governing the administration of retirement plans, and lowering the cost
    of setting up retirement plans.
        In addition, the Consolidated Appropriations Act, 2021 included
    supplemental funds for the Departments of Labor, Health and Human
    Services and Treasury to implement and enforce the Mental Health Parity
    and Addiction Equity Act (MHPAEA) and the No Surprises Act. Those funds
    expire at the end of 2024, though EBSA's obligations and ongoing work
    to implement and enforce these laws continues. Fully one-third of
    EBSA's enforcement staff are paid out of these supplemental No
    Surprises Act resources, which will soon expire. The Budget request for
    the Department of Health and Human Services proposes to replenish and
    extend this supplemental No Surprises Act and MHPAEA funding. The
    agency, and the participants and beneficiaries it works to protect, can
    ill afford the precipitous loss of staff that would result from the
    loss of supplemental funding.
                                advancing equity
        The Department remains steadfast in our commitment to building a
    worker-centered economy in a way that expands equitable opportunities.
    This begins by ensuring that workers can access the Department and its
    programs.
        The Department is committed to providing meaningful language access
    for individuals with limited English proficiency (LEP). The Department
    released its updated Language Access Plan in November 2023 and
    established the Centralized Office of Language Assistance, a new office
    within in the Department's Civil Rights Center. This office is
    dedicated to supporting the language assistance efforts of individual
    Department agencies to ensure that activities, programs, and services
    conducted by the Department are accessible to individuals with LEP.
        The Department also recognizes the need for expanded disaggregated
    data by race and ethnicity, as well as gender and other demographics in
    order to make informed decisions. To better provide this information,
    the Bureau of Labor Statistics (BLS) has expanded available labor
    market indicators, including for the American Indian and Alaska Native;
    Native Hawaiian and Pacific Islander; and detailed Asian and Hispanic
    or Latino communities. Beginning in September 2022, BLS published data
    that includes key economic metrics, such as the unemployment rate,
    employment-population ratio, and the labor force participation rate for
    the Native Hawaiian and Pacific Islander community, and, in September
    2023, began publishing monthly estimates of these metrics for detailed
    Asian groups. BLS also added labor force estimates for detailed
    Hispanic and Latino groups to its online database in October 2023.
        Finally, the Department also serves workers who have lost their job
    due to no fault of their own. As the COVID-19 pandemic showed, the
    unemployment insurance (UI) system is essential, and any delay in this
    critical earned benefit can have devastating consequences for families,
    particularly low-income families, and for the economy as a whole. The
    FY 2025 Budget improves states' ability to serve UI claimants more
    quickly and effectively by fully funding the formula for determining
    the amount states need to administer UI benefits based on current
    economic assumptions. The Budget also proposes resources to continue
    the Department's work to reduce identity fraud and to provide other
    critical supports to the states, as well as legislative proposals to
    improve UI integrity.
        The Department continues to use funding received through the
    American Rescue Plan Act to advance equity in the UI system by ensuring
    that all workers can securely access their hard- earned benefits. To
    date, the Department has awarded $219 million in grants to 45 states
    and the District of Columbia to address and improve equitable access to
    UI programs. Additionally, we have partnered with the General Services
    Administration and the U.S. Postal Service to provide both online and
    in-person options for UI claimants to verify their identity. Through
    the Department's identity verification services, we can ensure that the
    right payments go to the right workers without creating unnecessary
    barriers that disproportionately harm the most vulnerable workers.
                                   conclusion
        The Department is putting workers at the center of the Biden-Harris
    Administration's historic economic agenda and playing a leading role in
    the most pro-union administration in history.
        Thank you again for the opportunity to appear before you today, and
    I look forward to your questions.

        Senator Baldwin. Thank you, Acting Secretary Su. We will
    now begin a round of 5-minute questions, starting with myself,
    and then Senator Capito.

                    U.S. WORKFORCE REDUCTION IMPACTS & WARN

        Acting Secretary Su, I am deeply troubled by CNH
    Industrial's recent decision to lay off over 200 workers at a
    facility in Racine, Wisconsin, and move production to Mexico.
        Agricultural machinery has been made by workers in my home
    State for over 175 years. They have made Case New Holland, into
    the international manufacturing powerhouse that it is today.
        Even after delivering record profits for the company, plant
    workers at Racine are being told that their services are too
    expensive and are no longer welcome.
        An average worker at the Racine plant earns $52,000
    annually. CNH spent over $652 million in stock buybacks last
    year, or four times more than the $150 million they hope to
    save by reducing their workforce.
        Moving production to Mexico would not only be a slap in the
    face to the workers who have given so much, but it would
    destroy the institutional knowledge that the plant's workforce
    has developed over decades of building agricultural equipment.
        American workers are the best in the world, yet they face
    unfair disadvantages when it comes to competing against low-
    road employers in other countries, engaging in a race to the
    bottom and exploiting workers.
        So can you start by expanding on how the budget would
    promote a fair global playing field and protect workers'
    paychecks here at home by advancing workers' rights abroad?
        Ms. Su. Chairwoman Baldwin, thank you so much. And thank
    you also for your opening comments about the President's
    announcement yesterday in Racine, which demonstrates that the
    race to the bottom is not the only option. We can, with the
    right investments, create a race to the top in which America's
    workers benefit, America's businesses benefit, and our economy
    and our country are stronger.

                                 ILAB'S MISSION

        To your question, one of our agencies is ILAB, the
    International Labor Affairs Bureau. And the premise behind ILAB
    is the idea that the interests and welfare of working people in
    other countries is intricately tied to the welfare of workers
    in the United States.
        Too often I also hear what you have just suggested, which
    is companies saying that if we demand that workers do well in
    this country, we're going to take our work to another country
    in which there are even more vulnerable workers.
        And the work of ILAB is intended to create a more level
    playing field. ILAB engages in research and advocacy to make
    sure that conditions like child labor and forced labor in other
    countries are not condoned, that when goods that are made in
    such conditions try to enter the United States, that we do not
    allow that.
        We have also been very engaged in--in helping to monitor
    and assist the country of Mexico in implementation of the
    United States-Mexico-Canada Agreement that would help make sure
    that workers in Mexico also have their fair and free choice to
    join a union and to protect their working conditions--again, so
    that we really end the race to the bottom, as you mentioned.
        Senator Baldwin. Thank you for that answer. While we
    appreciate this important work to level the global playing
    field and discourage companies from moving jobs out of the
    United States in the first place, we also recognize the
    critical needs of these workers who are faced with losing their
    jobs unless CNH decides to reverse course.

                                    WARN ACT

        So I'd like to follow up on the WARN Act. This is an
    important law that, if followed, can help communities plan to
    provide services to workers affected by mass layoffs.
        Unfortunately, as in the case with CNH, not every company
    complies with WARN, and Department of Labor's authority to
    enforce the law needs to be strengthened. Will you work with me
    to explore how Congress can strengthen the WARN Act this
    Congress?
        Ms. Su. Yes, absolutely, Senator.
        Senator Baldwin. Thank you. We've discussed my desire to
    secure increased protections from workplace violence,
    especially for our Nation's nurses.

                    HEALTHCARE WORKERS & WORKFORCE VIOLENCE

        Unfortunately, nurses continue to suffer from rising levels
    of workplace violence. A 2023 report from National Nurses
    United found that nearly one in five nurses have changed or
    left their jobs due to workplace violence.
        With Wisconsin facing a projected shortage of 20,000 nurses
    by the year 2040, we must do all that we can to protect,
    retain, and strengthen the nursing workforce.
        I know the Department has taken some steps towards issuing
    a proposed rule on workplace violence in healthcare and social
    assistance. Can you update us on the actions the Department is
    taking now to provide all nurses the protections from workplace
    violence that they deserve? And describe your efforts to
    accelerate the issuance of this proposed workplace violence
    standard.
        Ms. Su. Yes. Thank you so much, Chairwoman Baldwin.
        So, as you note, workplace violence is too often the
    reality for many in our healthcare settings. I recently made a
    trip where I met in a community in which there was a home
    healthcare nurse who had been killed on the job.
        And I also meet with nurses, including those in nursing
    programs, who are passionate and want to do the job, but
    recognize that violence is a reality that they should face, and
    that they have to face, and that should not-- simply not be the
    case.
        This also points to something that we believe really deeply
    at the Department of Labor, which is that sometimes labor
    shortages, or people not being--not staying in jobs that
    they're trained for and want to do, is a result of job quality
    issues. And we need to make sure that every job is a good job.
        So, our efforts include creating a workplace standard that
    would help to reduce and hopefully eliminate the incidence of
    workplace violence when it comes to healthcare workers. We have
    gone through the initial--the small business review process,
    which is always something that our OSHA (Occupational Safety
    and Health Administration) rules require, and we are doing
    everything we can to issue a notice rule as soon as we can.
        Senator Baldwin. Thank you. Senator Capito.
        Senator Capito. Thank you.
        Acting Secretary Su, I wanted to ask about two of the rules
    that I brought up in my opening statement.

                               THE OVERTIME RULE

        Senator Capito. The Overtime Rule, I'd like to start with
    that. You finalized that regulation just 2 weeks ago, the new
    level of $59,000. And let me ask you a technical question here
    really quickly, because I was talking to somebody who called me
    about this, who's going to be deeply affected. That $59,000
    goes up, right? To another figure shortly? Is that correct?
        Ms. Su. So thank you very much. And actually, if I could
    just say one thing, Ranking Member, I know you mentioned some
    of the workforce investments in West Virginia. We also have a
    Strengthening Community Colleges grant for West Virginia
    University, Parkersburg, which is about nursing. So it kind of
    connects----
        Senator Capito. Right.
        Ms. Su [continuing]. The two points.
        So thank you for the question about overtime. Basically,
    what will happen is in July, there will be, using the current
    methodology, a bump up in the overtime to $14,808----
        Senator Capito. Right. 1,405 to 59. 65 percent increase.
        Ms. Su. The new methodology will not kick in until January
    1 of next year.
        Senator Capito. And that's projected to be $75,000? Is that
    correct?
        Ms. Su. No. That's the 55--the $58,565. That's the $58,000.
    So, this is an example of how our--you know, when we get
    comments, we really pay attention to them. And so in several of
    our rules, we're giving employers some ramp-up time in order to
    comply.

                       OVERTIME RULE COMPLIANCE TIMELINE

        So the July 1st ramp is using the current methodology, not
    the new methodology. It's a smaller bump. And the bump to the
    $58,000, based on the 35th percentile methodology, is going to
    be, is going to effect on January 1 of 2025.
        Senator Capito. So we've gotten a lot of comments for this
    because of, as I mentioned, threatening to reduce worker
    flexibility with little or no effect of what actually employees
    are going to take home. It threatens both--we're hearing from
    nonprofits and colleges and universities who are concerned that
    they may have to raise tuition, curb flexibilities, career
    development opportunities.
        I mean, how do you justify a 65 percent increase in this
    when it was just increased, I guess, what, 4 years ago under
    the Trump administration? Is that correct?
        Ms. Su. So Ranking Member Capito, one of the fundamental
    jobs of the Department of Labor is to make sure that we are
    protecting and looking out for the well-being of workers.
    Because the overtime threshold has been eroded over time, there
    were too many workers who basically were working over 40 hours
    a week and not being compensated for it. And some of this was
    happening through things like, you know, giving people titles
    of managers or supervisors when they were actually doing basic
    frontline work. Our effort in raising the overtime threshold
    was to make sure that the overtime law in the Fair Labor
    Standards Act remains meaningful.
        Senator Capito. So I would have to say, did you get a lot
    of pushback on this when you had your comments, when you put
    your first rule out? You had to have, for a lot of smaller
    businesses. I don't know how they're going to keep track of all
    this.
        Ms. Su. We did--so we engaged. We had several sessions. We
    did 27 virtual listening sessions around the country that had
    more than 2,000 participants in 2022. And then we conducted
    nine separate listening sessions with small business
    stakeholders. It's important for us to engage and to listen. I
    think we received something like 33,000 comments on that rule.
        Senator Capito. Right. I would imagine.
        Ms. Su. And then we respond to those comments. And again,
    one of the reasons for the two-tiered implementation was
    because we heard what the impact would be and wanted to make
    sure that especially small businesses had time to implement.
        The other thing I want to mention, Ranking Member, is that
    we also provide as much assistance as possible when
    implementing new rules like this. So we have charts, we have
    small business compliance assistance tools, and we stand ready
    to assist employers that need it in your State.
        Senator Capito. Okay. So let me just make sure I get the
    process here, because I was a little confused. It does go to
    the $58,000 on July 1 under the old methodology.
        Ms. Su. No.
        Senator Capito. No.
        Ms. Su. It will go----
        Senator Capito. It stays at the same level. It doesn't do
    that until January 1. Correct?
        Ms. Su. It will bump up to 14 thou--40--give me one second.
    It'll bump up----
        Senator Capito. It's coming to you----
        Ms. Su [continuing]. Slightly----
        Senator Capito [continuing]. Right behind you. It's coming.
        [Laughter.]
        Ms. Su. It'll bump up slightly on July 1, using the
    existing methodology, just applied to the current wage rates.
        Senator Capito. Okay.
        Ms. Su. It's basically a math equation.
        Senator Capito. Right. And then it goes----
        Ms. Su. Updated.
        Senator Capito [continuing]. To the 58 in--so full
    compliance is not until January.
        Ms. Su. Exactly.
        Senator Capito. Okay. Okay. I did want to ask about the
    independent contractor rule, but I'll just submit that for----
        Ms. Su. Thank you.
        Senator Capito [continuing]. Until you respond in writing.
    Thank you.
        Senator Baldwin. Thank you, Senator Capito.
        Senator Shaheen.
        Senator Shaheen. Good morning. Thank you for being here,
    Acting Secretary Su.

                               H-2B VISA PROGRAM

        I know it won't surprise you to hear that one of the issues
    I hear frequently about from our small businesses in New
    Hampshire is their difficulty in finding seasonal workers and
    using the H-2B visa program. New Hampshire has consistently,
    for as long as I can remember since covid, had an unemployment
    rate that's below 3 percent right now. The March adjusted rate
    was 2.6 percent. A year ago, it was below 2 percent.
        We can't find the workers we need, and in a State where we
    rely on tourism, it's our second-largest industry--we need
    those seasonal workers. We need those H-2B visa workers.
        And one of the things that we're hearing is that, as you
    know, before employers can apply to the Department of Homeland
    Security for the visa, they have to be approved by the
    Department of Labor to certify that there are no U.S. workers
    who can fill those jobs. They've had trouble getting that
    certification because of processing delays at the Department of
    Labor.
        What are you doing to address that? And what do we need to
    do to adjust this budget to make sure you have the funding you
    need to help make sure we can approve the people who need these
    workers to run their businesses?
        Ms. Su. Yes. Thank you very much, Senator. So I understand
    the importance of the H-2B program in your State and in many
    others, and in multiple industries across the country.
        This is a program that has grown in demand. In fact, in the
    first 4 days of January of this year, we had an application for
    more visa--4 times the number of visas than the maximum number.
    So I recognize just how dire the need is.
        I have also focused since I came as deputy secretary in
    2021 on everything we can do to improve our operational--the
    functioning of how we process. And I have heard that there have
    been improvements in processing. I'm very happy to talk to you
    further about those who continue to struggle in your home
    State, Senator.
        But one thing I will say is that the way that the
    Department of Labor is funded to process these claims, has no
    relationship to the number of claims that we get. So as the
    number has gone up, we have remained flat-funded. Our----
        Senator Shaheen. That's why I'm asking--
        Ms. Su. Yes.
        Senator Shaheen [continuing]. What you need in this budget
    in order to move those approvals, because I think it's a two-
    part process. One is getting workers certified, but the other
    is we don't have enough H-2B visas in the program.
        Ms. Su. Right.
        Senator Shaheen. We're looking at a nationwide unemployment
    rate, as you pointed out yourself, which is a good problem to
    have. But we're not producing enough workers to fill the jobs
    that we're creating.
        Ms. Su. Yes.
        Senator Shaheen. And we've got to figure out how to do
    that.
        Ms. Su. Yes.
        Senator Shaheen. And DOL's (Department of Labor) role in
    ensuring that there are enough H-2B visas available to
    employers is really critical.
        Ms. Su. Yes. Yes. And my team has been very hard at work to
    try to address that. Our budget request does include $1.8
    million to add staffing for processing. Keep in mind that is
    because our overall budget request comes in under the Fiscal
    Responsibility Act.
        Senator Shaheen. Right.
        Ms. Su. I mean, I'm very happy to explore with you other
    options. You know, one that has been floated in the past is
    having the Department of Labor get some of the fees that are
    submitted in order to again level up when the numbers increase.
    But I would be very happy to work with you on other creative
    ideas to make sure that we can process.

                        SALARY IMPARITIES IN RURAL AREAS

        Senator Shaheen. Thank you. I appreciate that.
        In New Hampshire, we have a Federal prison called FCI
    Berlin that has really struggled with recruiting and retaining
    qualified corrections officers and other employees that they
    need.
        And part of the problem is that there is a lack of parity
    in salaries that are offered by local agencies and firms who
    compete with companies in the region. And FCI Berlin falls
    within the rest of U.S. Pay Locality, and the Locality Pay
    program has simply failed to keep pace with local salaries in
    the area.
        Now we've been told that establishing a new Pay Area for
    the Berlin micropolitan statistical area would help address
    this issue. However, the Bureau of Labor Statistics has said
    that the current wage survey model is not capable of producing
    reliable salary estimates for micropolitan statistical areas or
    rural counties.
        So how can we encourage the Bureau of Labor Statistics to
    explore ways to address this? Because we have so many rural
    areas, not only in New Hampshire, but across the country, where
    this is a huge problem, where people are competing with an area
    like--well, we get thrown in with Boston, and there's a big
    difference between what's happening in New Hampshire with pay
    and what's happening in the Boston area.
        So what can you tell us that the Bureau of Labor Statistics
    could do to help us deal with this problem?
        Ms. Su. Thank you, Senator. This is definitely an issue
    that we are seeing. As you noted, and as the Chairwoman noted,
    this is a moment in which there's a--like a tight labor market.
    And it is resulting in workers with more choice, and employers
    needing to recruit and retain and--including competing on
    wages.
        This has had some positive impact in terms of workers and
    their wages, especially. One thing we've seen since President
    Biden came into office is real wages rise, especially for low-
    and middle-income Americans, and that means more money in the
    pockets of working families.
        But to your point, I'm happy to work with you----
        Senator Shaheen. Okay----
        Ms. Su [continuing]. To figure out what we----
        Senator Shaheen [continuing]. And I appreciate--we want
    workers to do better----
        Ms. Su. Yes.
        Senator Shaheen [continuing]. But the Federal Government
    has to keep up with that pay scale as well. And right now,
    we're not doing that. So thank you very much.
        Thank you, Madam Chair.
        Senator Baldwin. Thank you, Senator Shaheen.
        Senator Collins.
        Senator Collins. Thank you, Madam Chair.

              PROPOSED CHANGES TO NATIONAL APPRENTICESHIP SYSTEMS

        Acting Secretary Su, in December, the Department of Labor
    proposed significant and controversial changes to the National
    Apprenticeship System. Among other issues, the proposed rules
    would eliminate apprenticeship programs that face program
    completion on the mastery of skills, rather than an explicit
    time requirement.
        Competency-based apprenticeship programs are a very
    important part of the system in Maine, particularly in the
    areas of healthcare information technology and education. In
    Maine, we've found that competency-based programs often have a
    higher success rate than time-based or hybrid programs. Over
    the past 4 years, the percentage of apprenticeship that failed
    to complete either hybrid or time-based apprenticeship programs
    was almost double those of competency programs.
        So I don't understand why the administration made the
    decision to remove competency-based approaches to
    apprenticeships. Could you explain what the rationale was?
        Ms. Su. Thank you, full committee Ranking Member Collins,
    it's good to see you.
        So as--I think we--there's wide agreement here that
    Registered Apprenticeships are a proven and effective model of
    helping employers get the skilled and competent employees that
    they need, and to create opportunity for people who might not
    otherwise have seen themselves in jobs or be able to stop what
    they're doing and get the training that they need for another
    job. We know that the earn-and-learn model works for that.
        Since this administration has been in office, we have
    expanded those apprenticeship programs in numerous industries,
    including all of the ones that you mentioned. In healthcare, in
    IT, and in education. We now have teacher apprenticeships in
    over 30 States, and we need to continue to expand that. That's
    part of our budget request.
        I think--if you're referring to our proposed rule about
    this, our goal is not to limit the options for expanding
    Registered Apprenticeships. It is to make sure that those
    programs continue to have the standards that have made them so
    successful overall, and to make sure that when somebody
    finishes with an apprenticeship program, the employer knows
    that what they're going to get is somebody who has all the
    capabilities, including the experience and experiential
    learning that is needed to actually succeed in the job, to
    perform it, but also to keep themselves safe and healthy while
    doing it.
        Senator Collins. But the way that you do that is to measure
    their competency, not require an arbitrary amount of time. I
    know I have just a little time, so let me switch to a different
    issue.

                               H-2B VISA PROGRAM

        First, very quickly, I agree with the comments that Senator
    Sheehan made on H-2B visas. Those are absolutely critical in my
    State, where 10 times the State's population visits Maine. And
    I hope that you will be recommending to the Department of
    Homeland Security that it make available the full additional
    64,716 H-2B visas for this fiscal year.

                        NEW EMERGENCY RESPONSE STANDARD

        I want to switch to another issue that I'm hearing a lot
    about in the State of Maine from our firefighters and our first
    responders. And that has caused me to focus on aspects of the
    new Emergency Response standard proposed by OSHA (Occupational
    Safety and Health Administration) in February. When I talked to
    my small rural volunteer fire departments, they have huge
    concerns about the compliance costs, the potential retraining
    requirements that this proposed standard would entail.
        And indeed, OSHA itself has estimated nationwide compliance
    costs could exceed $100 million per year for volunteer fire
    departments alone.
        When I talked to the larger cities in Maine, there are
    fewer problems with complying with the standards. As your
    department finalizes this standard, will you commit to working
    with small, rural volunteer fire departments to ensure that we
    don't essentially force them to close down? Which would hurt
    public safety rather than help it.
        H-2B Visa Caps
        Ms. Su. Yes. Thank you. So just going back quickly to the
    H-2B caps, in this administration, we have used the discretion
    given to the Department of Homeland Security in partnership
    with us to make sure that we are meeting the needs that you've
    mentioned within the discretion that we do have. Obviously,
    Congress has the ultimate authority on the cap.
        Yes, I will definitely commit to you that we will work with
    all stakeholders, but especially what you're saying, the
    voluntary and rural first responder forces that are so vital,
    both to make sure that we hear them, and that we produce a
    standard that keeps them safe as well.
        Senator Collins. Thank you.
        Senator Baldwin. Thank you, Vice Chair Collins.
        Chair Murray.
        Senator Murray. Well, thank you very much, Chair Baldwin.
        Thank you, Acting Secretary Su, for coming here and joining
    us today.
        DOL has a really crucial charge, and that is protecting
    workers who are truly the backbone of our economy. It should
    not be controversial to say that we want all of our workers to
    have good wages and benefits and fair treatment from their
    employer, and safe workplaces.
        And the Department does crucial work on those issues,
    cracking down on wage theft, ensuring workplace safety, and
    even in some cases, fighting discrimination. So I'm really
    pleased you're here today to talk about what resources you need
    to support your work and support our workers.

                                CHILD LABOR LAWS

        Let me start with a topic that I've been particularly
    concerned about, the rise in child labor. The number of
    children and youth found employed in violation of Federal law
    has risen 88 percent since 2019. In my home State of
    Washington, a record number of businesses have been fined for
    violating child labor laws in recent years.
        Senator Casey and I actually introduced the Child Labor Act
    to help combat child labor and strengthen the law. And I know
    that DOL is already doing a lot to enforce our existing child
    labor protections.
        Can you talk with us about what the funding levels in your
    budget request would mean in real terms for child labor
    outreach and enforcement efforts?
        Ms. Su. Thank you so much, full committee Chair Murray,
    it's very good to see you. And thank you for raising this very
    important issue.
        As I think everybody knows, we have seen a rise in child
    labor. Part of the reason is because the Department of Labor is
    doing our job. We are exposing these practices. We are putting
    a stop to them. We are issuing penalties and using the full
    authority that we have. Not just penalties, but using ``hot
    goods'' and other ways to ensure that goods that are touched by
    child labor are not--that companies are not able to profit from
    it.
        So our budget request includes an overall increase of $35
    million for the Wage and Hour Division, with $7.5 million of
    that for child labor.
        We also have to keep in mind that our solicitor's office,
    the attorneys who advise on cases, who brings litigation, to
    drive home the, you know, the seriousness of enforcement, are
    also funded.
        And so both of those are part of the funding request.
        And we simply cannot stop the scourge of what we see, which
    has already been mentioned, like 13-year-olds working on the
    kill floor of the meat packing plant on the night shift with
    dangerous chemicals, or a 16-year-old who recently died in a
    sawmill. It's unconscionable that this is happening. And the
    Department of Labor often stands as the most important bulwark
    against those kinds of practices.
        And so our budget request is meant to stay within the
    bounds of the Fiscal Responsibility Act, but also increase our
    capacity to address this.
        Senator Murray. Right. So you're asking for funds for both
    the Wage and Hour Division and the Office of the Solicitor
    working together to combat this. Thank you. I think that's so
    important.

                             WAGE THEFT PREVENTION

        Another issue that I've been very focused on is combating
    wage theft. Workers deserve to be paid the full wages they
    earned. But unfortunately, some companies in the country are
    denying workers tens of billions of dollars in hard-earned pay
    each year.
        I actually introduced the Wage Theft Prevention and Wage
    Recovery Act to put money back into workers' pockets by
    protecting their right to fair and timely pay, and
    strengthening accountability for wage theft violations.
        I'm going to keep working on that, but I wanted to ask you
    today, what is the Department of Labor doing right now to fight
    wage theft?
        Ms. Su. So this is one of the most important things that we
    do, is to make sure that every worker gets a just day's pay for
    a hard day's work. We see violations of you know, basic failure
    to pay the minimum wage.
        The majority of violations we see when it comes to wage
    theft is in overtime. So workers not being paid when they're--
    when they work over 40 hours, and we have--our investigators
    are in the field every single day uncovering these kinds of
    violations.
        You know, it should be, I think, obvious to many that for
    employers who choose to violate the basic labor laws, they will
    go to great lengths to prevent those practices from being
    found. And so it's very important for the Department to be able
    to gain the trust of workers to learn about what is going on,
    to be able to do inspections at the workplace, too. For
    example, be able to see whether records are being kept and you
    know, what exactly is going on in the workplace.
        For those employers who've decided that it's cheaper to
    break the law, and the chances of getting caught are slim, and
    the consequences even if they do get caught are minimal, we
    need to tell them that that is not the proper way to--you know,
    we're not going to allow those kinds of violations.
        And it's also very important--we hear this often, is from
    other employers in that industry who are complying with the
    law, need to know that the Department of Labor will help them
    ensure a level playing field.
        Senator Murray. So there's fair competition?
        Ms. Su [Nods yes.]
        Senator Murray. Fair--all right. Thank you very much. Thank
    you.
        Senator Baldwin. Thank you, Chair Murray.
        Next, Senator Hyde-Smith.
        Senator Hyde-Smith. Thank you, Chairwoman Baldwin and
    Ranking Member Capito. And thank you for being here also as
    well, Acting Secretary Su.

                          IMPORTANCE OF SKILLED LABOR

        Mississippi, like the rest of the country, and that we've
    all had these discussions, is facing a pretty tough labor
    crisis, and the widening gap between jobs available to
    Mississippians and the career routes being chosen.
        Despite there being many positions offering significantly
    above-average wages, there's a huge shortage in our State of
    plumbers, electricians, diesel mechanics, utility linemen, HVAC
    technicians, precision manufacturing's, and many, many skilled
    jobs. Without more people pursuing these jobs, our workforce
    participation rate will continue to decline, average income
    increases will stall, and our economic health will suffer as we
    struggle to reach our economic potential.
        But from my conversations with training providers, State
    officials, community organizers, and employers, this shortage
    is not the result of a lack of opportunity or training
    resources. Rather, it is largely an issue of awareness and
    perception with these jobs.
        Many people exploring their career options are not aware of
    the high wages, good benefits, and the long-term stability
    these occupations provide. It's almost a little bit of a
    stigma. And if they are aware, there is a misguided view these
    occupations are less desirable. And that's really, really sad.
        But what is your stance on the importance of funding or
    supporting efforts to increase awareness of these jobs and
    their benefits, and to decrease any negative perceptions that
    may surround them?
        Ms. Su. Yes. Thank you so much, Senator. I also understand
    tomorrow is your birthday, so happy early birthday.
        Senator Hyde-Smith. Thank you very much.
        [Laughter.]
        Ms. Su. I could not agree more with what you are saying,
    and I see that also when I travel the country, that we do have
    to overcome a certain perception, both of the quality of the
    jobs--and again, in this moment when there are such historic
    investments in infrastructure, in manufacturing, in clean
    energy, in good jobs in every community, I think the reality is
    that these are good quality jobs.
        The other part of this is that--you know, one of the things
    I hear is that we need to do a better job of also aligning our
    educational system with this message. Too many young people
    hear that, you know, your only path, the only right path, is to
    go to a 4-year college. And I meet with people across the
    country who say, ``That's just not what I, that's not what I
    wanted to do. I wanted to work with my hands. I wanted to, you
    know, gain a trade.''
        And so making sure that our overall--those of us who are,
    you know, trusted messengers to young people, are also saying,
    there is another path, and this is a viable path, is very, very
    important.
        I hear from people who are--you know, let's say they're
    finishing an apprenticeship program, or they're in a career
    trade, who say, ``If I had known that this was available to me
    years ago, I could have started on this secure path with a good
    job, with benefits, with retirement a long time ago.''
        So we do have work to do there. I am very anxious to work
    with you on that. It's something that we're working on across
    the administration, you know, something that, for example,
    Secretary Cardona and I talk about as well. And everywhere I
    go, I try to raise awareness about that issue.
        I do think the added investments in actual training
    programs that reach communities that have been left out in the
    past would also help to create, you know, a climate in which
    people understand that these are real options for them.
        Senator Hyde-Smith. Yes, and we have great training
    centers. I mean, that's--we're not lacking that at all. It's
    just getting the students in there with the pride of being in
    there. And I know that's kind of hard to buy.

            STRENGTHENING COMMUNITY COLLEGE TRAINING GRANT PROGRAMS

        But in addition to getting the word out about the potential
    careers, it's also important to properly train. And I'm pleased
    that the Department is seeking an increase in the Strengthening
    Community College Training Grant programs. And for fiscal year
    2025, we have some great community college system and does an
    outstanding job of targeting specific needs for our State.
        And many of the community colleges in Mississippi continue
    to work with companies to fill the training gaps in
    manufacturing and the technical jobs so we can continue to
    produce a ready, well-trained workforce.
        But will you commit to making sure these grants continue to
    go to deserving community colleges in rural States so they can
    continue to fill the workforce gaps across all sectors?
        Ms. Su. Yes, absolutely. And our budget request does
    include a modest increase in our Strengthen Community College
    grants. And 100 percent, they are key to the overall workforce
    system. And one way that young people--and mid-career people,
    hear about opportunities that they might not have had, and have
    the ability to gain the skills in the classroom that match the
    skills they're going to need in the workplace, 100 percent.
        Senator Hyde-Smith. Okay. I'm over my time. Thank you,
    Madam Chairman.
        Senator Baldwin. Thank you, Senator Hyde-Smith.
        Senator Schatz.
        Senator Schatz. Thank you, Chair.
        And thank you, Secretary, for being here. And thanks for
    your great work and the way you engage with Congress. Even when
    members disagree with you, it's always substantive and
    respectful, and I just wanted to observe that it's not that
    easy to do so. So good job on that.
        I just want to quickly agree with Senator Murray about the
    Office of the Solicitor----
        Ms. Su. Yes.

                             CHILD LABOR PENALTIES

        Senator Schatz [continuing]. Especially as it relates to
    child labor. We can disagree about a lot, but the law already
    exists, and it is not sufficiently enforced. You've got around
    100 meritorious cases that are--that we are unable to prosecute
    per month. And there's a solution to that. We don't need a new
    statute.
        But I actually want to talk to you about an area where we
    do need a new statute. Senator Young and I also have a child
    labor bill that does something a fair amount more narrow than
    Senator Murray and Senator Casey, and that is simply crank up
    those penalties.
        As you know, it is $68,801 maximum penalty for a child
    labor violation that results in the death of a child. Sixty-
    eight grand is what we have in Federal statute.
        And so not only have companies made the judgment that
    between the Office of the Solicitor and overall resources for
    the Department that they may not get caught, but even if they
    get caught, it's not that expensive. And it can be booked as a
    cost of doing business. If a child dies on a factory floor,
    it's $68 grand. Capped.
        So I'm sorry to take such a long time to wind up, but I'd
    like you to talk about the practical impact of those penalties,
    and what would happen if those penalties were turned up to the
    point where it was, you know, a real financial hit.
        Ms. Su. Yes. Thank you so much, Senator. I mean, I can't
    say it better than you've already said it. When employers feel
    like breaking the law can just be a cost of doing business,
    because the consequences, even when they're caught, are so
    minimal, the incentives to comply are too poor. And we do
    everything we can at the Department of Labor, through our
    investigative resources, to expose illegal practices, to hold
    all of the companies who are responsible accountable.
        But we do appreciate the efforts of Congress in light of
    all of the attention to child labor, and the cases that we
    continue to see, to do everything in your power to help make it
    more costly for those who break the law.
        Senator Schatz. Thank you very much. And I guess I just
    want to reiterate this point.
        You know, it's Labor, right? So we're going to have a
    difference of opinion on a lot of things about independent
    contractors, about union organizing and regulatory questions.
    But I think we can all agree that there's no justification for
    a violation of Federal law being so inexpensive as to not be a
    disincentive.
        And so this is something that I just think we ought to fix.
    We can either pass it by consent, or in some other must-pass
    piece of legislation, but this is not the kind of thing that
    could get--that ought to get caught up in are pretty
    fundamental ideological disagreements.

                                 WOMEN'S BUREAU

        Speaking of fundamental ideological disagreements, here I
    move on to the Women's Bureau. I am continually impressed--and
    I have to say, I talk to my staff, and I'm always suspicious
    about bureaus, because our tendency on our side of the aisle is
    to identify a problem, and then establish a bureau for the
    thing we want to see fixed? And so they had to persuade me that
    this Women's Bureau was not just seven people in a bunch of
    cubicles.
        But boy, they've done really important work. And I'd like
    you to just spend a little bit of time talking about what the
    Women's Bureau has done for the workforce and for women in the
    workforce.
        Ms. Su. Thank you very much for that, Senator. So I think
    it's important to say that in many ways, women have helped to
    power the economic recovery that we have seen in this country.
    Last month, the labor force participation rate for prime age
    working women reached an all-time high, a high since we started
    collecting this data, which was back in 1948 when Harry Truman
    was elected President. So the role of women in this economy
    simply cannot be overstated.
        At the same time, we have much more work to do to tap into
    the full potential of women in the economy. And one of the
    studies that the Women's Bureau put out that I think is so
    important to note here, is that if our country invested in
    CARE, in the CARE infrastructure and policies that support
    CARE, like national paid leave, then about 5 million more women
    could enter the workplace, and that would result in $775
    billion worth of economic activity a year.
        So Women's Bureau's research and work in this space helps
    to tell us not just, you know, what policy--the impact of
    policies, but also what's happening when we don't invest in
    policies.
        The other piece that Women's Bureau puts out are grants
    called WANTO. They're Women Apprentices in Nontraditional
    Occupation. And it is meant to make sure that women see
    themselves in some of these good jobs that are being created
    that they have been underrepresented in for a very long time.
        I also feel like I need to say, because you asked about the
    Women's Bureau, and it's almost Mother's Day, that I want to
    thank all the working mothers who do this work. And our Women's
    Bureau is very much about continuing to lift up their voices
    and their stories and opportunities for them.
        Senator Schatz. Thank you.
        Senator Baldwin. Thank you, Senator Schatz.
        Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chair.

                           SEXUAL HARRASSMENT AT FDIC

        Madam Acting Secretary, welcome. Part of your job, Madam
    Acting Secretary, is to protect and support employees, is it
    not?
        Ms. Su. Yes, sir.
        Senator Kennedy. And do you believe that we should
    protect--do you believe passionately that we should protect and
    support our employees?
        Ms. Su. I am passionate about that, sir. Yes.
        Senator Kennedy. Okay. Do you believe that we should
    passionately protect and support our employees at the FDIC
    (Federal Deposit Insurance Corporation)?
        Ms. Su. I do believe that all employees should be entitled
    to fair pay and come home healthy and safe and----
        Senator Kennedy. Including the FDIC?
        Ms. Su. Yes.
        Senator Kennedy. Okay. Have you read the recent outside
    report--234 pages about the creepy old men at the FDIC?
        Ms. Su. I have not seen that, Senator.
        Senator Kennedy. Have you heard about it?
        Ms. Su. I have not.
        Senator Kennedy. Are you curious about it?
        Ms. Su. Yes, I am. Sure. Yes.
        Senator Kennedy. Well, the report that--the people who
    conducted the report, Madam Acting Secretary, and I'm surprised
    you haven't followed it, asked employees at the agency to phone
    in complaints.
        There are 6,000 employees. Five hundred--almost one out of
    ten--employees phoned in complaints. Many of them were sexual
    complaints, sexual discrimination complaints. One young woman
    said, ``My supervisor continuously sends me text messages with
    photographs of his penis.'' Is that a labor violation?
        Ms. Su. I mean, it's horrible----
        Senator Kennedy. Well, another employee, a Hispanic
    employee, said, ``My supervisor required me to recite the
    pledge of allegiance, because he said I had to prove I'm an
    American.'' Is that a labor violation?
        Ms. Su. I think, Senator, everything that you're saying is
    not acceptable in the workplace.
        Senator Kennedy. Okay.
        Ms. Su. The technical question about labor violation is I
    know--they fall under various statutes. But yes.
        Senator Kennedy. But one young woman said, ``My supervisor
    sent me a text message saying, quote, 'Get naked, bitch.''' Is
    that a violation? Labor violation?
        Ms. Su. I think it's unacceptable workplace behavior,
    certainly.
        Senator Kennedy. It's pretty bad. One young woman said,
    ``My supervisor regularly commented on my breasts and my legs
    and about his sex life.'' Is that a labor violation?
        Ms. Su. I think it's unacceptable behavior.
        Senator Kennedy. Yes, it's pretty bad, isn't it? One young
    woman testified--or sent in a complaint and said, ``One of my
    supervisors asked me the following question. Quote, 'Does your
    husband eat you?''' Close quote. Is that a labor violation.
        Ms. Su. Yes, I mean, it's unacceptable behavior. It's
    disgusting. It's----
        Senator Kennedy. Well, what do you plan on doing about it?
    Don't you think that all the senior management at the FDIC
    should resign and be prosecuted?
        Ms. Su. So, Senator, I don't know if a complaint was
    formally made to the EEOC (Equal Employment Opportunity
    Commission). That is the Federal agency----
        Senator Kennedy. But ma'am, you can----
        Ms. Su [continuing]. That opens the----
        Senator Kennedy. [continuing]. Initiate a complaint. I'm
    here----
        Ms. Su. Okay --

                    SEXUAL HARASSMENT IN FEDERAL GOVERNMENT

        Senator Kennedy [continuing]. You're Labor Secretary, and I
    know from your behavior you believe in protecting employees.
    Now this is as egregious as I've ever seen, and I suspect
    you've ever seen. And I thought we had already decided that
    this is no country for creepy old men.
        I'm asking you what you're planning. Do you--are you going
    to call for Martin Gruenberg to--the--who runs a place to
    resign? He's been there since 2005, and only--and one of two
    things are going on. If he says he didn't know about it, he's
    like a rock, only dumber. Or he condoned this behavior.
        Is--for the Biden administration, does ``Me, too'' apply
    except at the FDIC? Is that what you're saying?
        Ms. Su. No, Senator, I mean, I have seen some pretty
    horrible things. I mean, we see human trafficking and people
    forced to work in, you know, unconscionable conditions. We
    see----
        Senator Kennedy. What are you going to do about the FDIC?
        Ms. Su. So----
        Senator Kennedy. And how are you going to protect those
    employees?
        Ms. Su. Well, they definitely deserve protection. This is
    where the Department of Labor's authority over the Fair Labor
    Standards Act, the OSH Act, and other things--the sexual
    harassment claims that you were talking about fall under a
    different Federal agency. And----
        Senator Kennedy. So you're just going to ignore it?
        Ms. Su. No, I mean, you know, but I think that it's
    important for agencies to operate under the authority that
    they've been given by Congress----
        Senator Kennedy. Don't you think you have a moral----
        Ms. Su [continuing]. That's one reason I think I do know--
    --
        Senator Kennedy. [continuing]. Imperative to ask Mr.
    Gruenberg to resign? To quit?
        Ms. Su. I would say this, Senator. I think you said that a
    complaint had been made. I'm assuming it was made to the proper
    Federal agency. I trust that our sister agencies----
        Senator Kennedy. Not yet, but they're coming. I'm just----
        Ms. Su. Okay.
        Senator Kennedy [continuing]. Asking you what you're
    planning on doing, if anything. It doesn't sound to me like
    you're planning on doing anything to help these young female
    employees.
        Ms. Su. Well, now that you've brought it to my attention,
    I'm happy to make sure that the EEOC is aware that there is a
    case like this.
        Senator Kennedy. But you're not going to do anything about
    it as Labor secretary.
        Ms. Su. Well, let me say this, Senator. I know that the
    people of America need a very strong Department of Labor to
    protect working people across this country. Our authority to
    investigate, to cite, to end bad labor practices, are bound by
    the authority that's given by you to me. These investigations
    occur at another agency.
        Senator Kennedy. You're not going to do anything, are you?
        Ms. Su. Oh, I just said I'm happy to reach out to them to
    make sure they are aware of it, and if they need any support
    that I'm able to give----
        Senator Kennedy. Yes, but you're not going to do anything
    in your power to help those employees, are you?
        Senator Baldwin. Thank you, Senator Kennedy.
        We're going to begin a second round of questions. I do
    understand some members who were here earlier are trying to
    return for their opportunity to do their first round.

                  EBSA AND MENTAL HEALTH SERVICES ENFORCEMENT

        For far too long, many Americans were denied health
    coverage for life-saving mental health services. I was proud to
    support bipartisan legislation that requires private health
    insurance companies to cover mental health and substance use
    disorder just like they cover physical health.
        The Department of Labor plays a critical oversight role in
    securing parity compliance in employment-based health plans,
    covering an estimated 131 million plan participants.
        Supplemental appropriations Congress provided to help
    implement this legislation will be exhausted by the end of the
    year. These funds have helped the Department address parity
    violations, hold companies accountable, and facilitate access
    to treatment.
        Acting Secretary Su, how would additional resources
    requested in this budget help the Department's Employee
    Benefits Security Administration improve access to substance
    use disorder treatments that Wisconsinites and communities
    across the United States need to help overcome the crisis that
    claimed more than 100,000 American lives in the year 2022?
        Ms. Su. Chairwoman Baldwin, thank you so much for your
    leadership on this issue. Today is actually National Children's
    Mental Health Awareness Day, and this month is actually Mental
    Health Awareness Month.
        And at the Department of Labor, we play a very important
    role on making sure that individuals who need mental health
    services, substance use disorder treatment, actually get the
    coverage from the insurance company that they're supposed to
    get.
        Our EBSA that does this enforcement, our Employee Benefits
    Security Administration, the budget request there is an
    increase of $14.6 million. Again, in order to stay under the
    Fiscal Responsibility Act cap that was there, and in order to
    continue to do enforcement, as you mentioned, in a field that
    is so important, but in which the funding that was given is
    about to sunset.
        I just want to share a few examples of the kinds of
    enforcement that we do here. We have--I've spoken to several
    parents whose children needed some kind of mental health
    treatment, and they were denied coverage for it.
        And so sometimes it means that a family will simply forego
    the treatment, often with devastating results.
        Sometimes families will do everything they can, including
    get a second mortgage on their home, like go into great debt in
    order to pay what is needed.
        We had a case in which a child needed inpatient mental
    healthcare. The family took out a second mortgage for it and
    ended up paying over $200,000 out of pocket. Because of the
    Department of Labor's intervention, we got that amount covered
    by insurance--which, you know, the families will tell us that
    it's basically life-saving work.
        We have benefits advisors who answer the phone when
    somebody is being denied coverage, and sometimes that
    intervention will result in an immediate change.
        This is life-saving work. And oftentimes the impact of one
    enforcement effort is--has ripple effects, because once the
    insurance company recognizes what they're supposed to do in
    that one instance in which we got involved, they will change
    the way that they approach future requests for coverage. And
    then that has--you know, each of our investigations is
    amplified in terms of its impact.
        And so I can't overstate the importance of the work of
    EBSA, especially in this moment where we are seeing, you know,
    one in five adults report a mental health issue a year. And for
    young people, you know, I don't even know if the data is fully
    available.
        So we--you know, I can't overstate the importance of
    building up EBSA in order to continue this work.
        Senator Baldwin. Okay. Thank you. Give her a moment to get
    adjusted, and then I will recognize Senator Britt.

                   LACK OF SENATE CONFIRMED SECRETARY AT DOL

        Senator Britt. Thank you very much. Just got finished with
    Banking and headed down, so thank you, I appreciate it.
        Acting Secretary Su, thank you for being here today. I
    wanted to begin by expressing my concern about the length of
    time the Biden administration has allowed the Department of
    Labor to operate without a Senate confirmed secretary at the
    helm.
        As you are aware, your nomination to be the Secretary of
    Labor is opposed in a bipartisan majority of the Senate, and
    you will not be confirmed to this position during this
    Congress.
        Despite that reality and repeated requests to the President
    to put forth a nominee who can receive adequate support to be
    confirmed, the Biden administration has instead left you in
    place as acting secretary on an indefinite basis with no
    current plans to put forth another nominee for secretary of
    labor.

                        PRESIDENTIAL LINE OF SUCCESSION

        You've also been listed on the White House website as a
    member of the Cabinet, quote, ``in order of succession to the
    presidency,'' signaling that despite having never been elected
    to any office nor confirmed by the Senate to any Cabinet-level
    position, the White House believes that you are eligible to
    assume the presidency pursuant to the Presidential Succession
    Act of 1974.
        In October, I led a letter to President Biden, along with
    29 of my colleagues, urging that the White House clarify its
    position on this very issue. I've yet to receive a response to
    that letter.
        And so I want to raise that question with you today. Do you
    believe that if the need were to arise, that you are currently
    eligible to assume the presidency under the Presidential
    Succession Act of 1974?
        Ms. Su. Senator, it is the honor of a lifetime to have been
    nominated by the President to serve in his Cabinet.
        Senator Britt. Absolutely. And do you believe that you are
    in the line of presidential succession?
        Ms. Su. So prior to being nominated, I was confirmed as the
    deputy secretary of Labor in 2021. And then when my predecessor
    left, I became the acting secretary through the normal----
        Senator Britt. Yes, ma'am, I'm aware. My question is, do
    you believe that you should be in the presidential line of
    succession? It's just a yes or a no.
        Ms. Su. I mean, Senator, I put it this way. I serve at the
    pleasure of the President. I appreciate his confidence in me.
    We've spent some time here today talking about the work of the
    Department and the important ways that we are----
        Senator Britt. And Ms. Su, this isn't--my question is
    specifically about the presidential line of succession. Do you
    believe, yes or no, that you should be in that, having not been
    confirmed into this position by the United States Senate? So
    just yes, you believe you should be able to succeed in the
    presidential line of succession if that were ever to happen? Or
    no, you believe you are not actually in that line of
    succession?
        Ms. Su. Let me--can I say two things about that, Senator?
    The first is that----
        Senator Britt. Well, I--you know what----
        Ms. Su [continuing]. The question of----
        Senator Britt. Yes, I actually have a lot of questions I
    want to get to on this, but I thought that that would be a
    really easy yes or no. And to me, it's no, you haven't been
    confirmed, and therefore should not be in the line of
    succession. I mean, this is a big deal, and I think that's a
    simple answer. And unfortunately, I didn't get that from you.

                               NEW OVERTIME RULE

        Like many other of my colleagues, I've been very concerned
    about a number of rules that have been issued by the Department
    of Labor during your tenure, starting with the new Overtime
    Rule. And I know we've discussed that a bit today.
        The new rule increases the minimum salary threshold for the
    executive, administrative, or professional overtime exemption
    by 65 percent from the 2019 rule, and increases the minimum
    salary threshold for a highly compensated employee overtime
    exemption by 41 percent from the 2019 rule.
        I've heard from numerous stakeholders in Alabama about the
    huge detrimental impact that this rule will have on them. As an
    example, many of Alabama's small colleges and universities,
    which include HBCUs (Historically Black Colleges and
    Universities)--we have more HBCUs in Alabama than any other
    place in the Nation.
        And as I hear from them about dealing with this, it is
    going to have significant ramifications. My office has spoken
    to schools that don't have large budgets or endowments, but are
    facing hundreds of thousands of dollars in additional costs for
    the upcoming academic year having to implement this rule and
    reevaluate salaries across the board due to this rule's
    provisions.
        At the same time, those schools are unable to lock down
    their incoming freshman classes, or fully make informed
    decisions and budgetary choices about the upcoming academic
    year.
        And I--if you look at that, you know, this rule is
    obviously having a huge impact--in addition to all of those
    things, and small businesses in Alabama. And to me, small
    businesses are the heartbeat of this country. They're what make
    Main Streets go. They're what allow people to achieve the
    American dream.
        And given these realities, do you, at the very least,
    envision the Department granting additional flexibility with
    respect to the timing of this rules implementation across the
    country?
        Ms. Su. So Senator, I agree with what you said about the
    importance of small businesses in our economy. There's no
    question about that. And we engage with small businesses in all
    of our rulemaking, but also in our Overtime Rule.
        In terms of the timing, actually----
        Senator Britt. And they're supportive of that?
        Ms. Su. We got comments on all sides. We got--I think I
    said this, over 33,000 comments on Overtime? I believe that's
    the right number for that particular rule.
        But we do hear from small businesses who rely on the
    Department of Labor to create a level playing field on which
    they can compete, especially in a moment where they need to
    recruit and retain, you know--keep workers by making sure that
    their working conditions are competitive.
        But let me just address the timing, because that is one of
    the things, and the ranking member and I already talked about
    this some is, we heard comments about the need for some time to
    come into compliance. So our Overtime Rule goes into effect in
    two phases. The first is on July 1. It will go up--it's a bump
    based on the current methodology, not the new methodology, but
    the current rule multiplied by current wage levels. The other
    bump, the bump of the 35th percentile in the new rule, is going
    to go into effect on January 1 of 2025.
        Senator Britt. I hope you'll take these things into
    consideration. And I am obviously out of time, but I heard my
    colleague from New Hampshire mention there is a big cost of
    living difference, as she mentioned, from in New Hampshire and
    Boston. When you look at the low cost of living in Alabama,
    there is a detrimental effect that occurs, and it--I hope that
    you will take all of those things into account. So thank you
    very much for your time today.
        Ms. Su. If I could just also say, the way our formula works
    does take that into account. And I'm happy to follow up if you
    want to hear more about that.
        Senator Baldwin. Thank you, Senator Britt.
        Senator Capito.

                   ENVIRONMENTAL, SOCIAL, AND GOVERNANCE RULE

        Senator Capito. Thank you. Acting Secretary, I want to ask
    about ESG (Environmental, Social, and Governance), because I
    mentioned that in my opening statement. So in 2022, the
    Employee Benefits Security Administration issued a final rule
    under ERISA (Employee Retirement Income Security Act) that
    allows plan fiduciaries to consider climate change,
    environmental, social, and government factors when making
    investment decisions.
        What brought that decision forward? And was that a
    requirement from the President to have an all--throughout every
    department consideration of climate change?
        Because as we look at, say, the Social Security Trust Fund,
    which a lot of people are going to retire--relying on for
    retirement and also their retirement plans, in my view, the
    best way to keep our retirees as they move into their senior
    years in the best possible position, is to have the maximum
    financial benefit accrue to their plans, regardless of--I could
    see if things were illegal, but you know, if you're talking
    about a natural gas company or a coal company or somebody else
    who's really maximizing profits, this rule would--if that
    fiduciary takes this under consideration, would eliminate that
    as a possibility.
        Ms. Su. So, Ranking Member, I very much appreciate both the
    question and the way in which you asked it. Because I agree,
    and of course, you know, it's best for retirees for their
    investments to give them the maximum financial benefit. All of
    our work, our enforcement work, as well as our rulemaking is
    about that.
        This particular rule is consistent with that, in that it
    does not mandate, but it does allow an investor to take into
    account ESG factors, especially because--and I was just in a
    meeting about this with many investors who actually make these
    decisions.
        Sometimes when those factors--labor principles. You know,
    environmental, valuing environmental outcomes, those factors
    actually make an investment more profitable.
        And so what our rule did--the prior administration took
    away the ability to consider those factors. Said that you can't
    look at them. Our rule restores the ability for someone who's
    making those decisions to look at all of the factors that will
    help them to decide what is going to be best for the actual
    retiree.
        Senator Capito. In my opinion, this really politicizes a
    really important part of our financial fabric in this country.
    And I think that the pressures--you didn't answer the question
    as to whether the pressure to move forward with this rule came
    from the White House or from the financial institutions? Are
    you aware that there are a lot of ESG funds that have actually
    shuttered, closed down, because they're not generating the
    profits that they need.
        So who made the decision to move forward on this? Was this
    a decision you made, or the former head of Labor, or was it
    made in the White House?
        Ms. Su. Well, so, Ranking Member, if I could just say,
    again, it--just respond to that----
        Senator Capito. Well, answer that.
        Ms. Su. The politicization occurred in the prior
    administration when said, you cannot consider them. The point
    about being able to consider all factors is something that we
    heard from those people, financial advisors, those making those
    decisions, that they wanted to be able to consider all factors,
    but because of the prior administration's rule, they were
    afraid to do that, even when it would be in the best interests
    of the accounts in which it agree--in which it would result in
    the maximum investment return.
        So our rule was really about more flexibility. In terms of
    who made the decision, again, we went through the process for,
    you know, for rulemaking that we always go through. We are
    thoughtful, we are judicious, we take comments, we listen to
    them, we respond to them, and then we produce something that
    we--you know, that we believe is in the best interests of, in
    this case, not just the account holders, but also those who
    are--who asked for more flexibility in their decisionmaking.
        Senator Capito. Thank you.
        Ms. Su. Thank you.
        Senator Baldwin. All right. Senator Manchin.

                            THE JOINT EMPLOYER RULE

        Senator Manchin. Thank you, Madam Chairman.
        Thank you, Secretary, for being here. Recently, the
    President vetoed a bipartisan congressional resolution
    overturning the National Labor Relations Board NLRB rule,
    redefining who is a joint employer. The rule from NLRB will put
    the franchise model at risk, and I think you know how I feel
    about this.
        Small businesses are the heart of the economy and our
    communities, especially in our little State of West Virginia,
    which we love dearly, where more than 98 percent of our
    businesses are small businesses. One out of every three
    franchise owners say they wouldn't own a small business without
    the franchise business model. One--that's a tremendous--one in
    three, 33 percent.
        The last time NLRB tried this study, a study found that the
    policy led to 376,000 fewer jobs and $33 billion in lost output
    across the economy.
        While a Federal judge has currently blocked this rule from
    taking effect, I'm concerned what will happen if it does take
    effect.
        So my question would be, there continues to be bipartisan
    concern with what the NLRB is proposing. What does your
    Department plan to do to curb the job and economic output loss
    we experienced the last time if this would go into effect? And
    are you all still pushing it forward to be effective?
        Ms. Su. So Senator, it's nice to see you. I know everybody
    knows, but I will say this. The NLRB is a separate entity from
    the Department of Labor. The joint employer rule is not
    something that the Department of Labor has pursued or that we
    have put on our regulatory agenda.
        I will say, one of the things----
        Senator Manchin. Well, we tried to get rid of it, but the
    President over--he vetoed us. The President overrode us. You
    know, we tried to get rid of it, but he vetoed it. So he must
    believe, and the administration must believe, in the rule, the
    way the rule's been.
        Ms. Su. Yes. That is not a rule that the Department of
    Labor pursued or put into effect. I will say, though----
        Senator Manchin. Do you all acknowledge the job--can you
    acknowledge the job losses that came when they did implement it
    the last time?
        Ms. Su. I mean, Senator, I don't have any data about that.
    But I will acknowledge----
        Senator Manchin. Did you----
        Ms. Su [continuing]. The conversations we have had, and the
    important role that franchisees and franchisors played. I know
    we've talked about this, too.
        Senator Manchin. Sure, sure.
        Ms. Su. My own parents owned a franchisee business. And so
    I understand and have lived the benefits that such a business
    means for----
        Senator Manchin. If you would do me a favor with your able
    staff here, if they would just check and find out if that's
    accurate, the amount of jobs that we know have been lost before
    or our statistics shows, and the amount of revenue it's caused
    to our economy, and maybe that would make the President and his
    administration take a different look at this in a different
    way. We're very hopeful.
        Ms. Su. I mean, Senator, I know you know this, but since
    the President came into office, 15.4 million jobs have been
    added to the economy at the same time that the unemployment
    rate remains very low. It's been under 4 percent for 27 months
    straight. I know that's already been said as well.
        So we are in a moment of tremendous job creation, in no
    small part due to the investments that are being made through
    the President's Investing in America Agenda, which this body
    was obviously very critical in helping to make the----
        Senator Manchin. The way the bills that we all passed in a
    bipartisan way, and even the IRA (Inflation Reduction Act)
    bill, the way it's being implemented is different than the way
    we wrote it. So we're in contention. I mean, there's going to
    be a lot of legal cases that they're going to lose, because
    they're overstepping their boundary of how they're
    implementing.
        And I've said this many, many times. You're trying to
    implement a bill you never passed. I know the bills, because we
    wrote them. We all worked on them. We wrote the bills. We know
    what they are in them. And they're expanding those to a
    position that's going to exasperate the position we've taken.
        Bring manufacturing back to America. You can't bring
    manufacturing back if you relax the rules and where you get
    your critical minerals and where you put produce them. And if
    you allow China to keep doing it, all you're doing is promoting
    China's dominance in the market.

                           SCHEDULE A OCCUPATION LIST

        One final question was this. The Department of Labor
    scheduled a shortage occupation list which was designed to
    address workforce shortages by streamlining the process of
    hiring vetted international workers in high-demand industries
    like science, technology, engineering, and math--and STEM--and
    also healthcare.
        Schedule A is an important tool that exempts workers and
    understaffed industries from bureaucratic visa hurdles and
    backlogs. Despite having the authority to revise the Schedule A
    list, the Department has not updated it to include more than
    two specific occupation--professional nurses and physical
    therapists--since 2005.
        While the Department has not updated the list in over 20
    years, I was pleased to see the request for information, RFI,
    on how the Schedule A occupation list could be modernized to
    include STEM occupations, for which there is a demonstrated
    labor shortage.
        So what is the Department timeline to provide an update on
    Schedule A list? I'm glad you are taking it serious.
        Ms. Su. Yes, so that's what I was going to say. We did do
    an RFI on this to figure out exactly what we needed to do. And
    I can certainly get back to you more with the timeline.
        I thought, Senator, you were going to ask me about a rule
    that you had wanted to get done, that we did get over the
    finish line, which is I was in Uniontown, Pennsylvania recently
    to announce our silica rule, which is going to save thousands
    of lives and prevent thousands of injuries, but my----
        Senator Manchin. Let me thank you for that.
        Ms. Su [continuing]. But we didn't get to talk about it.
        Senator Manchin. I'm so sorry. I want to thank you for
    that, because it did help. Thank you.
        Thank you, Madam Chair.
        Senator Baldwin. Thank you, Senator Manchin.
        So that will end our hearing----
        Senator Kennedy. I would like my second round.
        Senator Baldwin. Senator Kennedy, you are recognized.

                           SEXUAL HARASSMENT AT FDIC

        Senator Kennedy. Thank you, Madam Chair.
        Again, Madam Acting Secretary, thank you for being here.
        I'm a little confused by some of your answers, but I think
    we've made some progress. I think we've established, number
    one, that many supervisors and some members of the senior
    leadership at the FDIC, are pigs. They are sexual predators.
    They are bigots.
        Number two, this issue has been out there for some time.
    Since the Wall Street Journal broke the story, at least 6
    months.
        And so far, the Department of Labor--Labor has said
    nothing. Zero. Zilch. Nada. In fact, I think you said you
    haven't even read the reports and aren't familiar with the
    issue. Maybe I'm overstating it. If I am, correct me.
        Number three, Madam Secretary, you have a long history,
    that I know you're proud of, of passionate activism on behalf
    of employees.
        So here's my question. Are you or are you not going to use
    your legal authority and moral authority to open an
    investigation of the FDIC and help those young women over there
    and help those young people of color over there?
        Ms. Su. Senator, I am deeply concerned any time a working
    person goes to work and does not get the dignity and respect
    that they deserve. I am charged with enforcing certain laws,
    based on the powers that Congress has given to the Department
    of Labor. I appreciate that you are raising an issue involving
    working people who have experienced clearly horrific sexual
    harassment and other kinds of abuse. And what it demonstrates
    is that too often, workers may feel like they have to endure
    things that no one should have to endure, because of a power
    imbalance in the workplace.
        Senator Kennedy. When are you going to--excuse me for
    interrupting, and I'm sorry, but I've only had five minutes.
    Are you going to do anything about it? That's all I'm asking.
    If you're not, just tell me.
        Ms. Su. I mean, I answered the question about what--you
    know, there's an agency in the Federal Government who
    presumably, if the complaint has been made----
        Senator Kennedy. You're not going to do anything about it?
        Ms. Su. We'll be investigating it.
        Senator Kennedy. You're not--but you're not going to take
    any in light of--I mean, this is gut check time for you, Madam
    Acting Secretary. You either believe in protecting workers or
    you don't. I can't believe you would just--you--you can--we can
    debate how many lawyers can dance on the head of a pen, but you
    certainly have legal and moral authority to investigate labor
    violence.
        Ms. Su. I mean, I--yes, so----
        Senator Kennedy. I'm honestly surprised. I thought you
    would pounce on this like a ninja. I thought you'd say----
        Ms. Su. Like a what?
        Senator Kennedy. Like a ninja. Pounce on it like a ninja.
    I've seen--heard that expression in movies before. I thought
    you were going to say ``Kennedy, I'm on it. This is the most
    disgusting stuff I've ever heard in my life, in the history of
    ever.''
        But you're kind of waffling on me. Like, ``Well, I don't
    know what I'm going to do.''
        Let me ask you my last question, because I'm going to run
    out of time. Are you or are you not going to call for Martin
    Gruenberg, who runs the FDIC and has been there since God was a
    corporal, and the senior leadership over there, to resign?
        Ms. Su. So Senator, I do care about working people. That is
    why I am here--

                       HIGHLIGHTS OF DOL'S BUDGET REQUEST

        Senator Kennedy. You refuse to show it----
        Ms. Su [continuing]. With a budget request for $13.9
    billion for the Department of Labor to do what we do. To combat
    wage theft, to stop child labor, to make sure every worker goes
    home healthy and safe at the end of the day, to expand
    apprenticeship programs. In fact, we have a Youth
    Apprenticeship Week that's happening right now, the first time
    ever, because young people should see themselves and the
    opportunities that are being built right now. It's Teacher
    Appreciation Week, and we are making sure that we're expanding
    access for teachers to good jobs. We are hard at work to
    deliver for the workers of America within the job that the
    Department of Labor is supposed to do. Enforcing mental health
    parity. Making sure that workers who saved their whole life for
    retirement actually have the benefits that they have saved for.
    Those are all within our budget request----
        Senator Kennedy. Ma'am----
        Ms. Su [continuing]. Because those are all within the work
    of the Department.
        Senator Kennedy [continuing]. You're flip-flopping like a
    banked catfish----
        Senator Baldwin. Thank you, Senator Kennedy.
        Senator Kennedy. Are you not going to answer my question? I
    mean, are you going to call for him to resign or not?
        Senator Baldwin. Thank you, Senator Kennedy.
        The Subcommittee on Labor, Health and Human Services,
    Education, and Related Agencies will adjourn shortly. I want to
    thank my fellow committee members for a thoughtful
    conversation. I want to thank you, Acting Secretary Su.

                         ADDITIONAL COMMITTEE QUESTIONS

        For any Senators who wish to ask additional questions,
    questions for the record will be due by May 16. The hearing
    record will also remain open until then for members who wish to
    submit additional materials for the record.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
                Questions Submitted to Acting Secretary Julie Su
                  Questions Submitted by Senator Tammy Baldwin
        Question. Acting Secretary Su, you are aware of the significant
    increase in children and youth employed in violation of Federal child
    labor law identified by the Department's Wage and Hour Division in
    recent years.
        One of the most notable cases last year involved a Wisconsin-based
    food sanitation services provider employing more than 100 children
    engaged in hazardous work in thirteen meat processing facilities in
    eight states. The New York Times has done extensive reporting on the
    growing problem of child labor exploitation in the United States and
    found a rapid increase of child labor fueled by migrant children and
    youth, largely from Central America.
        I supported the bipartisan compromise on border security and
    immigration reform that would have helped secure the border, stop the
    flow of fentanyl into our communities, and provide resources to
    communities needed to provide food and shelter to newly-arrived
    migrants. However, as long as corporations are willing to ignore
    Federal child labor law, migrants searching for better economic
    opportunities will continue to make the dangerous trek to our Southwest
    border.
        Acting Secretary Su, how would this budget help crack down on
    employers that exploit children and youth and reduce the economic
    incentive helping fuel the surge at the border?
        Answer. Providing the Department with the necessary resources to
    ensure it has adequate staff and enforcement capacity will increase the
    Department's ability to address child labor exploitation. Between
    fiscal years (FY) 2010 and 2023, the Wage and Hour Division (WHD) lost
    more than 15 percent of its full-time employees funded by its annual
    appropriation because it was nearly flat-funded during this period. The
    Office of the Solicitor (SOL) has essentially been flat-funded in its
    annual appropriation when compared to FY 2010, resulting in the loss of
    more than 100 staff (a 17 percent decline) from the peak as costs have
    increased. The number of workers protected by the laws enforced by the
    Wage and Hour Division is currently more than 165 million, however, WHD
    currently has the fewest investigators it has had on board in decades.
    For every $1 million investment, WHD can conduct 260 more cases,
    recover $2.7 million more in back wages, and help 2,300 more workers.
        The President's proposed budget acknowledges the Department's need
    for additional funding to combat the rise of exploitative and dangerous
    child labor across the nation. The FY 2025 budget requests 137
    additional FTE for WHD's enforcement activities overall plus an
    additional 50 FTE for enforcement to protect the most vulnerable
    workers and combat exploitative child labor. The increased resources
    will allow WHD to maintain progress in rebuilding enforcement staff
    responsible for carrying out mission- critical, evidence-based
    strategies protecting the most vulnerable workers. WHD has long faced
    budget constraints that require careful resource allocation and
    prioritization, and many child labor investigations are time- and
    resource-intensive. Since the start of the National Child Labor
    Strategic Initiative, WHD has been developing impactful cases involving
    the strategic use of enforcement tools and innovative strategies
    focused on addressing egregious forms of child labor across America.
    WHD's strategic approach to enforcement recognizes that combating
    illegal child labor requires leveraging its strength--its authority,
    expertise, and partnerships within and beyond the Federal government--
    alongside comprehensive, creative, and data-driven strategies and a
    focus on the most dangerous workplaces. WHD has also increased
    enforcement, education, and engagement among employers providing
    valuable first work experiences.
        Question. Please provide data on the use of each enforcement tool
    available to the Department for violations of child labor requirements
    for each of the prior 5 years.
        Answer. The Department is leveraging all of its existing
    enforcement tools to combat illegal child labor. The Department of
    Labor's Wage and Hour Division (WHD) investigates every child labor
    complaint, tip, and referral, and it ensures compliance with child
    labor protections in all of its FLSA investigations, including cases in
    which the complaint cites only wage violations.
        In FY 2023, the Department of Labor saw an 88 percent increase
    since FY 2019 in the number of children it has found employed illegally
    by businesses across the United States. In FY 2023 alone the
    Department's investigations found 955 companies that had employed
    nearly 5,800 children in violation of labor laws.
        Today, the Department has more than 900 open child labor cases
    nationwide while it continues to field complaints and initiate
    investigations to protect children across the country. WHD is using
    every tool at its disposal to enforce Federal child labor laws and
    combat the egregious use of child labor including assessing civil money
    penalties (CMPs) to both penalize employers who employ children in
    violation of the law and also to deter future violations. CMPs are
    often part of compliance and enforcement strategies, in addition to
    using search warrants, temporary restraining orders, preliminary
    injunctions, subpoenas, and enhanced compliance agreements.
        The strategic use of enforcement tools, combined with publicizing
    egregious findings from investigations, collaboration with OSHA and
    state partners, efforts to combat human trafficking when it arises in
    child labor cases, and strategic use of media, has allowed the
    Department to effectively combine strategies and tools to stop
    violations and create ripple effects across industries and geographic
    areas leading to greater accountability and better industry practices.
    Ongoing investigations highlight the continued threat illegal child
    labor poses to the health and well-being of children and the need for
    sustained, strong enforcement.
        WHD Concluded Cases with Child Labor Violations:
      --FY 2019: 858
      --FY 2020: 851
      --FY 2021: 747
      --FY 2022: 835
      --FY 2023: 955
        Children Found Employed in Violation of the Law:
      --FY 2019: 3,073
      --FY 2020: 3,395
      --FY 2021: 2,819
      --FY 2022: 3,876
      --FY 2023: 5,792
        Child Labor Civil Money Penalties Assessed:
      --FY 2019: $3,183,584
      --FY 2020: $3,578,081
      --FY 2021: $3,262,796
      --FY 2022: $4,386,205
      --FY 2023: $8,039,728
        Question. Please describe your key strategies for eliminating
    illegal child labor from employer supply chains.
        Answer. The Department is using all available tools and its full
    authority to stop illegal child labor when found, to hold accountable
    those employers that violate the law, and to ensure employers remain in
    compliance with the law. Through collaborative strategies between SOL
    and WHD, the Department works to employ all available legal authorities
    to protect children and address supply chain accountability. In
    addition to assessing civil money penalties, the Department is also
    using the FLSA's ``hot goods'' provision, where appropriate, to stop
    the movement of goods made with illegal child labor, seeking
    injunctions when necessary to immediately stop exploitative practices,
    taking prompt legal action when we discover that an employer is
    retaliating against employees for asserting their rights or cooperating
    with the Department, and identifying ways to ensure compliance up and
    down supply chains.
        WHD is using its full CMP authority to deter future violations and
    to hold employers that violate the law accountable. However, because
    current penalties for violations of Federal child labor laws are not
    sufficiently high to deter major profitable companies, the President
    has asked Congress to increase penalties beyond the current maximum
    $15,629 fine applicable to all child labor violations that do not cause
    a child's serious injury or death.
        Question. The Department's Office of the Solicitor also plays an
    important role in this work.
        How would additional resources requested in the FY25 budget for the
    Office of the Solicitor increase the Department's capacity to combat
    illegal child labor?
        Answer. The Office of the Solicitor (SOL) works hand-in-hand with
    the Wage and Hour Division (WHD) to enforce Federal child labor laws,
    and SOL is using every resource to root out exploitative child labor in
    our country. Given that the enforcement of unlawful child labor laws is
    a top priority for the Department of Labor (DOL) and the Biden-Harris
    Administration, more SOL resources will improve the quantity and depth
    of legal services required for full and effective enforcement of child
    labor laws.
        As context, SOL's appropriated base budget has been essentially
    flat since fiscal year (FY) 2012, combined with continually escalating
    personnel and operational costs. This led on-board staff levels to drop
    from a high 773 in FY2012 to 651 at the end of FY2023. As of May 17,
    2024, SOL has an on- board staff level of 627.
        Recent successful child labor cases have underscored that the legal
    work that SOL provides in enforcing the Fair Labor Standards Act's
    (FLSA's) child labor provisions requires significant staff time and
    resources to prove effective. To achieve meaningful legal results,
    especially when immediate relief is required to protect endangered
    children, SOL must work extensively with WHD from the very beginning of
    investigations to build cases.
        SOL attorneys are responsible for obtaining warrants, assessing
    whether hazardous orders have been violated with regards to specific
    machinery and working conditions, assessing whether DOL can rely on the
    ``hot goods'' provision of the FLSA to stop the shipment in commerce of
    goods produced in violation of child labor laws, filing motions for
    temporary restraining orders (TROs) or preliminary injunctions, and
    more. SOL also plays a lead role in crafting settlement terms that hold
    employers accountable, while also addressing supply chain issues. Some
    of these investigations may be resolved prior to litigation but
    achieving such resolutions is often complex and resource intensive. For
    the many cases that are not resolved at the investigation stage,
    litigation is needed to enforce the law, and SOL is the sole DOL agency
    responsible for litigating all such cases.
        For example, following a DOL investigation, a Federal court in Los
    Angeles entered a consent judgment in April 2024 that orders owners and
    operators to pay $4.8 million in back wages and damages to 476 workers
    and $221,919 in penalties. The case involved child labor violations and
    resulted in one of the largest wage settlements ever achieved for U.S.
    poultry workers. SOL's settlement also required the employers to
    disgorge $1 million in profits earned from the sale of goods tainted by
    oppressive child labor, as well as pay assessed penalties of $171,919
    for their child labor violations. The settlement followed SOL's
    successful request for a TRO that barred the shipment of goods into
    commerce and required the employer to disgorge all profits related to
    any such shipment. The consent judgment and TRO came after WHD
    investigators learned that the poultry enterprise illegally employed
    children--as young as 14 years old--to use sharp knives to debone
    poultry, a violation of Federal child labor regulations.
        When cases are not resolved at the pre-litigation stage or at the
    early stages of litigation, SOL is entirely responsible for litigating
    those cases through costly discovery, motion practice, settlement
    negotiations, and potentially trial.
        As noted in the President's FY2025 budget request for the
    Department, the Office of the Solicitor continues to experience rising
    demand for legal support in litigation, advice, and regulatory work,
    including with respect to child labor enforcement. Investigations rely
    on a credible threat of litigation to encourage employers to comply
    with the law, resolve investigations early, and enter into settlements
    that effectively protect children. Absent additional resources for SOL,
    the Department's ability to fully and effectively enforce child labor
    laws and other worker protection laws will be undermined. To avoid
    this, the President's Budget requests to increase SOL's funding by
    nearly $15 million, allowing SOL to, among other things, dedicate
    additional legal staff to become involved in child labor cases at the
    earliest possible stage to assist with investigation planning to
    develop the strongest possible cases for enforcement action and to
    provide legal advice.
        Question. Since enactment of the U.S.-Mexico-Canada Agreement
    (USMCA), the Department and the Office of the United States Trade
    Representative have mobilized resources and expertise to implement and
    enforce the labor provisions under USMCA, particularly the United
    States-Mexico Facility-Specific Rapid Response Labor Mechanism (RRLM)
    under Annex 31-A. To date, twenty cases have moved forward through the
    RRLM with largely positive results. Additional cases are necessary to
    realize the potential of the RRLM to close the wage gap between workers
    in the United States and Mexico.
        What is the Department's plan and timeline for accelerating the
    progress achieved under USMCA, particularly in a time of budget
    constraints and competing domestic priorities?
        Answer. The Interagency Labor Committee for Monitoring and
    Enforcement, co-chaired by the Department of Labor (DOL) and the Office
    of the U.S. Trade Representative, remains committed to using the Rapid
    Response Labor Mechanism (RRLM) as a tool to ensure Mexico's compliance
    with its labor commitments under the U.S.-Mexico-Canada Agreement
    (USMCA). As of the end of May 2024, the United States has found denial
    of rights and requested Mexico review the alleged denials in 23 RRLM
    cases. These cases have directly benefitted nearly 30,000 workers,
    providing millions of dollars in back pay and benefits to workers,
    ensuring wrongly terminated workers were reinstated, and securing free
    and fair elections in which workers selected independent unions to
    represent them and bargain historic compensation packages.
        An important driver of progress is ensuring that workers are aware
    of their rights and that they know how to access the national systems
    of labor justice, as well as the RRLM. To this end, DOL awareness-
    raising projects conducted with funding provided under the USMCA
    Implementation Act amplified the success of the RRLM process through
    videos, social media posts and educational materials. Information about
    the DOL-managed USMCA hotline resulted in a significant increase in
    labor-related tips that may lead to more RRLM actions in USMCA priority
    sectors. DOL expects that technical assistance projects initiated in
    prior years and scheduled to continue through 2027 will yield concrete
    improvements in the legal and institutional environment in support of
    the historic labor law reforms promoting freedom of association and
    collective bargaining. Five Mexico-based labor attaches, funded under
    the USMCA Implementation Act, are key points of contact with our
    government counterparts, the business community, and workers and
    unions. These relationships drive strategic use of the RRLM in key
    sectors. DOL continues to support the development of reliable
    government institutions, independent unions, and informed employers.
    All these efforts are expected to continue through 2027. The
    President's FY 2025 Budget request includes a program increase of $45
    million to replace the annual level of the USMCA resources that expired
    in December 2023, enabling ILAB to continue this important work.
        Question. How will the Department continue to prioritize global
    worker rights and union capacity building efforts in Mexico?
        Answer. DOL technical assistance projects launched with USMCA
    funding prior to 2024 will continue to build the capacity of industrial
    relations actors, which will lead to more and better collective
    bargaining agreements. This includes building on the success of
    Solidarity Center projects that have supported the expansion of
    independent unions such as La Liga Sindical Obrera into a national
    union, and the expansion of the Federation of Independent and
    Democratic Unions in the Auto Sector. In addition to the efforts
    outlined above, the Department will continue to prioritize global
    worker rights and union capacity building through initiatives such as
    the Multilateral Partnership for Organizing, Worker Empowerment, and
    Rights (M-POWER), which seeks to elevate the role of trade unions and
    organized workers as essential to advancing democracy.
        Question. On November 16, 2023, the Biden Administration issued the
    Memorandum on Advancing Worker Empowerment, Rights, and High Labor
    Standards Globally (Global Labor Strategy) to enhance the United States
    government's approach to protecting and promoting worker rights at home
    and around the world. The FY25 President's Budget does not include a
    specific request for the Global Labor Strategy.
        How will the Department contribute resources and capacity to ensure
    the successful implementation of the Global Labor Strategy and the
    elevation of the U.S. as a global leader on labor rights and standards?
        Answer. The Global Labor Strategy commits U.S. agencies operating
    abroad to a whole-of-government approach in the elevation and
    integration of workers' rights and the promotion of high labor
    standards in our foreign, international development, trade, climate,
    and global economic policy priorities. As one of the agencies with
    leading responsibilities in international labor affairs, the Department
    has developed a range of knowledge, resource, and training materials,
    which it will continue to make available to other U.S. departments and
    agencies. For example, the Department has used existing resources to
    collaborate with the Department of Homeland Security/Customs and Border
    Protection on training and to improve policy coherence with the
    Departments of Energy and State. Priority countries for implementation
    of the Global Labor Strategy identified by the White House are already
    providing opportunities for the United States to demonstrate leadership
    on key labor issues, and U.S. agencies operating abroad are promoting
    the whole-of-government approach in international engagements. The
    Department will continue to apply existing resources--primarily in the
    form of staff expertise and collaboration--to support full
    implementation of the Global Labor Strategy within the U.S. government.
        Question. How will the Department sustain and leverage the
    Multilateral Partnership for Organizing, Worker Empowerment, and
    Rights, the historic global initiative introduced in December 2021 as a
    component of the Biden-Harris Administration's Presidential Initiative
    for Democratic Renewal, to elevate the U.S. as a global leader on labor
    rights and standards?
        Answer. The Multilateral Partnership for Organizing, Worker
    Empowerment, and Rights (M-POWER) provides the Department an
    opportunity to amplify and multiply the impact of ILAB priorities by
    drawing on the collaboration of like-minded partners, including foreign
    governments, representative labor movements from around the world,
    labor-support organizations, and private philanthropic organizations.
    DOL has used its participation in M-POWER to coordinate international
    support for priority labor rights cases at the International Labor
    Organization (ILO), convene issue-focused discussions on emerging labor
    issues, and speed the United States Government (USG) and global
    responses to urgent incidents of labor organizations and activists
    facing threats and violence. M- POWER's activities and ILAB's work are
    mutually reinforcing and aligned with other high-profile whole-of-
    government approaches to worker rights, like the Global Strategy.
        Question. The International Labor Affairs Bureau has developed new
    methods and tools to trace child labor and forced labor in global
    supply chains and build capacity of interagency partners to enhance the
    U.S. Government's ability to prevent the importation of goods made with
    forced labor.
        How does ILAB measure this increased capacity of interagency
    partners, refine strategies as needed, and establish goals for
    continuous improvement?
        Answer. Within the U.S. government, ILAB is the leading provider of
    in-depth research and expertise, both in particular regions and
    countries, as well as sectors, on global labor abuses. ILAB plays a
    critical role in supporting Administration priorities on supply chains;
    and elevating worker rights by developing tools, identifying best
    practices, and funding technical cooperation projects. Furthermore,
    ILAB supports counterparts of U.S. government agencies to take
    enforcement actions that ensure global supply chains are free of labor
    rights abuses.
        ILAB analyzes and traces supply chains, including researching goods
    that are made with inputs produced with forced labor or child labor.
    These findings are made public on the List of Goods Produced by Child
    Labor or Forced Labor. ILAB shares this research with partner agencies
    to support implementation of the import prohibition under section 307
    of the Tariff Act of 1930 and the Uyghur Forced Labor Prevention Act
    (UFLPA) to make sure products sold in the U.S. are not tainted with
    forced labor.
        ILAB also prioritizes the promotion of labor rights and the voice
    of workers in global supply chains. ILAB expands efforts to counter
    forced labor through work with counterpart Federal agencies, including
    through the Forced Labor Enforcement Task Force (FLETF) as well as
    through work with the National Oceanic and Atmospheric Administration
    (NOAA). ILAB uses several indicators to measure progress on ongoing
    engagement and coordination strategy with interagency partners, which
    include:
      --Forced Labor Enforcement Task Force: ILAB contributes to the
            development of the FLETF's Biannual Enforcement reports to
            Congress, highlighting ILAB's work over the previous reporting
            period. To date, ILAB has contributed to seven reports. ILAB's
            Deputy Undersecretary Thea Lee serves as co-chair of the UFLPA
            Entity List Subcommittee, along with the Department of Homeland
            Security. This Subcommittee is responsible for additions,
            removals, and modifications to the UFLPA Entity List, a list of
            entities the FLETF has determined meet the criteria outlined in
            the UFLPA under Sections 2(d)(2)(B)(i), (ii), (iv), and (v).
            Since the initial release of the list in June 2022, ILAB has
            been actively involved in the addition of all 68 entities to
            the UFLPA Entity List and is committed to further expansion of
            the list. DOL also provides litigation advice and support to
            the Department of Justice to defend the FLETF's procedures for
            and additions to the UFLPA Entity List. Finally, as a principal
            member of the FLETF, ILAB participates in regular external
            stakeholder engagement sessions, such as the Biannual UFLPA
            Sessions with both private sector and civil society
            organizations (CSOs); to date, we have held six sessions.
      --Customs and Border Protection (CBP): The Trafficking Victims
            Protection Reauthorization Act of 2005 (TVPRA) mandated that
            DOL collaborate with U.S. government agencies, including CBP,
            to ensure that products made by forced labor and child labor in
            violation of international standards are not imported into the
            United States. As part of this same mandate, ILAB consults with
            CBP and other interagency partners to reduce forced labor and
            child labor internationally through sharing our reporting.
            Additionally, ILAB participates in joint stakeholder engagement
            sessions, including CBP's annual Trade Symposium, where ILAB
            has presented for the last 5 years.
      --Forced labor identification in Illegal, Unregulated and Unreported
            (IUU) Fishing: ILAB engages with interagency partners as
            directed by the Memorandum on Combatting Illegal, Unreported
            and Unregulated Fishing and Associated Labor Abuses (NSM-11).
            Examples include participation in the U.S. Interagency Working
            Group on IUU Fishing, collaboration with the U.S. Coast Guard
            on the development of forced labor training modules and
            Maritime Operational Threat Response processes, and with NOAA
            to include labor considerations in their Improving
            International Fisheries Management report to Congress.
        Question. Please provide examples of outcomes associated with
    ILAB's recent efforts in this area?
        Answer. ILAB's leadership on supply chain issues is demonstrated
    through participation in interagency working groups, such as co-
    chairing the Senior Policy Operating Group's Procurement and Supply
    Chain subcommittee, as well as contributing expertise to whole-of-
    government efforts like Executive Order 14017 Securing America's
    Critical Supply Chains and the National Action Plan for Responsible
    Business Conduct.
        ILAB leverages flagship reports (List of Goods Produced by Child
    Labor or Forced Labor, Findings on the Worst Forms of Child Labor, and
    List of Products Produced by Forced or Indentured Child Labor), tools
    (Sweat & Toil, Comply Chain, and Better Trade Tool), technical
    assistance, and expertise, to engage and collaborate with both
    interagency partners as well as trading partners, such as Mexico,
    Canada, and the European Union.
        Additionally, ILAB is uniquely positioned to contribute to the
    implementation of the Presidential Memorandum on Advancing Worker
    Empowerment, Rights, and High Labor Standards Globally. This includes
    development of training modules and capacity building for interagency
    partners. Examples of this include ILAB's coordination with the U.S.
    Coast Guard to incorporate identification of forced labor into training
    modules. In March 2024, ILAB hosted an interagency briefing on the
    ILAB-funded Handbook on Detecting Forced Labor in Commercial Fishing,
    which informed 54 government officials from U.S. Coast Guard, State
    Department, Department of Defense, Department of Homeland Security,
    NOAA, and others. In May 2024, ILAB staff met with the U.S. Coast Guard
    at port in Ecuador and discussed the use of the ILAB-funded Handbook on
    Detecting Forced Labor in Commercial Fishing and the useful tools this
    provides to U.S. Coast Guard personnel in their work. ILAB also works
    with NOAA to include considerations of forced labor within
    identification of nations engaging in IUU fishing. DOL's assistance
    resulted in NOAA identifying Taiwan and China for forced labor in
    fishing and has led to multiple rounds of bilateral consultations with
    Taiwan and China on these identifications.
        ILAB committed to mapping the List of Goods Produced by Child Labor
    or Forced Labor as well as List of Products Produced by Forced or
    Indentured Child Labor to procurement-related Product Service Codes
    (PSC) to increase use by the government acquisition workforce. Mapping
    the named products to PSC will facilitate analysis of procurement data
    by country of origin and assist contractors in implementing additional
    protections, such as those outlined in M-20-01, Anti-trafficking Risk
    Management Best Practices & Mitigation Considerations, where there is a
    heightened risk of forced labor issues. In addition, ILAB will also
    develop training material for Federal agencies on forced labor
    indicators to support their efforts to work with Federal contractors to
    combat labor risks in U.S. procurement supply chains. ILAB will
    disseminate trainings directly to USG procurement officers through
    ILAB's participation in the Senior Policy Operating Group. ILAB will
    make this information accessible for acquisition officers by creating a
    designated webpage with information about USG resources, including
    ILAB's child labor and forced labor reports.
        ILAB's technical assistance project Strengthening Decent Work in
    the Fishing Sector of South America, implemented by the ILO, has an
    objective to address labor abuses in the fishing sector in South
    America, with a focus on Ecuador and Peru. While the project is early
    in its implementation, there have been successes and a range of
    upcoming planned activities. For example, the project provided
    technical support for the Vice Ministry of Aquaculture and Fisheries of
    Ecuador with the objective of including labor matters into the
    organization's agenda. Between Peru and Ecuador, the project trained a
    total of 37 officials (17 women and 20 men) from government agencies
    dedicated to decent work in the artisanal aquaculture and fishing
    sector. Finally, the project adapted the ILO Handbook, ``Towards
    freedom at sea, Handbook for the detection of forced labor in
    commercial fishing,'' that will be used for upcoming trainings during
    the remainder of FY24 and in FY25.
        Question. How would the FY25 budget request further these efforts?
        Answer. Additional support will enable expanded supply chain
    research and greater coordination on key findings, UFLPA Entity List
    expansion, as well as additional engagement and coordination on
    responsible procurement efforts. In addition, ILAB's engagement and
    collaboration with key U.S. government agencies on forced labor issues
    enhances the U.S. government's ability to prevent the importation or
    procurement of goods made with forced labor. ILAB would further engage
    with key agency personnel on the Federal Acquisition Regulation (FAR)
    related to Executive Order 13126, which requires Federal contractors to
    certify that they have made a good faith effort to determine whether
    forced or indentured child labor was used to produce the items
    supplied. In addition to continuing close collaboration with the U.S.
    Trade Representative, Department of Homeland Security, Customs and
    Border Protection, and State Department on forced labor issues, ILAB
    will also continue to prioritize engagement and collaboration with the
    National Oceanic and Atmospheric Administration on labor abuses and
    forced labor in the seafood sector, particularly as connected to IUU
    fishing. Without additional funding, ILAB will instead be forced to cut
    various components of these activities, as ILAB's budget will not be
    able to support even current staff at a flat appropriation amount.
        Question. Acting Secretary Su, I know you share my appreciation for
    workers exercising their legal right to choose representation and have
    a voice in the workplace.
        Workers at hundreds of Starbucks locations across Wisconsin and the
    United States have filed petitions and voted to join a union as allowed
    under the National Labor Relations Act. That law is under the
    jurisdiction of the National Labor Relations Board, which has
    determined in dozens of cases that Starbucks violated that law.
        The Department of Labor oversees important requirements for
    employers to report on spending intended to persuade their workers not
    to join a union, including through the use of labor consultants.
    However, employers frequently cite loopholes to hide this spending from
    their workers.
        What actions are you taking to improve the required reporting of
    spending on efforts to persuade workers not to join a union, and how
    does the budget propose to further strengthen those efforts?
        Answer. The Department is committed to strengthening its
    enforcement activities to protect workers' right to unionize and
    bargain collectively. Workers have the right to know about the
    existence of persuader and consultant agreements at their worksites,
    and to receive that information in a timely and complete manner.
    Workers and the public benefit from knowing the sources and amounts of
    employer spending on persuader and surveillance activities regarding
    union organizing. Employers and labor relations consultants have an
    obligation to report their expenditures made, and agreements entered,
    where the objective is to persuade employees to not exercise their
    federally protected rights under the Labor-Management Relations Act.
        The Department has undertaken significant efforts to enforce and
    secure timely and accurate reporting from employers on persuader and
    surveillance activities. Some of these efforts include:
      --Expanding the ``cross-match'' program to better identify employers
            and consultants engaged in reportable activity;
      --Initiating a persuader tip line, beginning in May 2022, for the
            public to report persuader activity, which has led to 131 tips
            processed and 110 tip-related reports received, as of early
            May, 2024;
      --Creating a new and updating an existing fact sheet and conducting a
            nationwide webinar all geared toward advising employers and
            labor relations consultants on their obligations to disclose
            persuader activities and how to properly and timely complete
            the disclosure forms;
      --Initiating information sharing with the NLRB to obtain information
            on unfair labor practices as such activities may be reportable;
      --Increasing the number of ``special reports'' cases completed, which
            includes persuader cases, from just 70 in fiscal year (FY) 2021
            to 106 in FY 2022 and 100 in FY 2023; and
      --Conducting direct outreach to unions, employers, and consultants to
            inform them of persuader reporting obligations.
        These achievements have led to a significant increase in persuader
    reports collected, from just 314 Form LM-20 consultant reports in FY
    2021, to 747 in FY 2022, and 761 in FY 2023. We fully anticipate that
    the number of reports collected in the current fiscal year and FY 2025
    will further increase as we continue to step up our compliance
    assistance and enforcement efforts in this area.
        With the requested funding, the Department would allocate
    additional investigative resources to help drive more on-time and
    accurate persuader reporting. At the requested funding level, the
    Department could sustain its compliance assistance and enforcement
    efforts to ensure that employers and labor consultants fulfill their
    obligations to report their persuader and surveillance activities
    timely and accurately.
        Question. In which year did the Department conduct the highest
    proportion of H- 2A and H-2B visa program investigations relative to
    the total number of H-2A and H-2B worksites?
        Answer. In 2023, the Department certified approximately 378,000
    temporary agricultural jobs under the H-2A program compared to 258,000
    certified jobs in 2019. The Wage and Hour Division (WHD) is responsible
    for enforcing the terms and conditions of employment required under the
    H-2A program, including those related to recruitment, wages, housing,
    transportation, and recordkeeping for employers of temporary non-
    immigrant agricultural workers and non-H-2A workers in corresponding
    employment.
        Over the last 5 years, WHD has concluded 2,000 H-2A compliance
    actions in the agricultural industry where it found violations.
        WHD Concluded Cases with H-2A Violations:
      --FY 2019: 431
      --FY 2020: 377
      --FY 2021: 358
      --FY 2022: 421
      --FY 2023: 413
        Under the H-2B program, employers may temporarily employ
    nonimmigrants to perform nonagricultural labor or services in the
    United States. The H-2B program requires the employer, among other
    obligations, to attest to the Department of Labor that it will offer
    and pay a wage that equals or exceeds the highest of the prevailing
    wage, applicable Federal minimum wage, the State minimum wage, or local
    minimum wage to the H-2B nonimmigrant worker for the occupation in the
    area of intended employment during the entire period of the approved H-
    2B labor certification. The H-2B program also establishes certain
    recruitment and displacement standards to protect similarly employed
    U.S. workers.
        Over the last 5 years, WHD has concluded 530 H-2B compliance
    actions where it found violations. WHD Concluded Cases with H-2B
    Violations:
      --FY 2019: 108
      --FY 2020: 124
      --FY 2021: 125
      --FY 2022: 100
      --FY 2023: 73
        Question. What was the total cost of conducting these
    investigations that year?
        Answer. WHD enforces more than 13 statutes that protect more than
    165 million workers at 11 million workplaces nationwide and conducts
    approximately 20,000 compliance actions each year with its current FY
    2024 appropriation of $260,000,000. These actions include
    conciliations, limited investigations, and full investigations. WHD
    continues to be as strategic as possible with its limited resources to
    have the greatest impact for the most vulnerable workers, on average,
    across all the laws it enforces.
        Question. What would it cost the Department to conduct H-2A and H-
    2B temporary visa program investigations in FY25 at or above the level
    identified in 6a?
        Answer. The President's budget for FY 2025 requests an additional
    187 FTE and an increase of $20,818,000 to restore WHD's enforcement
    strength to address the full breadth of WHD's enforcement to protect
    the most low-wage, vulnerable workers including workers under the H-2A
    and H-2B program. For every $1 million investment in WHD enforcement,
    the agency can conduct 260 more cases, recover $2.7 million more in
    back wages, and help 2,300 more workers.
        Question. Please describe the Department's process to prioritize
    complaint-based investigations.
        Answer. The Department's WHD continues to fully maximize resources
    to protect workers and ensure a level playing field for employers,
    despite experiencing historically low staffing levels and virtually
    flat- funding. The Department is one of the only avenues that
    nonimmigrant workers have to obtain remedies from employers that
    violate the law, as affected employees have no private right of action
    under H-1B, H-2A, or H-2B programs. WHD achieves impact in the H-
    programs through strategic planning, ingenuity, and data-driven
    enforcement strategies coupled with training improvements for
    enforcement staff.
        Based on the Department's enforcement experience, workers employed
    under the H-2A program face unique risks of exploitation, in part
    because of the temporary nature of the work, frequent geographic
    isolation and dependence on a single employer for housing,
    transportation, and employment. WHD prioritizes investigations where
    farmworkers' safety and health are at risk. This includes, for example,
    instances where it is reported workers do not have access to drinking
    water while working in the fields, workers report a pest infestation at
    the housing facility, or workers are not provided adequate heating
    during cold weather. Similarly, WHD prioritizes its resources to
    address situations where the safety of H-2B workers is at risk, such as
    situations where H-2B workers are transported by the employer in
    vehicles that do not comply with all applicable Federal, state, and
    local laws and regulations.
        WHD would welcome the opportunity to brief the Senator's staff
    further regarding this set of questions to ensure they are getting the
    feedback necessary to understand WHD's enforcement and related budget
    needs.
        Question. The FY25 President's Budget for the Department of Labor
    proposes to make certain appropriations to the Department available for
    obligation for two fiscal years. This includes proposals for the
    Department's worker protection agencies. The Department notes in its
    budget summary ``The multi-year availability would reduce the impact of
    short-term continuing resolutions at no cost to the annual
    appropriations bill, enhance staff oversight of the programs they are
    administering, and provide greater capacity to maintain staffing even
    if operating under a continuing resolution.''
        Please provide more information on how 2 year authority would
    achieve each of the benefits noted above for the Department's worker
    protection agencies.
        Answer. Multi-year authority would enable the Department's agencies
    to carry over funds from one fiscal year to the next, reducing
    disruptions caused by short-term continuing resolutions. The Congress
    often does not appropriate full-year funds until well into the fiscal
    year, typically between December and April, leaving a short timeframe
    for agencies to carry out their spending plans. Having multi-year
    funding would provide more time for agencies to plan and execute their
    funding, rather than trying to accomplish twelve months of work in the
    last few months of a fiscal year. In future years, this greater
    certainty will also allow agencies to maintain more staff, as they
    would be able to smooth out some of their contract and procurement
    activities. Additional staff are critical to the Department's worker
    protection agencies, because these enforcement personnel safeguard
    working conditions, health and retirement benefits, and pay for
    America's workers.
        Congress often passes full-year appropriations legislation at the
    end of December, but there is lack of certainty even in that timeframe.
    In fiscal year (FY) 2024, the Department received full-year funding at
    the end of March, and in FY 2017, Congress did not pass a full-year
    bill until May. Throughout the FY 2024 budget process, Congress was
    negotiating with very different funding levels, and agencies must wait
    to make decisions until there is certainty with regard to funding
    levels. This lack of certainty provides an extremely short window for
    accomplishing a full year's worth of work before the funds expire.
    Multi-year funding will allow agencies to plan and appropriately devote
    resources towards contracts, rent, and personnel over 15 to 18 months,
    rather than having to compress decisions into the last few months of a
    fiscal year.
        Question. What policies would be established to ensure appropriated
    funds are used in a timely way to most effectively achieve the missions
    of worker protection agencies?
        Answer. The Department is committed to ensuring funds are used in a
    timely way to achieve the missions of its worker protection agencies.
    Multi-year funding would allow the Department to better plan, and more
    effectively utilize appropriated dollars.
        The Department currently has several policies and procedures in
    place to support the goal of timely use of funds. Funds are apportioned
    quarterly, and the Department follows all of the policies and
    procedures for apportioning funds, as outlined in the Office of
    Management and Budget's Circular No. A-11. Following apportionment, the
    Department allots and sub-allots funds, following the same quarterly
    breakdown and budget activity/program as outlined in the apportionment.
    Departmental budget staff regularly monitor the status of obligations.
    OMB posts apportionments, including the Department of Labor's
    apportionments, publicly on their central webpage. In addition, OMB
    regularly produces the Standard Form (SF)-133, a Report on Budget
    Execution and Budgetary Resources. These documents assist Congress in
    its oversight responsibilities by providing the status of funds,
    including unliquidated obligations, unobligated balances, cancelled
    balances, and adjustments made to appropriation accounts during the
    fiscal year.
        Through these policies and procedures, the Department ensures the
    timely use of funds and provides transparency on the status of all
    funds.
        Question. The Department's New Core Financial Management System
    (NCFMS) is the financial system of record that annually processes an
    estimated 454,000 invoices, 266,000 payments, and 47,000 obligation
    documents, and is used to manage and account for nearly $60 billion of
    taxpayer funds. The contract for NCFMS ends in 2026. The Department has
    stated that it will continue working with the Department of Treasury
    and Office of Management and Budget to implement a government-wide
    Financial Management Quality Service Management Office (QSMO) solution
    for the Department's NextGen financial management and transaction
    processing. QSMOs offer solutions for Federal agencies that, over time,
    will standardize processes, shrink the technology footprint, and cut
    government-wide operating costs.
        Would the Department please outline its two-year replacement
    schedule (including time for proper systems migration and testing) to
    meet that objective?
        Answer. The Department of Labor (DOL) is following the General
    Services Administration's (GSA) Modernization and Migration Management
    (M3) Playbook processes and procedures. In October 2022, the Office of
    the Chief Financial Officer (OCFO) collaborated with cognizant
    acquisition personnel to outline the vision for the operational end
    state. OCFO submitted a modernization plan to the Department of
    Treasury in April 2023.
        DOL Leadership is actively and collaboratively engaged with
    Treasury Financial Management (FM) Quality Service Management Office
    (QSMO) leadership via bi-monthly touchpoint meetings. The teams'
    ongoing activities include reviewing updates to the Financial
    Management Capabilities Framework, providing annual Financial System
    Profile information, attending Treasury Financial Management Working
    Group meetings, and Vendor User Group Meetings/Industry days.
        DOL has been identifying potential commercial vendors that provide
    Financial Management (FM) Technology Operations Support Services. There
    is currently a limited number of vendors that are technically
    qualified, and that limitation is preventing the Department from
    performing an adequate Analysis of the Alternatives. Given those
    limitations and keeping in mind the magnitude of DOL's operations and
    to permit time for proper systems migrations and testing, DOL is not on
    schedule to transition to a new Core Financial System before the end of
    the current contract (Period of Performance--09/29/2026). Accordingly,
    DOL is developing a plan for the possible extension of the operations
    and maintenance services for NCFMS. If necessary, DOL would adopt that
    plan to bridge any gap between the end of our current contract and the
    time we go live with an FM QSMO Core Financial System. Upon selection,
    OCFO will determine the proper systems migration and testing schedule
    and ensure it is factored into the replacement schedule.
        Question. Please summarize what the Department of Labor has learned
    thus far from the third-party evaluations under the Strengthening
    Community Colleges Training Grant Program (SCCT), including how much
    grantees are setting aside for third party evaluations and the
    processes grantees are using to find evaluators.
        Answer. To date, the Department's evaluation contractor for the
    Strengthening Community Colleges (SCC) program has provided the Round 1
    Grantee Interim Report Synthesis, which compiles responses from the
    implementation or developmental studies procured by the eleven Round 1
    (SCC1) grantees. The interim report suggests that SCC1 grantees have
    focused on developing employer and workforce partnerships as an initial
    step toward informing the development and implementation of newly
    (re)designed SCC courses and credentialing programs. Overall findings
    highlight how community colleges are making unique yet disparate
    strides in establishing collaborative and often formal partnerships
    with employers and workforce partners; developing learning
    opportunities for accelerated and accessible career pathways through
    technology, stackable credits, and work-based learning; developing
    pathways and courses that directly align to the knowledge, skills, and
    abilities their local employers need from their prospective employees;
    supporting successful systems change using cohesive recruitment
    strategies; securing buy-in from internal and external partners; and
    relying on gap analysis and solution development. Grantees are allowed
    to use up to 5 percent of their grant budget for their third-party
    evaluation for an implementation or developmental evaluation and must
    follow competitive procurement procedures under Federal Uniform
    Administrative Requirements at 2 CFR Part 200, as well as their
    college's procurement guidelines.
        The Department also launched a national evaluation of the SCC
    program in fiscal year (FY) 2023, which the Department believes will
    provide a broader landscape with a wide-ranging assessment and
    information distinct from the individual grantee evaluations. As part
    of the national evaluation, it is the Department's intent to conduct a
    rigorous impact study, which will add depth to the SCC research base.
    In its FY 2025 Budget, the Department proposes to eliminate the
    requirement for third-party evaluations for each individual grant
    proposal. The Department has found that requiring individual third-
    party evaluations is not cost-effective, the quality of the evaluations
    varies significantly, and it is difficult to obtain national results
    from separate evaluations, even with syntheses.
        Question. What is the timeline for the national evaluation for FY23
    SCCT grantees described on page TES-5 of the FY25 Congressional Budget
    Justification?
        Answer. FY 2023 Strengthening Community Colleges Training Grants
    (fourth round, referred to as SCC4) started their period of performance
    on May 1, 2024. The national evaluator began its contract on March 19,
    2024. While all Round 4 grantees will be included in the implementation
    evaluation, the contractor will determine a study design for the impact
    evaluation and select grantees to be included in the impact evaluation
    by August 2024. Beginning in Fall 2024, and continuing through Winter
    2028, grantees will enroll students into the impact study, and the
    evaluators will conduct site visits and collect data. DOL will receive
    interim reports, briefs, and final reports starting in Summer 2025 and
    concluding in Winter 2029.
        Question. Please describe how a national database for WIOA Title I
    participants would allow better measurement of program output and
    outcomes to improve service delivery and impact.
        Answer. A national database of WIOA Title I and Wagner-Peyser Act
    Employment Service participants would help mitigate grantee burden and
    provide the flexibility to use multiple national data sources to
    calculate participant outcomes. Currently, the Department depends on
    state grantees to capture participant outcomes, but grantees are
    limited to the State Wage Interchange System (SWIS) to capture outcomes
    for participants that receive services in their state but find
    employment in another state. This has led to a situation where there
    are significant gaps in State and Eligible Training Provider reporting.
    A national database would allow for a cost-effective and comprehensive
    approach for capturing participant outcomes without the need for
    maintaining a comprehensive data sharing agreement with state grantees.
    Furthermore, the data in SWIS is limited to state unemployment
    insurance (UI) wage records and this data source does not capture
    information on self-employed individuals, Federal workers, and military
    personnel. A national database would allow the Department to supplement
    UI wage record matches with other data sources, such as Internal
    Revenue Service (IRS) data.
        The most effective way to definitively match WIOA and Wagner-Peyser
    participants to wage record data sources (e.g., NDNH, state quarterly
    UI wage records, SWIS, etc.) is with the participant's social security
    number (SSN). WIOA programs that provide training services through
    Eligible Training Providers rely on the availability of SSNs to conduct
    automated wage matching for performance outcome purposes. It is often
    challenging and resource intensive to collect employment status and
    earnings information through supplemental means such as manual
    participant follow-up. In addition to the core purpose of providing
    accurate performance outcomes, having SSNs would allow the Department
    to match participants to other data sources, allowing for a plethora of
    long-term research and evaluation activities. Allowing the Department
    to collect this information would enable the Department to directly
    link participants to external data sources such as NDNH and IRS to
    enhance outcome data and research and evaluation studies. Furthermore,
    the ability to collect participant SSNs would allow the creation of
    Federal longitudinal data sets, as well as foster the Department's
    ability to explore additional approaches to reduce the burden
    associated with state grantee performance reporting. The Department
    notes that a strong Federal data management role has been instrumental
    to the success of other efforts to measure the outcomes of education
    and training programs. A notable example is the Department of
    Education's (ED's) College Scorecard, which matches administrative ED
    student data with IRS tax data to produce rich, granular information on
    higher education program outcomes.
        Question. Please describe how DOL will support states in
    prioritizing job quality to help workers attain high quality jobs.
        Answer. The Departments of Labor and Commerce published Good Jobs
    Principles to clearly articulate what comprises a good job. The
    Department has incorporated job quality into all its competitive grant
    opportunities, for instance, requiring grant applicants to include
    partnerships with worker organizations and businesses or scoring
    applicants based on the degree to which they include strategies to
    advance Good Jobs Principles. The Department also published guidance
    for the public workforce system on incorporating job quality into
    workforce development activities, as Training and Employment Guidance
    Letter No. 7-22, Increasing Employer and Workforce System Customer
    Access to Good Jobs. The guidance described ways that states and local
    areas can prioritize job quality to help workers attain high quality
    jobs. The Department also hosted a Job Quality Academy that provided
    technical assistance to sixteen communities on how to prepare workers
    for Good Jobs in specific sectors growing in their regional economy.
    Subsequently, the Department shared these lessons with all workforce
    development grantees through webinars and discussions. The Department
    will continue to provide technical assistance to states to prioritize
    job quality.
        Question. What is the timeline for guidance and technical
    assistance that aims to increase youth voice in the WIOA Youth program
    described on pages TES-27/28 of the FY25 Congressional Budget
    Justification? How will DOL involve youth or organizations representing
    young people in the development of this guidance and technical
    assistance?
        Answer. The Department of Labor plans to publish technical
    assistance resources that will guide local youth and young adult
    workforce development programs in effectively engaging youth voice into
    programming in Fall 2024 and Winter 2025 and provide examples of ways
    communities can incorporate youth in strengthening youth service
    delivery systems. The technical assistance will be developed from the
    input provided by young adults (participants and subject matter
    experts) and youth-serving organizations during the two cohorts of the
    Youth Systems Building Academies conducted in 2023 and 2024--consistent
    with the Department's Youth Employment Works Strategy that aims to
    provide a ``no wrong door'' approach to young people in the workforce
    system. The Department is also committed to incorporating youth voice
    into its work through career pathway interns and ongoing work with 4-H.
        Question. Please provide more detail on the research and
    evaluations that will be conducted in support of continuous program
    improvement in the WIOA Youth program described on page TES-31 of the
    FY25 Congressional Budget Justification, including when data from such
    research and evaluations will be publicly available.
        Answer. A Youth Case Management and Services Formative Study is now
    underway. The study seeks to understand the key elements of effective
    case management/career coaching for youth, which in turn can inform the
    basis of professional development opportunities for youth-serving
    staff. Using existing evidence scans, analysis of existing program
    data, and information collected from several former and active youth-
    related program evaluations, the study team will develop a paper that
    will describe the taxonomy of key youth case management competencies,
    skills, and practices; promising case management practices and
    strategies for underrepresented and marginalized youth populations; and
    professional development recommendations for youth case managers and
    related staff. The Department is also interested in identifying
    strategies that help eliminate barriers to accessing youth service
    programs. The Department anticipates release of the report in Spring
    2025.
        Question. Please describe how the Department will provide the
    technical assistance to dislocated workers described on page TES-40 of
    the FY25 Congressional Budget Justification, including what specific
    entities the TA will be provided to and whether it will be distributed
    nationwide.
        Answer. The Department provides technical assistance to all its
    grantees, including states, local areas, and competitive grantees. Most
    of the Department's technical assistance is distributed nationwide
    through the online platform WorkforceGPS.org. Additionally, the
    Department's regional offices provide tailored coaching to individual
    grantees facing unique challenges. Planned technical assistance for FY
    2025 touches topics including equity and job quality, such as the Job
    Quality Academy previously discussed, regular training for workforce
    development boards such as that available at WorkforceGPS, retraining
    and reemploying Americans impacted by economic change, integrating
    intake and case management systems such as the Aligned Case Management
    Institute, replicating effective practices often conducted in
    partnership with the Chief Evaluation Office, enhancing capacity to
    conduct and use evaluation such as the technical assistance available
    on WorkforceGPS' Evaluation and Research Hub, and performance
    accountability also available within WorkforceGPS' community of
    practice.
        Question. Please provide more detail on the efforts to expand
    registered apprenticeship opportunities for diverse and underserved
    populations as detailed on page TES-80 of the FY25 Congressional Budget
    Justification, including how DOL will measure the success of such
    efforts and provide publicly available information on the results of
    such efforts.
        Answer. Registered Apprenticeship (RA) programs are a powerful tool
    for growing and diversifying the American workforce. Ensuring equitable
    access to these opportunities for all qualified individuals remains a
    primary goal of the system as the Department works to ensure that
    apprenticeship opportunities are available to qualified workers who
    have historically been underrepresented in RAs. Sponsors of RA programs
    are tasked with ensuring that their apprenticeship workforces are
    accessible to all individuals available for apprenticeship within the
    communities in which they operate. To support that goal, the Department
    of Labor has in place Equal Employment Opportunity (EEO) regulations
    for Registered Apprenticeship. These provisions, found at 29 CFR Part
    30, prohibit discrimination against apprentices and applicants for
    apprenticeship, with the intent of bolstering RA opportunities for all
    Americans, and require sponsors to identify and address possible
    barriers to apprenticeship for certain underrepresented populations,
    including Black and Hispanic women.
        The Department also strives to support pre-apprenticeship programs,
    which are designed to prepare individuals to enter into and succeed in
    a Registered Apprenticeship program. The American Apprenticeship
    Initiative (AAI) evaluation found that 89 percent of pre-apprentices
    supported through this initiative are from underrepresented populations
    and that these programs are a valuable strategy for diversifying
    pathways into Registered Apprenticeship. Given evidence of the growing
    use of pre-pprenticeships among underrepresented populations and their
    effectiveness as a tool to promote diversity, equity, inclusion, and
    accessibility, the Department recently released guidance on the
    characteristics of quality pre-apprenticeship programs, which includes
    strategies for embedding EEO principles in pre-apprenticeship program
    designs and examples of quality pre-apprenticeship programs in diverse
    settings. In addition, the Department has announced the availability of
    $100 million in funds for a second round of State Apprenticeship
    Expansion Formula (SAEF) grants and $95 million through the second
    round of Apprenticeship Building America (ABA) grants. These grants aim
    to support strategies that promote equitable Registered Apprenticeship
    pathways and partnerships, including through pre-apprenticeship, and
    also promote other efforts to strengthen external linkages that are in
    furtherance of equity and diversification goals that concurrently align
    with the Department's Good Jobs Principles. These efforts include the
    enforcement of codified Equal Employment Opportunity (EEO) requirements
    that serve to expand the RAP model into both new and traditional
    industries in such a way that recruitment and enrollment outcomes are
    improved for workers from underrepresented populations and underserved
    communities. The Department continues to invest in formal evaluations
    of these grants to build an evidence-based portfolio for increasing
    access to and retention in Registered Apprenticeship for
    underrepresented populations.
        Finally, the Department's Office of Apprenticeship (OA) recently
    released an interactive tool on Apprenticeship.gov, the Apprenticeship
    Population Dashboard, which provides a comparison of all available
    demographic categories for active registered apprentices against the
    same demographic representation of the total available workforce at
    national, regional, state, and county levels. By pulling data from the
    Registered Apprenticeship Partners Information Database System (RAPIDS)
    and total available workforce data from the 2020 United States Census
    Bureau's American Community Survey (ACS), the dashboard promotes the
    value of data analysis to best inform strategic planning for the growth
    and modernization of Registered Apprenticeship.
        Question. The FY25 Congressional Budget Justification mentions that
    DOL conducted an inventory of equity-oriented data collected by
    agencies to better understand equity gaps in workforce programs (TES-
    87). The budget justification further states that there is often
    missing demographic data for program participants. Please describe what
    if any TA DOL is providing to workforce agencies to improve the
    collection of this demographic data and any statutory or regulatory
    hurdles to collecting such data.
        Answer. The Department has several tools and resources to help
    states improve demographic data reporting:
        Tools:
      --State Workforce Services Dashboards: These dashboards examine WIOA
            Title I & Wagner- Peyser Act Employment Service program data
            quality, system reach, and differences in access to services
            and outcomes between demographic groups by state. These
            analyses were produced in response to Executive Order 13985,
            Advancing Racial Equity and Support for Underserved Communities
            Through the Federal Government.
      --WIOA by the Numbers: States collect and report key data about who
            is served and their outcomes. The Department invites the public
            and workforce system stakeholders to explore the performance
            accountability data for WIOA Title I and the Wagner-Peyser Act
            Employment Service. This tool allows users to better understand
            workforce system outcomes, including Data by Map, State
            Comparisons, and Data by Tables. Data can be filtered by race/
            ethnicity, veteran's status, and disability status. Data is
            compiled from the WIOA Individual Performance Records Full Use
            Data files, which takes data submitted by states on a quarterly
            and yearly basis to the Department and is aggregated so there
            are no fewer than three individual participants in a subgroup
            so the data underlying the dashboard can be released while
            respecting privacy concerns.
        Resources:
      --The Demographic Data Quality and Collection Self-Assessment Tool
            increases awareness about the quality of demographic data and
            helps State Workforce Agencies (SWA) and local American Job
            Centers (AJCs) determine whether the demographic data
            collection processes and procedures are effective and lead to
            high-performing data collection. This resource also helps
            agencies consider whether improvements can be made to increase
            the quality and completeness of the data stored in the
            workforce registration and performance reporting system. This,
            in turn, enhances the service delivery and customer experience
            for the workforce system.
      --The Demographic Data Quality Promising Practices brief provides
            examples from workforce programs across the country. These
            practices have helped workforce programs improve the quality
            and completeness of ethnicity and race data responses in the
            Participant Individual Record Layout (PIRL) and workforce
            registration systems. The Demographic Data Quality Promising
            Practices brief covers four areas: 1. Promoting Effective
            Communication, Understanding, and Collaboration for Program
            Equity 2. Determining Staffing Needs and Roles 3. Designing
            Technical Processes to Improve Demographic Data Quality and
            Completeness 4. Using Data to Make Informed Decisions.
        Question. Please provide data for FY19 to FY23 describing how many
    YouthBuild applications were submitted, how many YouthBuild
    applications were awarded, and the percentage of both rural and Native-
    serving applicants and awardees for both FY19 to FY23.
        Answer.

    --------------------------------------------------------------------------------------------------------------------------------------------------------
                                                        YouthBuild # of       Tribal           Rural          YouthBuild
                        Fiscal Year                       Applications     Applications     Applications       Awarded      Tribal  Awarded   Rural  Awarded
    --------------------------------------------------------------------------------------------------------------------------------------------------------
    2019..............................................             165         3 (1.8%)       27 (16.4%)               67         0 (0.0%)       11 (16.4%)
    2020..............................................             130         1 (0.8%)       20 (15.4%)               68         0 (0.0%)       13 (19.1%)
    2021..............................................             122         0 (0.0%)       23 (18.9%)               68         0 (0.0%)       13 (19.1%)
    2022..............................................             142         2 (1.4%)       17 (12.0%)               68         1 (1.5%)       12 (17.6%)
    2023..............................................             154         4 (2.6%)       36 (23.4%)               72         1 (1.4%)         18 (25%)
    --------------------------------------------------------------------------------------------------------------------------------------------------------

        Question. Please describe any steps DOL can take to provide a more
    stable and predictable timeline for releasing FOAs and award
    announcements for the YouthBuild program.
        Answer. We appreciate that consistent YouthBuild FOA publication
    and grant awards are beneficial to the stability of YouthBuild
    programs. For the last 3 years (2021, 2022, and 2023) the Department
    has published the YouthBuild FOAs in November and subsequently
    announced awards in late April/early May. We will continue to work with
    internal and external stakeholders to ensure potential applicants are
    aware of the forecast for FOA publication, and we will widely share the
    funding opportunity.
        Question. On page TES-98 of the FY25 Congressional Budget
    Justification, DOL proposes to allows YouthBuild funds to count towards
    AmeriCorps' match requirements. Is legislation needed to accomplish
    this goal or could DOL change its policies administratively as other
    agencies have done on this issue?
        Answer. Yes, legislation would be necessary. Currently, Federal
    funds may only be used to match where the ``Federal statute authorizing
    a program specifically provides that Federal funds made available for
    such program can be applied to matching or cost sharing requirements of
    other Federal programs.'' (See Uniform Guidance at 2 CFR
    200.306(b)(5)). Even though the authorizing statutes for the CNCS
    programs allow required matches to be provided from other Federal
    sources, the YouthBuild provisions do not specifically provide that
    YouthBuild grant funds may be applied to such matching or cost sharing
    requirements.
                                     ______

                  Questions Submitted by Senator Patty Murray
        Question. The Women's Bureau plays an important role in supporting
    paid leave.
        What steps has the Women's Bureau taken to support paid leave in
    fiscal year 2024?
        Answer. As the data make clear, women shoulder disproportionate
    unpaid caregiving obligations that can force untenable choices between
    the earnings their families rely on and the care needs of family
    members. Paid family and medical leave programs are a critical linchpin
    to ensure women can deliver on both sets of obligations, and the
    Women's Bureau champions inclusive and effective paid family medical
    leave policies. Although the Women's Bureau did not receive funding to
    revive the $10 million Paid Leave Analysis Grants Program proposed in
    the President's fiscal year (FY) 2024 Budget, the Women's Bureau
    maximized available resources to mount a robust set of paid leave-
    related research and technical assistance activities in the first half
    of FY 2024.
        The Women's Bureau commissioned microsimulation modeling to produce
    data and analysis related to how paid family and medical leave programs
    interact with and enhance the reach and impact of existing safety net
    programs, and how policy changes increasing access to leave would
    affect the broader economy and individuals' economic security and well-
    being. At the same time, the Women's Bureau has delivered sustained
    technical assistance to five states and numerous academic research
    teams over the course of the fiscal year in the use and functionalities
    of the Department's Worker Paid Leave Usage Simulation (Worker PLUS)
    model and posted the resulting analyses to the agency's website for
    public use. Worker PLUS is an open-source tool designed to estimate
    administrative costs, as well as the effects of various worker leave
    scenarios and policy options on leave taking behavior.
        In 2023, the Women's Bureau updated the Department's 2015 analysis
    of the economic costs incurred by not providing a universal paid family
    leave program, producing a new ``Cost of Doing Nothing'' report. The
    report found if women in the U.S. replicated the labor force attachment
    of countries with more comprehensive paid leave and related work/family
    supports, five million more women would participate in the labor force,
    with $775 billion in additional annual economic activity.\1\
    ---------------------------------------------------------------------------
        \1\ https://www.dol.gov/sites/dolgov/files/WB/paid-leave/
    CostofDoingNothing2023.pdf.
    ---------------------------------------------------------------------------
        The Women's Bureau also posted information to its website about
    paid family and medical leave, creating a Federal government resource
    on the state programs. This website includes issue briefs on paid
    leave, data, and information for workers and employers.
        In 2024, the Women's Bureau entered into an agreement with the
    Department's Bureau of Labor Statistics (BLS) to initiate data
    collection on workers' access to and use of paid and unpaid leave and
    job flexibilities. This data will provide one of the best sources of
    nationally representative worker reported data on leave access. The
    2024 data collection effort will also provide a critical comparator to
    gauge leave and flexibility policies in the aftermath of the COVID-19
    pandemic. The Women's Bureau is also supporting the Department of
    Labor/Office of Personnel Management (DOL/OPM) partnership responsible
    for conducting a multi-year paid leave research and evaluation
    initiative to answer key questions surrounding the implementation and
    effects of the fledgling Federal Employee Paid Leave Act (FEPLA)
    program, enacted in 2020 to provide paid leave benefits to the nation's
    two million Federal public servants.
        Question. What steps does the Women's Bureau plan to take in
    supporting paid leave in fiscal year 2025?
        Answer. Even under the budget caps set by the Fiscal Responsibility
    Act, the Department is proposing to invest in the important
    Administration priority of supporting paid leave. The President's FY
    2025 Budget includes a $2.5 million increase for the Women's Bureau to
    re-launch its State Paid Leave Analysis Grants Program, alongside a
    complementary technical assistance effort to support states,
    researchers and others in proper utilization of the Department's Worker
    PLUS simulation tool, as well as a new Technical Assistance Hub to
    share best practices among states. In the original grant deployment
    between 2014 and 2016, WB funded $3M in paid leave micro-grants, which
    engaged 17 states and municipalities in exploring how they could
    establish paid family medical leave programs, to demonstrable effect.
    Namely, three states passed paid leave laws after receiving these
    grants; two states expanded their laws; and three large, urban
    jurisdictions helped establish conditions for their states subsequently
    passing legislation, as well as one locality that implemented a paid
    leave program for the public workforce.
        In the absence of additional funding, in FY 2025, the Bureau will
    only be equipped to provide limited technical assistance to states and
    other requesters interested in deploying Worker PLUS analysis. At the
    same time, the agency will continue to continue to staff the ongoing
    DOL/OPM evaluation of the Federal Employee Paid Leave Act (FEPLA)
    program for Federal workers. In addition to commissioned research and
    data collection, the Women's Bureau will continue to publish and
    disseminate shorter-form research briefs on various aspects of paid
    leave program models on the dedicated paid leave section of its
    website, as well as any resulting analysis from technical assistance in
    use of the Worker PLUS tool.
        Question. Climate change is increasing workers' exposure to smoke--
    which is a huge issue in my home state of Washington where many
    agricultural workers already suffer from smoke-related illnesses. Right
    now, there are still no Federal standards specifically protecting
    workers from smoke.
        What steps has the Occupational Safety and Health Administration
    taken to better protect workers who are exposed to dangerous levels of
    smoke while doing their jobs in fiscal year 2024?
        How does the Occupational Safety and Health Administration propose
    to better protect workers in fiscal year 2025?
        Answer. The Occupational Safety and Health Administration (OSHA)
    has a comprehensive website with safety tips and resources to help
    employers and workers reduce their exposure to smoke during wildfires.
    OSHA also has a preparedness page that provides information on
    evacuation plans, safety zones around buildings, and equipment to have
    on hand in case a wildfire occurs. Preparing evacuation plans in
    advance is key to helping workers get to safety before a wildfire
    affects an area and can also help prevent the impact from smoke. In
    addition, OSHA issued a national news release last summer (OSHA News
    Release, June 9, 2023) urging employers to have a plan to protect
    outdoor workers from hazards associated with poor air quality. The news
    release outlined the hazards associated with wildfires and provided
    ways that employers can prepare for and implement procedures to reduce
    exposures to smoke when necessary.
        OSHA will continue its outreach efforts to educate employers and
    will consider reissuance of its June 9, 2023, News Release to reiterate
    the need for employers to plan and prepare to protect workers from
    dangerous levels of smoke, as well as timely reminders to employers in
    regions of Federal OSHA coverage where workers are expected to be
    exposed to high levels of smoke.
        Question. Last year, I led the effort to pass the Beryllium Testing
    Fairness Act as part of the National Defense Authorization Act for
    Fiscal Year 2024. What steps has the Office of Workers' Compensation
    Programs taken to implement the new law, including any outreach the
    Department has conducted to make potential claimants aware of the
    changes to the program?
        Answer. The Beryllium Testing Fairness Act (the Act), passed as
    part of the Fiscal Year 2024 National Defense Authorization Act,
    includes a change to the Energy Employees Occupational Illness
    Compensation Program Act (EEOICPA) in relation to the establishment of
    beryllium sensitivity under Part B. In addition to existing statutory
    provisions, beryllium sensitivity under Part B can now also be
    established by submitting three borderline beryllium lymphocyte
    proliferation tests or beryllium lymphocyte transformation tests,
    performed on blood cells, that are conducted over a period of 3 years.
    The Department of Labor (the Department) is committed to increasing
    awareness of these program changes.
        To share this information, the Department's Office of Workers'
    Compensation Programs (OWCP), Division of Energy Employees Occupational
    Illness Compensation (DEEOIC), published EEOICPA Bulletin No. 24-01,
    Updated Criteria for Establishing Beryllium Sensitivity.\2\ The
    Bulletin provides DEEOIC staff with guidance about operationalizing the
    new standard during the evaluation of beryllium sensitivity claims.
    OWCP is currently in the process of making the necessary regulatory
    changes consistent with the Act's EEOICPA amendment. In addition, OWCP
    is in the process of reviewing all denied cases (1,158 cases) that may
    be impacted by the statutory, and resulting rule, change. DEEOIC will
    reopen and accept any cases that meet the new criteria.
    ---------------------------------------------------------------------------
        \2\ EEOICPABulletin24-01.pdf (dol.gov).
    ---------------------------------------------------------------------------
        OWCP notified claimants and other stakeholders multiple times about
    the beryllium-related law changes. Specifically, OWCP emailed EEOICPA
    Bulletin No 24-01 to claimants and stakeholders. OWCP also promoted and
    held a Stakeholder Updates Webinar at which the changes to the law were
    discussed. This webinar was announced to claimants and stakeholders in
    advance of the event. The slides from the March 2024 webinar are posted
    on the Department's website.\3\ Finally, the DEEOIC Policy Branch
    provided a briefing to the Department's Advisory Board on Toxic
    Substances and Worker Health on the changes to the law and their impact
    on claimants.
    ---------------------------------------------------------------------------
        \3\ https://www.dol.gov/sites/dolgov/files/OWCP/energy/regs/
    compliance/Outreach/Outreach _Presentation/
    stakeholder_update032824.pdf.
    ---------------------------------------------------------------------------
                                     ______

                    Questions Submitted by Senator Jack Reed
    WIOA Formula Grants
        Question. Rhode Island, like many other states, is experiencing
    record employment, and we desperately need more skilled workers . . .
    to build submarines . . . to work on our burgeoning life sciences
    sector . . . to build our infrastructure . . . and in many other areas.
    Unfortunately, just when we desperately need more investment in
    workforce development, our WIOA formula grant funding is declining by 8
    to 9 percent each year because our unemployment rate is low. What are
    your recommendations for ensuring that the formulas for distributing
    WIOA funds are responsive to workforce development needs during a time
    of very low unemployment?
        Answer. The statutory formulas governing WIOA Youth, Adult and
    Dislocated Worker funds are designed to shift funds to states with
    proportionally more unemployment than other states and already use stop
    loss, or minimum provisions, to mitigate losses. Given the design of
    the current formulas, there will always be some states that lose funds
    over prior year allotments. In times of low unemployment, the excess
    unemployment rate of 4.5 percent established in WIOA can result in a
    state losing out on one- third of the funding associated with that data
    factor. In these circumstances, the minimum provisions mitigate the
    drop in funding. To a lesser extent, the Areas of Substantial
    Unemployment threshold of 6.5 percent can also result in similar
    exclusions to one-third of the funding at the state level, but this is
    more of a concern within sub-state allocation formulas than state
    allotment formulas. Periods of very high and low unemployment can both
    result in reduced allotment levels for some states. During the great
    recession in 2008, states with chronically high unemployment that
    always received one-third of the funding associated with the excess
    unemployment data factor saw steep losses to their formula funds for
    several years because many new states suddenly had excess unemployment,
    which reduced the relative share of that data factor for those states
    with chronically high unemployment. In response, Congress added a stop
    gain provision to the Dislocated Worker formula in WIOA (in addition to
    the provisions for Youth and Adult that existed in WIA) to mitigate
    large shifts in funding.
        WIOA reauthorization legislation could revise the definition of
    excess unemployment and set different thresholds based on the level of
    national unemployment (and for sub state formulas and state
    unemployment). Any change to the formula impacts all states. The
    Department would be pleased to discuss this issue further and can model
    scenarios to evaluate the impact of various changes to the formula.
    Public Libraries and Workforce Development
        Question. In the FY24 Report that accompanied the Labor, HHS,
    Education, and Related Agencies Appropriations bill, I included
    language asking the Employment and Training Administration to work with
    the Institute of Museum and Library Services to identify barriers to
    libraries participating in WIOA programs and develop a plan to address
    those barriers. Please provide an update on your actions to address
    this report language.
        Answer. The Department held periodic meetings with Institute of
    Museum and Library Service (IMLS) staff throughout FY 2023 and will
    continue to do so in FY 2024, including discussions on how the
    Department can help identify barriers to libraries participating in
    WIOA programs. With IMLS input, the Department held a live webinar in
    May 2023 for librarians, showing the capabilities of CareerOneStop.org
    and how librarians can utilize the website to assist customers in job
    search, career exploration, completing job applications, and many other
    tasks. Since 2023, the Department and IMLS have continued to engage
    libraries as they provide workforce services to their customers. The
    Department conducts quarterly webinars regarding CareerOneStop.org to
    demonstrate the tools available on the website, to which libraries,
    including Public Library Association (PLA) members, are invited to
    attend. Additionally, staff that work on the CareerOneStop site
    routinely attend the national PLA conference where they provide
    demonstrations to attendees; CareerOneStop promotes the conference and
    its website content via the CareerOneStop social media channels. The
    Department will continue to engage public libraries in workforce
    service delivery, on how to improve content on CareerOneStop, and on
    how to help remove barriers for library participation in providing
    workforce services within WIOA.
    Job Corps
        Question. The FY23 NDAA mandated the inclusion of Navy shipbuilding
    workforce development incentives into new shipbuilding construction
    contracts. This month, the Exeter Job Corps Campus in Rhode Island
    hosted a shipbuilding workforce event with the Navy and its
    shipbuilders, including Electric Boat. Please provide information about
    the work Job Corps is doing with the Navy and our nation's shipbuilders
    to help address this critical workforce shortage.
        Answer. Since September 2023, the Department has coordinated with
    the Department of the Navy (DON) and the Naval Sea Systems Command
    (NAVSEA) to build awareness, career pathways, and opportunities for
    young adults to gain exposure to shipbuilding careers and occupations,
    and to begin building a pipeline of qualified workers who are ready to
    work for employers that serve the Navy's shipbuilding interests, some
    of which may provide registered apprenticeship program opportunities.
        The Department began this partnership through targeted
    collaboration and by hosting five shipbuilding-themed career fairs. The
    goal of these career fairs is to introduce shipbuilding occupations to
    students who are currently enrolled in technical training programs,
    including machinist, sheet metal fabricator, and electrical training
    programs.
        Job Corps programs are advancing the connection with the Navy's
    shipbuilding contractors beyond the major events the Department has
    hosted. For example:
      --Fincantieri, located in Green Bay, WI, has hosted Job Corps
            students on tours of their facility, met with local Job Corps
            leaders, and hosted job interviews for the initial group of
            students who were interested in careers with their
            organization.
      --Portsmouth Naval Shipyard, located in Kittery, ME, has hosted
            discussions on the Federal hiring system with students who are
            interested in applying for jobs in their organization and has
            provided advice on how to submit applications with the best
            chance for acceptance. The team at Portsmouth Naval Shipyard
            also continues to provide the Job Corps program with valuable
            feedback related to the curriculum and training equipment used
            to prepare students for jobs in the shipbuilding industry.
      --Eastern Shipbuilding, located in Pensacola, FL, has hosted numerous
            virtual information sessions since the career fair events were
            held. These sessions have included overviews of their available
            occupations and feedback related to the skills needed to
            maintain jobs in their organization. Eastern Shipbuilding has
            hired five Job Corps students from as far away as Shreveport,
            LA, and continues to be one of the employers of choice for many
            students who are focusing the outcome of their training on
            shipbuilding occupations.
      --Huntington Ingalls Shipbuilding (Ingalls), located in Pascagoula,
            MS, has been exceptionally active within the Job Corps
            community. Since the career fair in which they participated,
            Ingalls, at the request of the Office of Jobs Corps (OJC), was
            a co-presenter at the National Association of Workforce Boards
            Forum held in Washington, DC, in March 2024. Ingalls, along
            with partners from the Department of the Navy's Shipbuilding
            Industrial Base Task Force, addressed workforce leaders to
            describe the need for skilled workers in this industry sector
            and to tout the relationship with Job Corps to provide younger
            job seekers with high quality training that can lead to jobs in
            the shipbuilding workforce. Ingalls has held numerous virtual
            and on-site dialogues with Job Corps campuses in the
            southeastern part of the country to help acculturate
            shipbuilding occupations in the Job Corps community and thus
            create larger pipelines of interested students. Ingalls is
            preparing to visit nine additional campuses by the end of July
            2024 to meet with students who are enrolled in technical
            training programs that support shipbuilding occupations to
            describe the benefits of working in the shipbuilding industry,
            and more specifically, in the Ingalls Shipbuilding
            organization.
        OJC continues to hold regular discussions with the Department of
    the Navy's Industrial Base Task Force to strategically address the
    challenges related to connecting Job Corps students to shipbuilding
    employers with high-volume occupational needs. The Department has
    identified relocation as a significant barrier, given that most of the
    Job Corps campuses are not located near shipbuilding ports. The Navy
    appears to be working with its shipbuilding community to contemplate
    ways in which it may be able to help overcome this challenge.
        OJC and the Navy also are planning to focus partnership efforts in
    Arkansas, as Camden, AR, is host to the largest ammunitions
    manufacturing companies in the country. The Navy has advised the
    Department that, as with shipbuilding occupations, the organizations
    that provide them with ballistics are facing hiring challenges. Work is
    currently underway to bring these organizations to Job Corps campuses
    to initiate dialogue with interested students.
        In support of the activities detailed above, Job Corps will
    continue to host career fairs, which, to date, have been hosted by Job
    Corps campuses that are in relative proximity to areas that have a high
    density of shipbuilding vendors who are contracted to build or maintain
    the Navy's fleet and have a substantial need for a skilled workforce to
    meet their contracted deliverables. Since the initial shipbuilding
    career fair, a total of 41 Job Corps campuses have participated in the
    events and over 600 students have attended. A detailed breakdown of the
    five career fairs the Department has hosted follows:
      --Mississippi Job Corps Shipbuilding Career Fair (September 2023):
        --Employers Represented: 5
          -- Eastern Shipbuilding
          -- Austal USA
          -- Hiller
          -- Bollinger Mississippi Shipyards, LLC
          -- Ingalls Shipbuilding
        --Job Corps Students Attended: 150
        --Job Corps Campuses Represented: 8
          -- Campuses in Attendance: Shreveport (LA), New Orleans (LA),
                Little Rock (AR), Gulfport (MS), Mississippi (MS), Finch-
                Henry (MS), Benjamin Hooks (TN), Gadsden (AL)
      --Milwaukee Job Corps Shipbuilding Career Fair (November 2023)
        --Employers Represented: 6
          -- INGE Team
          -- Milwaukee Valve
          -- Metal TEK International
          -- DRS Naval Power
          -- Fincantieri Marine Group
          -- Fairbanks Morse Defense
        --Job Corps Students Attended: 70
        --Job Corps Campuses Represented: 5
      --Campuses in Attendance: Milwaukee (WI), Blackwell (WI), Paul Simon
            (IL), Joliet (IL), Gerald Ford (MI)
      --San Diego Job Corps Shipbuilding Career Fair (January 2024)
        --Employers Represented: 3
          -- Continental Maritime of San Diego
          -- General Dynamics
          -- Austal USA
        --Job Corps Students Attended: 110
        --Job Corps Campuses Represented: 7
          -- Campuses in Attendance: San Diego (CA), Treasure Island (CA),
                San Jose (CA), Los Angeles (CA), Inland Empire (CA), Long
                Beach (CA), Sacramento (CA)
      --Penobscot Job Corps Shipbuilding Career Fair (April 2024)
        --Employers Represented: 2
          -- General Dynamics Bath Iron Works
          -- Portsmouth Naval Shipyard
        --Job Corps Students Attended: 120
        --Job Corps Campuses Represented: 18
          -- Campuses in Attendance: Penobscot (ME), Loring (ME),
                Northlands (VT), New Hampshire (NH), Shriver (MA), Grafton
                (MA), Exeter (RI), Hartford (CT), New Haven (CT), South
                Bronx (NY), Edison (NJ), Glenmont (NY), Westover (NY),
                Oneonta (NY), Iroquois (NY), Delaware Valley (NY),
                Cassadaga (NY), Arecibo (PR)
      --Exeter Job Corps Shipbuilding Career Fair (May 2024)
        --Employers Represented: 3
          -- Portsmouth Naval Shipyard
          -- Amtrol Inc
          -- Electric Boat
        --Job Corps Students Attended: 160
        --Job Corps Campuses Represented: 21
          -- Campuses in Attendance: Penobscot (ME), Loring (ME),
                Northlands (VT), New Hampshire (NH), Shriver (MA), Grafton
                (MA), Exeter (RI), Hartford (CT), New Haven (CT), South
                Bronx (NY), Edison (NJ), Glenmont (NY), Westover (NY),
                Oneonta (NY), Iroquois (NY), Delaware Valley (NY),
                Cassadaga (NY), Arecibo (PR), Red Rock (PA), Keystone (PA),
                Philadelphia (PA)
        The Department is currently planning its sixth shipbuilding career
    fair, which will take place in Virginia in August 2024.
        Question. The Fiscal Year 2024 National Defense Authorization Act
    included a provision to allow Job Corps Centers to be eligible
    placements for the Troops to Teachers Program. What are some other
    steps we can take to better support Job Corps Center staffing?
        Answer. The Troops to Teachers (TTT) program provides funds to
    recruit, prepare, and support service members and veterans to become
    certified and employed as teachers, including in schools in areas with
    high levels of poverty. Successful TTT candidates obtain certification
    or licensing as elementary and secondary school teachers, as well as
    vocational or technical teachers. The TTT program also helps
    participants find employment in high-need local education agencies or
    charter schools. Section 573 of the National Defense Authorization Act
    for Fiscal Year 2024, Public Law 118-31, titled, ``Extension of Troops-
    To-Teachers Program To The Job Corps'', extends the opportunity to Job
    Corps Centers to hire these highly qualified teachers.
        Other steps that would support Job Corps Center staffing include
    the Executive Orders increasing the minimum wage for Federal
    contractors. In addition, personnel incentives such as eligibility for
    loan forgiveness and tuition reimbursement, modern technology to
    support academic learning, and sponsorship for professional development
    and certifications all could increase retention.
        Question. How much of a factor is pay in recruiting teachers and
    how do Job Corps salaries compare with salaries in our public schools?
        Answer. Despite contract requirements to recruit and retain
    qualified staff at competitive wages, Job Corps center operators have
    struggled to attract qualified individuals with expertise to serve
    opportunity youth.
        Pay is a significant factor in Job Corps' struggle to recruit and
    retain quality teachers. Job Corps collects and analyzes data on
    contractor staff vacancies as well as the salaries operators report
    they are paying staff. During the last two calendar years, the data
    collected has consistently shown that teachers have one of the highest
    rates of vacancy amongst all labor categories under center operations
    contracts. At the same time, a 2024 review of salary data showed that
    91% (983) of the 1080 full-time academic positions were not paid wages
    comparable to the wages and benefits paid in the local area market for
    like occupations, as reported by the Bureau of Labor Statistics. The
    average wage gap is $20,484. This pay gap is further exacerbated when
    taking into consideration that teachers in the Job Corps program work
    year-round due to the program's open enrollment, whereas teachers in
    the public school system have summer months off.
        Beginning in May 2017, the Department of Labor developed a contract
    term, H.6 Wage Comparability, that required center operations
    contractors to pay wages comparable to those in the local labor market
    for like occupations. The contract term also identified a minimum
    salary amount for Academic and Career Technical Training Teachers.
        Then, in 2020, the Department began converting Job Corps center
    operations contracts from cost reimbursement to fixed price type
    contracts. Within these contracts, the Department retained the contract
    term regarding wage comparability, but instead of identifying a minimum
    salary amount, the Department required contractors to determine the
    compensation level required to be competitive with the local labor
    market for each position at a center. The risk assumed by the center
    operator under the fixed price contract type has made it more likely
    that the operator will not be willing or able to keep up with rising
    labor market demands. This has especially been the case after the
    COVID-19 pandemic, as the labor market for teachers has become
    increasingly competitive. To try to combat the impact of insufficient
    staffing under the fixed price contracts, Job Corps instituted a
    vacancy ``takeback'' to recoup the value of a vacant position. But this
    takeback has not resulted in significant improvement in contractors'
    vacancy rates, especially for teaching positions.
        As a result, Job Corps has renewed focus on teacher pay by
    publishing Bureau of Labor Statistics salary data in its Request for
    Proposal, to provide the operator community with better data on what
    teachers in the center's locality are paid. The Department also made
    the contractors' proposed staff compensation plans a rated factor in
    the evaluation to select the contract awardee.
        The Department anticipates that as greater pressure is put on
    center operators to recruit and retain teachers by paying more
    competitive salaries the operators will propose higher priced
    contracts.
        Question. Please provide a cost estimate for bringing Job Corps
    teacher pay to parity with public school teachers.
        Answer. Job Corps collects and analyzes data on center staff
    vacancies as well as the salaries operators report they are paying
    staff. A 2024 review of salary data showed that 91% (983) of the 1080
    full-time academic positions were not paid wages comparable to the
    wages and benefits paid in the local area market for like occupations,
    as reported by the Bureau of Labor Statistics. The average wage gap is
    $20,484.
        To remediate this issue at its source, DOL developed new
    solicitation language for fixed price Center Operations contracts,
    including standardized position descriptions for Job Corps center
    positions and a crosswalk to Bureau of Labor Statistics (BLS) data and
    local wage comparisons to ensure vendors propose fair and competitive
    compensation when bidding on Center Operations contracts. Even with
    these mechanisms in place, DOL's Job Corps Acquisition Services
    continues to see vendor proposals with salaries below the comparable
    local wage and is actively addressing the concerns prior to contract
    award. As Job Corps Acquisition Services continues to hold contractors
    accountable for paying competitive wages, it anticipates that the price
    of contracts will increase.
        Question. The Department of Labor (DOL) has been charged along with
    the Department of Health & Human Services and the Department of the
    Treasury with promulgating rulemaking for the provider
    nondiscrimination provision that were in the No Surprises Act and the
    Affordable Care Act. The agency has taken the lead on this rulemaking
    but has missed multiple deadlines and is now more than 2 years past the
    statutory deadline set out in the No Surprises Act. Will the agency
    work to ensure that this rulemaking is done this calendar year?
        Answer. The Department remains committed to promulgating rulemaking
    to implement the provider nondiscrimination provision of section
    2706(a) of the Public Health Service Act (PHS Act), as added by the
    Affordable Care Act. This rulemaking is required by section 108 of the
    No Surprises Act, and the Department's current Unified Regulatory
    Agenda reflects that notice-and-comment rulemaking implementing the
    provider nondiscrimination provision is a priority in the near term.
        To that end, the Department is actively studying the issues
    relating to the provider nondiscrimination provision. The Department,
    along with the Departments of Health and Human Services and the
    Treasury (together, the Tri-Departments), held a listening session on
    January 7, 2022, to foster an exchange of information and views and
    afford interested individuals and organizations an opportunity to share
    their perspective on what should be included in forthcoming proposed
    regulations.\4\ In addition, on August 3, 2023, the Tri-Departments
    issued a notice of proposed rulemaking, Requirements Related to the
    Mental Health Parity and Addiction Equity Act (the MHPAEA NPRM), in
    which they sought comments on ways that the Tri-Departments can enhance
    access to mental health and substance use disorder benefits through
    their implementation of section 2706(a) of the PHS Act.\5\ The
    Department is considering the comments received at the 2022 listening
    session and in response to the MHPAEA NPRM, as well as feedback from
    other conversations with interested individuals and organizations, as
    it prepares to undertake the required rulemaking.
    ---------------------------------------------------------------------------
        \4\ A transcript of the listening session is available at https://
    www.dol.gov/sites/dolgov/files/ebsa/laws-and-regulations/laws/no-
    surprises-act/listening-session-regarding-provider-nondiscrimination-
    under-section-2706a-of-the-phs-act.pdf.
        \5\ See 88 FR 51552, 51598 (Aug. 3., 2023), available at https://
    www.govinfo.gov/content/pkg/FR-2023-08-03/pdf/2023-15945.pdf.
    ---------------------------------------------------------------------------
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. Recently, the President vetoed a bipartisan Congressional
    resolution overturning the National Labor Relations Board (NLRB) rule
    redefining who is a joint employer. This rule from the NLRB will put
    the franchise model at risk.
        Small businesses are the heart of our economy and our communities,
    especially in West Virginia where more than 98% of our businesses are
    small businesses. One out of every three franchise owners say they
    wouldn't own a small business without the franchise business model.
        The last time the NLRB tried this, a study found that this policy
    led to 376,000 fewer jobs and $33.3 billion in lost output across the
    economy. While a Federal judge has current blocked this rule from
    taking effect, I am concerned what will happen if it does take effect.
        Acting Secretary, there continues to be bipartisan concern with
    what the NLRB is proposing. What does your Department plan to do to
    curb the job and economic output loss we experienced the last time a
    similar standard took effect?
        Answer. The Department of Labor defers to the National Labor
    Relations Board (NLRB) on this particular rulemaking, which is not
    under our jurisdiction. However, the Department is engaging in efforts
    to improve workers' access to good jobs, including through the Good
    Jobs Initiative, which is aimed at improving job quality throughout the
    country by providing critical information to workers, employers, and
    government entities as they seek to improve job quality and create
    access to good jobs. As part of this initiative, the Department has
    helped Federal agency partners incentivize job quality criteria in over
    $239.6 billion dollars of their competitive grant funding. The
    Department is also working with other Federal partners to issue
    guidance to further promote job quality, including through six
    Memorandums of Understanding with the Departments of Transportation,
    Commerce, Energy, and the Interior, as well as the General Services
    Administration and Environmental Protection Agency, and by establishing
    shared Good Jobs Principles with the Department of Commerce.
        Finally, the Department has ongoing commitments to provide
    technical assistance to states and organizations on best practices for
    workforce development. This includes intensive technical assistance
    academies, including the Good Jobs, Great Cities Academy, the Youth
    Systems Building Academy, and the Job Quality Academy to enhance equity
    and job quality throughout the workforce development system. These
    efforts, coupled with the Yes, WIOACan! Initiative, https://
    ywc.workforcegps.org/, are spurring innovation and enabling state and
    local workforce areas to shape plans for building the skilled workforce
    necessary for implementing the historic Federal investments provided
    for under the Bipartisan Infrastructure Law, the CHIPS and Science Act,
    and Inflation Reduction Act.
        Through the Good Jobs Initiative and our other important work, the
    Department remains committed to building a modern, inclusive
    workforce--ensuring workers have good jobs, opportunities for
    advancement, and seats at the table to have their voices heard.
        Question. Acting Secretary, as you know, your Department has been
    active in the retirement space in the past 2 years. In November 2022,
    you released a final rule that permits Employee Retirement Income
    Security Act (ERISA) retirement plan fiduciaries to use ESG factors
    when selecting investments and exercising shareholder rights. The rule
    replaced a previous rule that mandated fiduciary decisions be made
    solely with the intent of getting the best returns for Americans.
        And most recently--in fact less than two weeks ago--the Department
    published a final rule that, among other things, broadens the
    definition of a fiduciary for investment planning purposes, a
    definition that has been in place and effective since the 1970s.
        West Virginians are concerned with the actions that your Department
    is taking. They are concerned with the politicization of their
    retirement savings, and they are horrified about potentially losing
    access to their investment advisors. West Virginians and Americans
    alike need protection, not uncertainty, when it comes to their long-
    term financial security, and they do not need the Federal government
    further involved in their retirement decisions.
        It is quite evident that there is bipartisan concern in Congress
    for the actions taken by your Department. Why did your team seek to
    enact monumental changes to the ERISA process via rulemaking rather
    than engaging with Congress and making changes through the legislative
    process?
        Answer. These recent rulemakings are well within the Department's
    regulatory authority. Each rule was preceded by a proposal that was
    published in the Federal Register with an invitation for public
    comment. The Department received and considered written comments and
    petitions (e.g., form letters) submitted during the open comment
    period. In each case, comments were received from a variety of
    interested parties, both in support of and in opposition to the
    proposal.
        The recent rulemakings also provide important protections for
    Americans' long-term financial security. The Retirement Security Rule:
    Definition of an Investment Advice Fiduciary rule will protect workers
    and retirees from conflicted investment advice that can erode their
    retirement savings. It was necessary to update the prior regulatory
    definition of an investment advice fiduciary which was adopted in 1975
    when the most common type of retirement plan was a defined benefit
    pension plan. These plans were primarily managed by professional money
    managers and funded by employers, who shouldered the risk of poor
    investment performance and shortfalls. Individual Retirement Accounts
    (IRAs) were not commonplace and 401(k)-type plans did not even exist.
    In the decades since, 401(k)-type plans and IRAs have become the most
    common way workers save for retirement. In these plans, individual
    retirement investors, rather than professional money managers,
    typically are responsible for making important investment decisions
    regarding their retirement savings, and they, rather than their
    employers or plan officials, shoulder the risk of loss. The 1975 rule
    had not kept up with these important changes in the marketplace.
        The final rule entitled Prudence and Loyalty in Selecting Plan
    Investments and Exercising Shareholder Rights adopted in November 2022
    (``Investment Duties Regulation'') reflects the core principle that the
    duties of prudence and loyalty require ERISA plan fiduciaries to focus
    on relevant risk-return factors and not subordinate the interests of
    participants and beneficiaries (such as by sacrificing investment
    returns or taking on additional investment risk) to objectives
    unrelated to the provision of benefits under the plan. We do not
    believe the Investment Duties Regulation reflected a monumental change
    to ERISA. However, it was an important rulemaking, as the previous rule
    was perceived by some as creating a ``chilling effect'' that would
    potentially discourage ERISA plan fiduciaries from considering risk-
    return ESG-factors that other investors in the marketplace would take
    into account. As stated in the 2022 rule, ``[t]he Department has a
    longstanding position that ERISA fiduciaries may not sacrifice
    investment returns or assume greater investment risks as a means of
    promoting collateral social policy goals.'' Under the final rule,
    fiduciaries may consider collateral benefits as a tiebreaker, but only
    when choosing between otherwise prudent competing investment options,
    which equally serve the financial interests of the plan.
        Question. Did your Department consider the impacts that these rules
    will have on rural and minority communities nationwide, who are much
    more susceptible to drastic changes to the retirement and financial
    landscape?
        Answer. For each rulemaking, the Department conducted the required
    regulatory impact analysis, including satisfying the requirements of
    Executive Orders 12866 (as amended by EO 14094) and 13563 that direct
    agencies to assess all costs and benefits of available regulatory
    alternatives.
        In the case of the Retirement Security Rule, the Department
    reviewed recent regulatory and legislative actions concerning
    investment advice, market developments in industries providing
    investment advice, and research literature weighing in on investment
    advice. From this review, the Department determined there was
    compelling evidence that retirement investors, including those with
    small account balances or of modest means and inexpert investors,
    remain vulnerable to harm from potentially imprudent advice and
    conflicts of interest in the investment advice they receive. The
    Department concluded that retirement investors would benefit from more
    uniform protections from conflicted advice that would ensure prudent
    and loyal investment recommendations from financial advisers regardless
    of the type of investment vehicle used. The Department further
    concluded that by requiring advisers to accurately represent the nature
    of their relationship and advice, retirement investment advice markets
    will work more efficiently and result in innovations and cost-efficient
    delivery models to provide prudent and loyal advice to small investors.
        In the case of the Investment Duties Regulation, the Department
    determined that the concerns with the prior regulation, if left
    unaddressed, would have a negative impact on plans' financial
    performance as they avoid using climate change and other ESG
    considerations in investment analysis even when directly relevant to
    the financial merits of the investment. The literature examined by the
    Department generally showed that the consideration of ESG factors can
    be beneficial to investing in many circumstances. Thus, Department
    anticipated that the benefits of the final rule would be significant.
        Question. The Department of Labor's Schedule A Shortage Occupation
    list was designed to address workforce shortages by streamlining the
    process of hiring vetted international workers in high demand
    industries, like Science, Technology, Engineering, and Math (STEM) and
    healthcare. Schedule A is an important tool that exempts workers in
    understaffed industries from bureaucratic visa hurdles and backlogs.
        Despite having the authority to revise the Schedule A list, the
    Department has not updated it to include more than two specific
    occupations--professional nurses and physical therapists--since 2005.
        While the Department has not updated the list in over 20 years, I
    was pleased to see the Request For Information (RFI) on how the
    Schedule A occupation list could be modernized to include STEM
    occupations for which there is a demonstrated labor shortage.
        Acting Secretary Su, what is the Department's timeline to provide
    an update on the Schedule A list?
        Answer. Consistent with President Biden's Executive Order on
    Artificial Intelligence, which directed the Secretary of Labor to ``to
    publish a RFI soliciting public input to identify AI and other STEM-
    related occupations, as well as additional occupations across the
    economy, for which there is an insufficient number of ready, willing,
    able, and qualified U.S. workers for purposes of updating Schedule A,''
    the Department of Labor published a Request for Information (RFI) on
    December 21, 2023.
        The Department's Office of Foreign Labor Certification (OFLC)
    developed the RFI and published it for comment so that the public could
    provide input, including data, statistical metrics or models, studies,
    and other relevant information, on how the Department may establish a
    reliable, objective, and transparent methodology for revising Schedule
    A to include Science, Technology, Engineering, and Math (STEM) and
    other non-STEM occupations that are experiencing labor shortages,
    consistent with requirements of the Immigration and Nationality Act.
        The comment period for the RFI closed on May 13, 2024. During the
    comment period, the Department received over 2,000 comments and is
    currently reviewing those comments to inform decisions regarding
    whether or how to improve Schedule A and ensure that its purpose in
    responding to national labor shortages is more effectively met. Once
    comment review has been completed during Fall 2024, the Department will
    consider how, and through which process, it may apply any data,
    statistical metrics, models, studies, or other information provided in
    the comments to develop a reliable, objective, and transparent
    methodology for amending Schedule A.
        Question. In January, the Department of Labor published a final
    rule on whether a worker may be considered an independent contractor,
    or an employee. The rule the Department previously put together on this
    was delayed, withdrawn, then ultimately reviewed and decided by the
    courts.
        Before issuing this rule, the Wage and Hour Division said it would
    hold two public forums to hear feedback directly from both employers
    and workers. However, the rule as written is largely similar to
    previous attempts, and does not appear as if the Department took
    different viewpoints into account.
        While I was glad to hear that the Department wanted to consult with
    both employers and workers on the rule, I am concerned about the degree
    their comments and opinions were taken to account when this rule was
    finalized.
        Acting Secretary Su, can you share how the Department incorporated
    feedback from a wide array of stakeholders, from small businesses to
    workers, in the final rule?
        Answer. In developing the Employee or Independent Contractor
    Classification Under the Fair Labor Standards Act final rule, WHD
    considered input provided by stakeholders prior to the development of
    its proposal and received approximately 55,400 comments during the
    public comment period that followed the proposal's issuance in October
    2022. The input and comments were provided by a diverse array of
    stakeholders, including employees, self-identified independent
    contractors, businesses, trade associations, labor unions, advocacy
    groups, law firms, members of Congress, state and local government
    officials, and other interested members of the public, and commenters
    expressed a wide variety of views on the merits of the Department's
    proposal. Several adjustments were made in the final rule after careful
    consideration of the comments received.
        For example, business stakeholders expressed concern about language
    in the proposed rule advising that control implemented by a business
    for the purpose of complying with legal obligations ``may be
    indicative'' of an employment relationship. 87 FR 62275. We heard from
    commenters that such guidance, if adopted as proposed, could be
    confusing or disruptive for businesses in highly regulated industries,
    such as real estate or financing, and could have negative unintended
    consequences in other industries, such as healthcare or transportation.
    89 FR 1691-92. Therefore, in the final rule, we revised the language to
    state that ``[a]ctions taken by the potential employer for the sole
    purpose of complying with a specific, applicable Federal, State,
    Tribal, or local law or regulation are not indicative of [an employment
    relationship].'' 89 FR 1743. (emphasis added)
        Question. Job Corps is an educational and workforce training
    program administered by the Department of Labor. The Job Corps program
    helps youth build the skills they need to succeed, complete their high
    school education and help students find employment after they leave.
    West Virginia is proud to be home to two Job Corps centers, one in
    Charleston and one in Harpers Ferry.
        Many Job Corps centers currently have openings, that would allow
    homeless youth to be able to receive housing, education and training
    for free. This important program has the capacity to serve our youth,
    and help prevent cycles of poverty and substance use disorder that many
    of our communities are facing.
        However, the application requirements can often be too burdensome
    for someone experiencing homelessness to be able to navigate.
        Acting Secretary Su, how is the Department working to expedite and
    streamline the enrollment of homeless youth into Job Corps?
        Answer. Ensuring unhoused youth and other underserved youth have
    expedited and streamlined Job Corps enrollment is an important
    Departmental priority. While the Job Corps program currently allows
    expedited enrollment for victims of natural or man-made disasters,
    consistent with eligibility requirements set forth in the Workforce
    Innovation and Opportunity Act (WIOA), the Office of Job Corps (OJC) is
    working to update its policy to allow for expedited enrollment for
    individuals experiencing homelessness and for victims of severe forms
    of trafficking. In addition, OJC has built relationships with
    colleagues in the Department of Health and Human Services' Family and
    Youth Services Bureau who administer the Runaway and Homeless Youth
    Program and in the Department of Education's McKinney-Vento program to
    encourage states and community-based providers to refer youth
    experiencing homelessness to Job Corps for enrollment.
                                     ______

                 Questions Submitted by Senator Lindsey Graham
        Question. Processing times for Labor Certifications and Prevailing
    Wage Determinations are currently 18-20+ months, which were previously
    6-8 months. Why does this delay hinder American businesses seeking to
    utilize legal employment-based visa pathways?
        Answer. The adjudication times in the Permanent Labor Certification
    (PERM) program have increased due to higher application filings across
    foreign labor certification programs, which stretch resources in each
    program, as well as statutory and regulatory processing deadlines in
    high-demand temporary labor certification programs, which at times
    require directing resources away from PERM. The Department's mandate is
    to review each employer's request for temporary or permanent labor
    certification to ensure U.S. workers have first access to apply for
    these job opportunities, protect U.S. workers from adverse effect on
    their wages and working conditions, ensure employer compliance with
    program requirements, and protect the integrity of the program from bad
    actors.
        As noted in its fiscal year (FY) 2025 Budget Request, the
    Department's Employment and Training Administration (ETA) has
    experienced a dramatic rise in application volumes in recent years,
    with application levels in most foreign labor certification (FLC)
    programs more than doubling since FY 2010 and new prevailing wage and
    labor certification requirements established for the CW-1 visa program.
    U.S. employers requested more than 1.7 million worker positions through
    the FLC programs in FY 2023. While application levels have doubled
    since FY 2010, inflation-adjusted funding for Federal FLC case
    adjudications decreased 13 percent over the same time period.
        The Department is building on its technology in the Foreign Labor
    Application Gateway (FLAG) System to modernize the application process
    for permanent, temporary, and prevailing wage applications, enhance
    program integrity, and assist analysts with their review of
    applications. To reduce the risk of delays associated with increasing
    application volumes, ETA cross-trains existing staff--which increases
    the number of trained personnel available to adjudicate applications
    across programs--and authorizes overtime to meet processing demands
    during peak filing periods.
        Question. What more can the agency do to prioritize the current,
    functional technology of attestation-based PERM Processing?
        Answer. Although ETA's Office of Foreign Labor Certification (OFLC)
    administers a fully electronic application filing and processing system
    that helps mitigate the risk of delays and avoid unnecessary
    administrative costs, the Department's mandate is to review each
    employer's request for temporary or permanent labor certification to
    ensure U.S. workers have first access to apply for these job
    opportunities, protect U.S. workers from adverse effect on their wages
    and working conditions, ensure employer compliance with program
    requirements, and protect the integrity of the program. The analysis
    necessary to meet these statutory mandates cannot be accomplished by a
    process that is completely attestation-based.
        As noted in the Department's FY 2025 Budget Request, while
    application levels have more than doubled since FY 2010, inflation-
    adjusted funding for Federal FLC case adjudications has decreased by 13
    percent over the same time period. Although using the latest
    technologies--as ETA has endeavored to do--has and will continue to
    create efficiencies in the administration of employment-based visa
    programs, the Department must strike a proper balance between
    consistent and reasonable processing times and ensuring employer
    compliance with program requirements.
        ETA, in collaboration with the Department's Office of the Chief
    Information Officer (OCIO), developed the Foreign Labor Application
    Gateway (FLAG). Applications for all FLC programs are now submitted
    electronically in FLAG; most recently, FLAG replaced the nearly 20-
    year-old legacy PERM case management system as the means by which ETA
    processes permanent labor certification applications. The Department
    agrees that use of the most up-to-date technologies can create
    efficiencies in processing and reduce unnecessary administrative costs.
    Indeed, as the replacement of the PERM processing system reflects, over
    the years ETA has continually enhanced its technology, as resources
    have allowed, to strategically improve its applications processing
    capacity. However, the significant annual increases in workload over
    the past decade, when combined with inadequate funding, have far
    outpaced ETA's capacity to process applications, even with these
    technological improvements. Additionally, a process to review employer-
    filed applications that is completely attestation-based would make it
    more difficult for the Department to monitor and enforce employer
    compliance with program requirements, protect the integrity of the
    program, and make the required statutory determinations regarding the
    availability of qualified U.S. workers for the employer's job
    opportunity and the lack of adverse effect on the wages and working
    conditions of similarly employed U.S. workers.
                                     ______

                Questions Submitted by Senator Cindy Hyde-Smith
        Question. I want to express my concern over the department's
    continued overreach in respect to regulations, which is par for the
    course when it comes to this administration. Many of my constituents
    tell me they're concerned about these overreaches. For instance, the
    proposed ``walk around'' rule that would allow a third-party entity to
    accompany Occupational Safety and Health Administration inspectors. A
    third-party entity could be from any organization, which leads to the
    potential for a conflict of interest and an inspector who would not be
    objective in their findings of whether a workplace is safe.
        Why does the department deem it necessary now to allow such
    activities during OSHA inspections when these inspections have happened
    time and time again without the need of a third party?
        Will you and your department commit to seriously reconsidering this
    rule and only allowing certified inspectors in businesses during these
    reviews?
        Answer. Congress, in Section 8(e) of the Occupational Safety and
    Health Act (``OSH Act''), granted both employers and employees the
    right to designate representatives to accompany inspectors during an
    OSHA inspection. OSHA has long recognized this right in its regulations
    and practices, which allow employers and employees to designate third
    parties as authorized walkaround representatives. See 89 Fed Reg.
    22558, 22559-60 (Apr. 1, 2024) (discussing 29 CFR 1903.8(c) and OSHA's
    guidance related to the regulation). However, in 2017, a district court
    found that although OSHA's longstanding practice was consistent with
    the OSH Act, with respect to employee representatives, it was not
    consistent with the OSHA regulation as then written implementing
    Section 8(e). See NFIB v. Dougherty, No. 3:16-CV- 2568-D, 2017 WL
    1194666 (N.D. Tex. Feb. 3, 2017). In response, OSHA revised its
    regulation to reflect its long-standing practice of who may be
    designated as an authorized employee representative. Additionally, as
    discussed in the preamble to the Walkaround rule, see 89 Fed. Reg. at
    22563-22572, OSHA determined, through the agency's own enforcement
    experience and based on numerous comments providing real-life examples,
    that third-party walkaround representatives will improve OSHA
    inspections and benefit employee safety and health.
        The notice of proposed rulemaking was published on August 30, 2023,
    and commenters had until November 13, 2023, to submit their comments.
    OSHA received 11,529 timely comments. These comments were both in favor
    of the rule and opposed to it, ranging from requests to withdraw the
    rule entirely to criticism that the rule does not go far enough to
    ensure that employees are able to select a representative of their
    choice for the walkaround inspection. OSHA considered all issues raised
    in these comments, such as the qualifications of compliance safety and
    health officers, and the scope of authorized third-party
    representatives, as detailed in the explanation of the final rule, see
    89 Fed. Reg. 22558 (Apr. 1, 2024). Ultimately, OSHA determined that the
    revised 1903.8(c) more clearly aligns with the language and purpose of
    section 8(e) of the OSH Act, 29 U.S.C. 657(e).
        Question. Another regulation that concerns me and my constituents
    is the recently-published overtime rule. This rule will ultimately
    require businesses to pay overtime wages to employees who earn less
    than $58,656. This is a one-size-fits-all approach that simply doesn't
    make sense for rural states where the cost of living is far lower.
    Additionally, this rule alters the executive, administrative, and
    professional exemption under the current law. Some businesses fear they
    may have to cut staff if changes are not made to this rule.
        Please walk us through the reasons for a nearly 65% increase in the
    minimum salary?
        Answer. The Fair Labor Standards Act (``FLSA'' or ``Act'')
    generally requires that covered employers pay employees at least the
    Federal minimum wage (currently $7.25 an hour) for all hours worked,
    and overtime pay of at least one and one-half times an employee's
    regular rate of pay for all hours worked over 40 in a workweek.
    However, section 13(a)(1) of the FLSA exempts bona fide executive,
    administrative, or professional (EAP) employees from both of these wage
    and hour protections. Pursuant to Congress' grant of rulemaking
    authority, since 1938 the Department has issued regulations (located at
    29 CFR part 541) which define and delimit the scope of the section
    13(a)(1) exemption.
        The Department's final rule, Defining and Delimiting the Exemptions
    for Executive, Administrative, Professional, Outside Sales, and
    Computer Employees, updates and revises the regulations issued under
    section 13(a)(1) of the FLSA implementing the exemption from minimum
    wage and overtime pay requirements for EAP employees. Specifically, the
    final rule increases certain earnings thresholds for the EAP exemption
    and establishes a mechanism that provides for the timely and efficient
    updating of these earnings thresholds to reflect current earnings data.
    Employees who earn below the new thresholds (or do not meet the other
    components of the tests for exemption), are entitled to the FLSA's
    minimum wage and overtime pay protections.
        On July 1, 2024, the standard salary level increased to $844 per
    week (the equivalent of an annual salary of $43,888), and on January 1,
    2025, it will increase to $1,128 per week ($58,656 per year). The July
    1st increase updated the existing salary threshold of $684 per week
    ($35,568 per year) based on the same methodology used during the prior
    administration to set the threshold in the 2019 overtime rule update--
    the 20th percentile of salaried earnings in the lowest-wage Census
    Region and/or in the retail industry nationally. The January 1, 2025
    increase applies the new methodology under the rule--the 35th
    percentile of weekly earnings of full-time salaried workers in the
    lowest-wage Census Region (currently the South). In addition, the rule
    will adjust the threshold for highly compensated employees. Starting
    July 1, 2027, salary thresholds will update every 3 years by applying
    up-to-date wage data to determine new salary levels.
        Question. Does the rule have exemptions for states that, on
    average, have a lower cost of living, and if not why is this not a
    consideration for states with lower cost of living?
        Answer. In the Defining and Delimiting the Exemptions for
    Executive, Administrative, Professional, Outside Sales, and Computer
    Employees final rule, the Department maintained a single standard
    salary level that applies to all employers nationwide. As the
    Department explained in the 2019 rule, ``[h]aving multiple salary
    levels would . . . introduce unnecessary complexity, particularly for
    employers and employees who operate or work across state lines.'' 84 FR
    51239; see 89 FR 32868 n.187. In the final rule, effective July 1,
    2024, the salary threshold increased to $844 per week (the equivalent
    of an annual salary of $43,888), based on the methodology used in the
    2019 overtime rule update. On January 1, 2025, the standard salary
    level will increase to $1,128 per week (the annual equivalent of
    $58,656), equal to the 35th percentile of weekly earnings of full-time
    salaried workers in the lowest-wage Census Region, which is currently
    the South.
                                     ______

                   Questions Submitted by Senator Katie Britt
        Question. I have a number of concerns about DOL's new independent
    contractor rule, which is designed to significantly curtail the ability
    of millions of Americans around the country to work as independent
    contractors rather than as employees.
        I worry that the ramifications of this rule will be similar to
    those of the disastrous California Assembly Bill 5 (AB5), which you
    championed and implemented during your time as secretary for the
    California Labor and Workforce Development Agency. In addition to the
    detrimental impacts this rule will have on the private sector, I'm also
    concerned about the impact the rule could have on labor costs for the
    Federal Government itself--costs that will ultimately be paid by the
    American taxpayer.
        The Federal Government often enters into agreements with individual
    independent contractors. As an example, in issuing this rule, DOL
    didn't even address its potential impact on Federal agencies like the
    U.S. Postal Service (USPS), which relies on almost 8,000 contracted
    delivery services to reach millions of its delivery points. Under this
    rule, potentially thousands of those contractors would have to be
    classified as employees of USPS--costing taxpayers hundreds of millions
    of dollars per year.
        In promulgating this rule, why did DOL fail to address this issue
    with respect to agencies like USPS or discuss potential increases in
    Federal employment costs?
        Answer. The Employee or Independent Contractor Classification Under
    the Fair Labor Standards Act final rule revises the Department's
    guidance on how to analyze who is an employee or independent contractor
    under the Federal Fair Labor Standards Act (FLSA). Specifically, the
    final rule rescinds the 2021 Independent Contractor Rule that was
    published on January 7, 2021, and replaces it with guidance for how to
    analyze the employee or independent contractor classification that
    aligns with the FLSA as consistently interpreted for decades by the
    Supreme Court and U.S. Courts of Appeals.
        Unlike AB5 in California, the Department's final rule does not
    adopt an ``ABC'' test, which permits an independent contractor
    relationship only if all three factors in a three-factor test are
    satisfied. The Department's final rule instead relies on the long-
    standing multifactor ``economic reality'' test used by courts to
    determine whether a worker is an employee or independent contractor
    under the FLSA. This test relies on the totality of the circumstances
    where no one factor is determinative.
        WHD considered input provided by stakeholders prior to the
    development of its proposal and received approximately 55,400 comments
    during the public comment period that followed the proposal's
    publication in October 2022. The input and comments were provided by a
    diverse array of stakeholders, including employees, self-identified
    independent contractors, businesses, trade associations, labor unions,
    advocacy groups, law firms, members of Congress, state and local
    government officials, and other interested members of the public.
    Commenters expressed a wide variety of views on the merits of the
    Department's proposal. Several changes were made in the final rule
    after careful consideration of the comments received, including
    comments from employers.
        As explained in the final rule, the Department does not expect
    widespread reclassification or job loss as a result of this rule
    because the Department is adopting guidance in this rule that is
    essentially identical to the standard it applied for decades prior to
    the 2021 IC Rule, and that is derived from the same analysis that
    courts have applied for decades and have been continuing to apply since
    the 2021 IC Rule was published. Workers who were properly classified as
    independent contractors before the 2021 IC Rule will likely continue to
    retain their status as independent contractors. Therefore, the
    Department does not expect that this rule will significantly impact
    Federal agencies.
        Question. How many other Federal agencies that rely on contracted
    services would be impacted by this rule?
        Answer. The Employee or Independent Contractor Classification Under
    the Fair Labor Standards Act final rule revises the Department's
    guidance on how to analyze who is an employee or independent contractor
    under the Federal FLSA. As explained in the final rule, the Department
    does not expect widespread reclassification or job loss as a result of
    this rule because the Department is adopting guidance in this rule that
    is essentially identical to the standard it applied for decades prior
    to the 2021 IC Rule, and that is derived from the same analysis that
    courts have applied for decades and have been continuing to apply since
    the 2021 IC Rule was published. Workers who were properly classified as
    independent contractors before the 2021 IC Rule will likely continue to
    retain their status as independent contractors. Therefore, the
    Department does not expect that this rule will significantly impact
    Federal agencies.
        Question. Does DOL have any estimates of what those increased
    Federal employment costs might be?
        Answer. The Department does not expect that the new rule, Employee
    or Independent Contractor Classification Under the Fair Labor Standards
    Act, will result in increased labor costs for the Federal government.
    As explained in the regulatory impact analysis included in the final
    rule, the Department does not expect that a significant number of
    independent contractors will be reclassified into FLSA-covered
    employees as a result of this rule because the Department is adopting
    guidance in this rule that is essentially identical to the standard it
    applied for decades prior to the 2021 IC Rule, and that is derived from
    the same analysis that courts have applied for decades and have been
    continuing to apply since the 2021 IC Rule was published.
        Question. The 2024 fiduciary rule attempts to regulate sales of
    annuities to retirement investors, which are already regulated by the
    states. The Department of Labor claims its fiduciary proposal is
    necessary to fill loopholes and gaps.
        Is there evidence that gaps and loopholes exist in the NAIC model
    regulation and that those gaps are being exploited to harm consumers?
        Answer. The Department's final Retirement Security Rule, which
    covers compensated retirement recommendations under conditions when it
    is reasonable to place trust and confidence in the advice, falls well
    within the Employee Retirement Income Security Act of 1974's (ERISA)
    broad fiduciary definition, even if it is more protective of federally-
    protected retirement investments than State insurance regulations. The
    U.S. Supreme Court has made it clear that ``the McCarran-Ferguson Act
    does not surrender regulation [of insurance products] exclusively to
    the States so as to preclude the application of ERISA to an insurer's
    actions . . . . . . . .'' John Hancock Mut. Life Ins. Co. v. Harris
    Trust & Sav. Bank, 510 U.S. 86, 98 (1993).
        The Regulatory Impact Analysis for the Retirement Security Rule
    notes that the market for fixed annuities is very large, with sales
    estimated at $286 billion in 2023. Commenters on the Department's
    proposed rule discussed significant conflicts of interest associated
    with large commissions on annuity sales, as well as abusive sales
    practices. Conflicted, imprudent, and disloyal advice with respect to
    such annuity sales can result in large investor losses.
        The Retirement Security Rule further provides a discussion of
    research that demonstrates the low levels of financial literacy of many
    advice recipients. Given the complexity of some annuity products, it is
    very easy for investors to purchase products that have very different
    risks and benefits than they thought they were purchasing, and that
    have considerably more downside than they expected. For all these
    reasons, one type of annuity--fixed indexed annuities--has been the
    subject of various regulatory alerts, warning investors of the dangers
    associated with the products. See, e.g., Securities and Exchange
    Commission Office of Investor Education and Advocacy Updated Investor
    Bulletin: Indexed Annuities (July 31, 2020) and Iowa Insurance
    Division, Bulletin 14-02 (September 15, 2014).
        The NAIC Model Regulation, updated in 2020, includes a gap under
    which it does not apply at all to transactions involving contracts used
    to fund an employee pension or welfare plan covered by ERISA. It also
    is not as protective as the Department's Retirement Security Rule and
    related prohibited transaction exemptions. The NAIC model's specific
    care, disclosure, conflict of interest, and documentation requirements
    do not expressly incorporate the ``best interest'' obligation not to
    put the producer's or insurer's interests before the customer's
    interests, even though compliance with these component obligations is
    treated as meeting the best interest standard. Instead, the core
    conduct standard of care includes a requirement to ``have a reasonable
    basis to believe the recommended option effectively addresses the
    consumer's financial situation, insurance needs, and financial
    objectives.'' Additionally, the obligation to comply with the ``best
    interest'' standard is limited to the individual producer, as opposed
    to the insurer responsible for supervising the producer.
        The Model Regulation's definition of ``material conflicts of
    interest'' that must be identified and avoided or reasonably managed
    and disclosed also excludes all ``cash compensation'' and ``non-cash
    compensation.'' As a result, the NAIC Model Regulation excludes ``any
    discount, concession, fee, service fee, commission, sales charge, loan,
    override, or cash benefit received by a producer in connection with the
    recommendation or sale of an annuity from an insurer, intermediary, or
    directly from the consumer,'' as well as ``any form of compensation
    that is not cash compensation'' despite their obvious potential to
    drive recommendations that favor the financial professional's own
    financial interests at the expense of the investor's interests.
                                     ______

                   Questions Submitted by Senator Marco Rubio
        Question. I drafted report language that was included in the FY24
    appropriations legislation on the disclosure of apprenticeship data,
    engagement between the Departments of Labor and Education to address
    mismatches between worker skills and employer needs, and the steps that
    the Labor Department has taken or plans to take to study numerous
    issues in the labor market.
        Will you commit to comply with the report language's requirement
    that the department disclose apprenticeship data within 180 days?
        Answer. The Department is aware that Senate Report 118-84, which
    accompanied the Further Consolidated Appropriations Act, 2024, Public
    Law 118-47, directs the disclosure of apprenticeship data within 180
    days of the March 23, 2024, enactment of the Act, and is working to
    ensure compliance with this requirement. The Department is committed to
    and anticipates being able to meet the deadline.
        Question. Will you commit to complete the other two reporting
    requirements within 365 days after the legislation's enactment?
        Answer. Senate Report 118-84 also requested that the Department
    report to the Senate Committee on Appropriations on the extent to which
    it is engaging with the Department of Education to address mismatches
    between worker skills or their participation in the labor force and
    employer needs and the steps the Department has taken or plans to take
    to study the drivers of skills mismatches, workforce shortages,
    productivity fluctuations, turnover fluctuations, stagnant wages, and
    poor working conditions across occupations, industries, and the economy
    as a whole. In addition, Senate Report 118-84 requested that the
    Department assess the feasibility of supporting a pay-for-success
    initiative to increase and expand registered apprenticeships. The
    Department is aware of these requirements and is working to comply with
    them within the requested deadline.
        Question. Will you commit to update my office on the department's
    progress on all three requirements?
        Answer. Yes.
        Question. As some scholars have noted, we have a ``depression-
    level'' crisis of non-work on hand. Nearly one in seven working-age men
    (age 25-54) is neither working nor looking for work. Depression levels
    of non-work for American men are leading to social breakdown all around
    us. In June 2016, the Obama Administration released a report titled
    ``The Long-Term Decline in Prime-Age Male Labor Force Participation.''
        Are you concerned about this depression-level crisis of non-work?
        Answer. The Department of Labor closely follows data on workers and
    working age adults, including data on prime age men's labor force
    participation. The Department analyzes detailed data on civilian
    noninstitutional prime age men's and women's labor force participation
    rate (LFPR) following each month's data release from the Bureau of
    Labor Statistics to monitor and evaluate changes over time. As
    discussed below, prime age men's labor force participation has fully
    recovered from pandemic-related declines, but the Department recognizes
    that this progress has not reversed longstanding declines in LFPR.
        Data from the Bureau of Labor Statistics on labor force
    participation among men ages 25 to 54--otherwise known as ``prime age''
    working men--begins in 1948.\6\ Prime age men's LFPR, as measured on an
    annual basis, hit a series high of 97.4 percent twice: \7\ once in 1953
    and again in 1955.\8\ The rate has generally been declining ever since;
    for example, between 1955 and 1977 prime age men's LFPR fell or
    remained static every year, with a total cumulative decline of 3.2
    percentage points. The largest declines have occurred during
    recessionary periods and since 1970 the rate typically has not fully
    rebounded during subsequent economic recoveries (see Chart 1).
    ---------------------------------------------------------------------------
        \6\ U.S. Bureau of Labor Statistics, Current Population Survey,
    (Washington DC: U.S. Bureau of Labor Statistics).
        \7\ The series high for seasonally adjusted monthly data was 97.9%
    in September 1954. --, Current Population Survey, Series IDs:
    LNS11300061, January 1948-May 2024, Raw Data.
        \8\ --, Current Population Survey, Series ID: LNU01300061, January
    1948-May 2024, Raw Data.
    ---------------------------------------------------------------------------
        The lowest recorded labor force participation rate for prime age
    men--whether measured annually or on a seasonally adjusted monthly
    basis--occurred in 2020. In April 2020 prime age men's LFPR hit a
    series low of 86.3 percent,\9\ the point at which it would be most
    accurate to say that ``nearly one in seven working-age men (age 25-54)
    is neither working nor looking for work.'' However, prime age men's
    LFPR increased by 0.9 percentage point the following month and measured
    87.9 percent on an annualized basis in 2020.\10\ Prime age men's LFPR
    has since remained significantly above the April 2020 low (see Chart
    2).
    ---------------------------------------------------------------------------
        \9\  --, Current Population Survey, Series IDs: LNS11300061,
    January 1948-May 2024, Raw Data.
        \10\  -- Current Population Survey, Series ID: LNU01300061;
    LNS11300061, January-December 2020, Raw Data.
    ---------------------------------------------------------------------------
        In 2023 the annual labor force participation rate for prime age men
    was 89.1 percent, which translates to nearly 1 in 9 prime age men not
    working or looking for work and is the same rate as 2019.\11\ This is
    the highest annual prime age men's LFPR since 2010 and is more than 1
    percentage point higher than would be predicted based on historical
    trends (see Chart 3). As measured on a seasonally adjusted monthly
    basis, prime age men's LFPR has averaged 89.2 percent thus far in 2024.
    ---------------------------------------------------------------------------
        \11\ --, Current Population Survey, Series ID: LNU01300061, January
    2010-May 2024, Raw Data.
    ---------------------------------------------------------------------------
        Question. Is the department or the administration continuing the
    investigation into the long-term decline in prime-age male labor force
    participation? If not, why?
        Answer. Yes, the Department of Labor is continuing to research
    changes in prime age labor force participation rates for men.
        Question. What do you think are the drivers of this decline?
        Answer. Our data analysis is ongoing, and full results are not yet
    available. We hope to publish findings before the end of the year.
        Question. What is the department doing to reverse this decline in
    prime-age male labor force participation?
        Answer. Over the last 3 years, prime age men's labor force
    participation has steadily increased as the economy recovered from the
    effects of the pandemic-induced recession (see Chart 2). As of May
    2024, prime age men's LFPR has increased by 2.9 percentage points
    relative to the series low in April 2020 (86.3 percent) and is at the
    same rate as in February 2020 (89.2 percent).\12\ This is in stark
    contrast to the effects of the Great Recession (December 2007 to June
    2009), when prime age men's LPFR continued to decline well after the
    recession ended (see Chart 1).
    ---------------------------------------------------------------------------
        \12\ -- Current Population Survey, Series ID: LNS11300061, February
    2020-December 2020, Raw Data (Washington DC: U.S. Bureau of Labor
    Statistics).
    ---------------------------------------------------------------------------
        Prior research suggests that this positive trend among prime age
    men is likely tied to the overall strength of the recovery. While
    economists continue to debate the degree of cyclicality--in other
    words, what portion of change in LFPR is attributable to changes in the
    business cycle compared to structural changes--there is a well-
    documented relationship between labor market conditions and labor force
    participation.\13\ For example, there are strong correlations between
    prime age men's LFPR and wages at the bottom of the wage distribution
    and demand in traditionally male sectors like construction.\14\
    ---------------------------------------------------------------------------
        \13\ Cajner, Tomaz , John Coglianese, and Joshua Montes. ``The
    Long-Lived Cyclicality of the Labor Force Participation Rate.'' Board
    of Governors of the Federal Reserve System. (2021).
        \14\ ``The Long-Term Decline in Prime-Age Male Labor Force
    Participation.'' The White House. (June 2016).
    ---------------------------------------------------------------------------
        The Department of Labor continues to work alongside our sister
    agencies across the Federal government to ensure that the historic
    investments currently being made in infrastructure and clean energy
    lead to high quality jobs that pay family-sustaining wages. The
    Department does not claim credit for all of the positive gains made
    across the economy, and it is not possible to fully capture all the
    direct and spillover effects of our ongoing work. But we can measure
    total private constant dollar (inflation-adjusted) average hourly
    earnings, which remain higher than pre-pandemic, with the largest gains
    among production and non-supervisory employees.\15\ And employment in
    the construction industry continues to set new records, with 8.2
    million jobs in May 2024, seasonally adjusted, including more than 7
    million men.\16\
    ---------------------------------------------------------------------------
        \15\ U.S. Bureau of Labor Statistics, Current Employment Statistics
    survey, Survey IDs: CES0500000013; CES0500000032, January 2020-May
    2024, Raw Data.
        \16\ --, Current Employment Statistics survey, Survey IDs:
    CES2000000001; CES2000000010, January 1939-May 2024, Raw Data.
    ---------------------------------------------------------------------------
        Economists have also linked declining prime age men's LFPR to
    declining demand and wages for workers without a college degree, the
    increase in opioid-related substance use disorders, and the rising
    share of men who have previously been incarcerated or otherwise
    involved with the criminal justice system.\17\ The Good Jobs
    Initiative, led by the Department of Labor, is focused on providing
    critical information to workers, employers, and government as they work
    to improve job quality and create access to good jobs free from
    discrimination and harassment for all working people. This work
    incorporates an emphasis on underserved communities, which includes
    those without a college degree, people with or recovering from a
    substance use disorder, and justice-involved individuals.
    ---------------------------------------------------------------------------
        \17\ Tuzeman, Didem, and Thao Tran. ``The uneven recovery in Prime-
    Age labor force participation.'' Federal Reserve Bank of Kansas City,
    Economic Review 104.3 (2019): 21-42; Aliprantis, Dionissi, Kyle Fee,
    and Mark E. Schweitzer. ``Opioids and the labor market.'' Labour
    Economics 85 (2023): 102446; Abraham, Katharine G., and Melissa S.
    Kearney. ``Explaining the decline in the US employment-to-population
    ratio: A review of the evidence.'' Journal of Economic Literature 58.3
    (2020): 585-643.
    ---------------------------------------------------------------------------
        The Department of Labor is proud to support all workers, job
    seekers, and retirees, including prime age men. The examples briefly
    outlined above should in no way be considered an exhaustive cataloging
    of our efforts. And because there is a connection between labor market
    activity, wages and working conditions and prime age men's labor force
    participation, all the efforts of the Department to advance
    opportunities and ensure worker health and safety can directly and
    indirectly contribute towards increasing LFPR.

    Chart sources: U.S. Bureau of Labor Statistics, Current Population
    Survey, Series ID: LNS11300061, LNU01300061, Raw Data.

        Question. Employee ownership improves productivity, builds more
    wealth for workers, and can make businesses more resilient during
    economic downturns, among other benefits. However, employee-owned
    businesses remain a minority in our economy, so there is much to do to
    encourage employee ownership, close workers' capital gap, and help
    workers navigate the process.
        Do you agree with Employee Stock Ownership Plans' (ESOP) ability to
    improve productivity, build more wealth for workers, and make
    businesses more resilient?
        Answer. Worker ownership arrangements, including ESOPs, can help
    create pathways for employees to earn a fair share of the profits that
    their labor makes possible and can play a critical role in the Biden-
    Harris administration's fight to give workers a voice on the job and a
    seat at the table. These types of arrangements can also help balance
    the distribution of power in America's workplaces and empower the
    workers who fuel their employers' ability to be successful day in, day
    out, while demonstrating to employers how worker ownership can be good
    for business, Through our administration of ERISA, we seek to ensure
    that these workers' benefits, when offered through an ESOP, which is an
    ERISA retirement benefit plan, are protected. The Department has
    created the Division of Employee Ownership within the Employee Benefits
    Administration's (EBSA) Office of Outreach, Education and Assistance,
    to explore further the role that worker ownership models, including
    ESOPs, can play to further these shared goals.
        Question. The Labor Department is required by the WORK Act to set
    up the Employee Ownership Initiative to promote employee ownership.
    Please describe the current state of your implementation and outreach.
        Answer. Section 346 of the SECURE 2.0 Act directed the Secretary of
    Labor to establish an Employee Ownership Initiative to promote employee
    ownership and worker democracy. Since the passage of the WORK Act
    (Worker Ownership, Readiness, and Knowledge Act), EBSA has engaged a
    variety of stakeholders to open lines of communication and determine
    how best to promote worker ownership, voice, and democracy. In 2023,
    the Department created the Division of Employee Ownership within EBSA's
    Office of Outreach, Education, and Assistance to implement and
    coordinate the Department's new responsibilities. In fiscal year (FY)
    2024, EBSA continued stakeholder engagement to determine community
    needs regarding outreach and education events and materials; recruited
    for the position of Chief, Division of Employee Ownership; and is in
    the process of developing a webpage on this topic. In FY 2025, EBSA
    will develop materials and expand its website to promote worker
    ownership. EBSA's efforts will provide education and training generally
    about different worker ownership options; educate and assist employee
    efforts to become business owners or otherwise participate in worker
    ownership models; encourage employers and employees to explore and
    assess the feasibility of transferring full or partial ownership to
    employees; and promote the possibility of starting new employee-owned
    businesses.
        Question. What could the department do to improve its outreach, and
    how could it better partner with SBA entrepreneurial development
    programs?
        Answer. Section 346 of the SECURE 2.0 Act directed the Secretary of
    Labor to establish an Employee Ownership Initiative to promote employee
    ownership and worker democracy. Since the passage of the WORK Act
    (Worker Ownership, Readiness, and Knowledge Act), EBSA engaged a
    variety of stakeholders to open lines of communication and determine
    how best to promote worker ownership, voice, and democracy. In 2023,
    the Department created the Division of Employee Ownership within EBSA's
    Office of Outreach, Education, and Assistance to implement and
    coordinate the Department's new responsibilities. In FY 2024, EBSA
    continued stakeholder engagement to determine community needs regarding
    outreach and education events and materials; recruited for position of
    Chief, Division of Employee Ownership; and is in the process of
    developing a webpage on the topic.
        In FY 2025, EBSA will develop educational materials based on
    stakeholder input and expand its website to promote worker ownership.
    EBSA will leverage its existing relationship with the Small Business
    Administration to identify opportunities to expand to their
    entrepreneurial development programs, such as the Small Business
    Development Centers, Women's Business Centers, the CareerOneStop
    Business Centers, and the Veterans Business Operations Center. EBSA's
    efforts will provide education and training generally about different
    worker ownership options; educate and assist employee efforts to become
    business owners or otherwise participate in worker ownership models;
    encourage employers and employees to explore and assess the feasibility
    of transferring full or partial ownership to employees; and promote the
    possibility of starting new employee-owned businesses.
        Question. When do you expect that the department will issue a
    proposed rule on the ``adequate consideration'' under Section 408(e) of
    the Employee Retirement Income Security Act of 1974?
        Answer. Departmental staff currently is developing a proposed rule
    on ``adequate consideration'' that will be published in the Federal
    Register for public comment. In an effort to develop a proposal that is
    responsive to the need for guidance, staff began meetings with ESOP
    stakeholders (including ESOP sponsors, appraisers, and plan service
    providers) in Fall 2023 to learn about issues they believe the
    Department's rule should address. Staff is continuing to meet with
    stakeholders as it makes progress in drafting the proposal. The
    Department also will consult with the Secretary of the Treasury as part
    of the rulemaking process.

                              SUBCOMMITTEE RECESS

        Senator Baldwin. And now the subcommittee will stand in
    recess.
        [Whereupon, at 11:35 a.m., Thursday, May 9, the
    subcommittee was recessed, to reconvene subject to the call of
    the Chair.]

      DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
              RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2025

                                  ----------

                             THURSDAY, MAY 23, 2024

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10 a.m., in room SD-124, Dirksen
    Senate Office Building, Hon. Tammy Baldwin (chairwomen)
    presiding.
        Present: Senators Baldwin, Murray, Durbin, Reed, Shaheen,
    Schatz, Capito, Moran, Kennedy, Hyde-Smith, Boozman, Britt and
    Collins.

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    STATEMENT OF DR. MONICA M. BERTAGNOLLI, M.D., DIRECTOR
    ACCOMPANIED BY:
            DR. W. KIMRYN RATHMELL, M.D., PH.D., M.M.H.C., DIRECTOR,
                NATIONAL CANCER INSTITUTE
            DR. JEANNE MARRAZZO, M.D., M.P.H., DIRECTOR, NATIONAL INSTITUTE
                OF ALLERGY AND INFECTIOUS DISEASES
            DR. NORA D. VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE ON DRUG
                ABUSE
            DR. RICHARD J. HODES, M.D., DIRECTOR, NATIONAL INSTITUTE ON
                AGING
            DR. GARY H. GIBBONS, M.D., DIRECTOR, NATIONAL HEART, LUNG, AND
                BLOOD INSTITUTE

                   OPENING STATEMENT OF SENATOR TAMMY BALDWIN

        Senator Baldwin. The Senate Appropriations Subcommittee on
    Labor, Health and Human Services, Education, and Related
    Agencies will please come to order. Good morning. Today is our
    fourth hearing on the Biden Administration's fiscal year 2025
    budget request. And I'm happy to welcome Dr. Bertagnolli to
    testify for the first time in front of this committee as the
    Director of the National Institutes for Health.
        As the granddaughter of an NIH-funded scientist myself, I
    understand what an important role biomedical research plays in
    treating and curing disease, bolstering our economic growth,
    and ensuring America is a global leader in innovation. I know
    my colleagues here today agree.
        I'm looking forward to working in a bipartisan manner again
    this year to develop a Labor HHS (Health and Human Services)
    bill that can pass the Senate, pass the House, and be signed
    into law by the President. That should be a bill that invests
    in NIH (National Institutes of Health) and the promise of
    finding lifesaving cures and treatments for deadly diseases.
        But I want to be clear, our ability to do that depends upon
    agreeing to adequate top line discretionary funding levels.
    Because of House Republicans insistence on cutting funding for
    domestic programs, last year's Labor HHS allocation was more
    than $2 billion less than in fiscal year 2023, the first such
    decrease in more than a decade.
        Even under those constraints, I was proud that we were able
    to fight back cuts to secure a $300 million increase for NIH in
    fiscal year 2024. But we should do better. Just like last year,
    more than a decade ago, Republicans insisted on cutting
    discretionary funding as the price of raising the debt limit.
        As a result, back in fiscal year 2011, through fiscal year
    2015, funding for the Labor HHS bill actually decreased in
    nominal terms. And as a result, NIH funding also decreased over
    that same period. Starting in fiscal year 2016, Congress
    finally decided overly restricted discretionary caps were
    stifling critical investments, including on NIH.
        So, Congress began modestly increasing domestic spending as
    a result. From 2016 to fiscal year 2023, funding for Labor HHS
    increased on average by $7.7 billion annually, a modest 3.3
    percent per year. But that allowed this subcommittee to
    increase funding for NIH on average by $2.3 billion annually
    over the same period of time.
        Unfortunately, Republicans are now, again, insisting on
    cutting funding for domestic programs, including in Labor HHS,
    and that's putting consistent meaningful increases for NIH in
    peril. I'm deeply concerned that that will put us on a path of
    stagnating funding for NIH, just like what happened last time,
    as I described. Almost every Senator here today will say that
    they strongly support NIH funding. That's easy. But if that's
    the case, as we have seen over the last decade, we need a
    workable top line that allows for a workable Labor HHS
    allocation. And I hope we can return to the bipartisan
    consensus of just a few years ago and agree to adequate funding
    for Labor HHS that allows meaningful, consistent increases for
    NIH.
        Alternatively, agreeing to the draconian cuts proposed by
    our House Republican colleagues, on the other side of the
    Capitol, it would be devastating for biomedical research. It
    would set back years of progress made towards curing disease
    and weaken America's competitiveness, particularly against
    China. And we just can't let that happen.
        So, today, I am happy to welcome Director Bertagnolli and
    her colleagues to our subcommittee, to discuss the budget
    request for NIH. Director Bertagnolli, this budget highlights
    the need for continued investments along a wide range of
    bipartisan priorities that speaks to the breadth of research
    that you oversee as director of the NIH.
        I'm pleased to see the support for biomedical research and
    innovation to develop better diagnostics, to improve treatment
    and precision care for patients, including targeted investments
    for research on women's health and in support of the goal to
    cut the cancer death rate by at least 50 percent over the next
    25 years.
        And at a time when we are seeing the spread of H5N1 bird
    flu across cattle herds and the detection of another human
    infection yesterday, it highlights the urgency of NIH work.
        I'm interested to hear from Dr. Marrazzo about the
    important work NIAID (National Institute of Allergy and
    Infectious Diseases) is funding to detect and monitor this
    virus so that we can limit its spread. The fiscal year 2025
    budget request, includes $49.8 billion in total resources for
    NIH, including ARPA-H (Advanced Research Projects Agency for
    Health) and Mandatory Cures Act funding, an increase of $1.25
    billion over fiscal year 2024.
        I want to point out, however, that most of this increase is
    to backfill Decreased Cures Act funding that falls under this
    jurisdiction of the HELP Committee. Declining Cures Act
    funding, combined with very difficult discretionary spending
    caps created a uniquely challenging situation for fiscal year
    2024 and will again in fiscal year 2025.
        Outside of those increases in discretionary spending for
    Cures Act programs, which I'm happy to see maintained, I'm
    pleased to see increases for cancer research, mental health
    research and neuroscience research. And during a time when
    women's health and reproductive rights are under attack in this
    country, I was pleased to see the budget proposes a $76 million
    increase for the Office of Research on Women's Health.
        But I was surprised to see that the budget does not call
    for any new resources for Alzheimer's disease research. I want
    to hear more about that and what impact that will have on the
    progress we have made in Alzheimer's disease research from Dr.
    Hodes.
        And I want to hear about how NIH is working to address our
    Nation's mental health and substance use disorder crises.
    Tragically, overdose deaths remain stubbornly high. In 2022,
    nearly 108,000 people died of an overdose in my State. There
    were 1,828 drug overdose deaths in 2022 surpassing the records
    set in 2021 of those deaths, 1,464 involved opioids. I'd like
    to hear from Dr. Volkow about how NIDA (National Institute on
    Drug Abuse) and NIMH (National Institute of Mental Health) are
    working together to bring an end to this crisis.
        I also want to hear about how NIH is investing in the next
    generation of researchers, particularly in light of new data
    that reveal a decline in the number of U.S. postdoctoral
    scholars at NIH, over the last 2 years. I want to know how you
    are supporting early-stage investigators, particularly women
    and those from diverse backgrounds.
        And finally, I want to hear about NIH's ongoing research on
    Long COVID.
        [Applause.]
        Senator Baldwin. It's been more than 3 years since Congress
    appropriated $1.2 billion for Long COVID research. And NIH has
    moved slowly to enroll patients and has yet to deliver
    treatments for this debilitating disease. Dr. Gibbons, I want
    to know how you plan to leverage the RECOVER Initiative to be
    more efficient and effective to finally move the needle for
    millions of Americans who continue to suffer.
        I look forward to your testimony and appreciate all of you
    being here today. And in a moment, I'll turn it over to Ranking
    Member Capito for her opening remarks. Following Senator
    Capito's opening statement, we will hear from Director
    Bertagnolli, and after that, Senators will each have 5 minutes
    for a round of questions. Senator Capito, Thank you.

                   STATEMENT OF SENATOR SHELLEY MOORE CAPITO

        Senator Capito. Well, Thank you, Chair Baldwin. Thank all
    of you for being here. And Dr. Bertagnolli, it's good to see
    you. Thank you for being here today, but also congratulations
    on your fairly new role as NIH Director.
        I also want to thank you, as you know, for coming to West
    Virginia in March, to see firsthand all of the amazing things
    that we are doing at West Virginia University, including seeing
    the work that Dr. Rezai and his team are doing to combat
    Alzheimer's disease and addiction.
        As you witnessed, my home State of West Virginia is a rural
    State, where we have some of the highest rates of health
    challenges in the country, a partnership with NIH is critical
    for us to make improvements. Dr. Volkow, who has also visited
    West Virginia and Dr. Hodes, who says he's coming, we just got
    to get the date right. Dr. Rathmell and Dr. Marrazzo, it's
    wonderful, and Dr. Gibbons, thank you for being here today to
    discuss the many important health issues facing our Nation.
    Many of you, as I said, have visited or will visit, and I'm
    very grateful for that.
        This will be a challenging funding year as Chair Baldwin
    aligned that out. But for me, biomedical research at NIH is a
    priority for me and has been for these long bicameral
    bipartisan priorities as well.
        The budget proposes $49.8 billion in funding for NIH,
    including 21st Century Cures and ARPA-H. The budget also
    proposes an additional $1.5 billion in mandatory funding for
    the Cancer Moonshot. Last year, I was proud we were at least
    able to get an increase of $300 million in very tough headwinds
    in discretionary spending for NIH. NIH is not just great
    biomedical research institution, it's also a driver of economic
    growth, funding more than $92.89 billion in national economic
    activity across the Nation in 2023.
        My small State of West Virginia, NIH supports 759 jobs and
    $148 million in economic impact in 2023 alone. And this is in a
    State that we really don't see too--many don't see us as one of
    the areas for medical innovation, but we are proving the Nation
    wrong every day.
        The NIH impacts every American in some way, and I hope to,
    again, work in a bipartisan way to fund our joint priorities,
    such as finding cures and treatments for cancer, Parkinson's,
    ALS (Amyotrophic Lateral Sclerosis), Alzheimer's disease, and
    many other conditions that plague Americans.
        As I mentioned, Dr. Bertagnolli, I'll get it there--with a
    name like Capito that gets for mispronounced as Capto, half the
    time, you'd think I would be better at this. I'm trying. She
    joined me at WVU (West Virginia University) and witnessed the
    innovative research, talented researches, advancements that we
    are doing in West Virginia.
        Much of this has been made possible by the partnerships
    that have been fostered by NIH over the years. Researchers
    throughout our State are making significant contributions to
    biomedical research, in areas ranging from cancer to
    Alzheimer's disease, to substance use disorders.
        Unfortunately, West Virginia continues to rank above the
    national average, both in new cancer diagnoses and deaths. So,
    I'm pleased that the budget devotes increases to finding cures
    and treatments for cancer. As a lead sponsor of the Childhood
    Cancer STAR Act, I look forward to hearing about your
    priorities and advancements to combat cancer and grow our
    clinical trial networks, especially among our children.
        I will continue to prioritize fostering NIH collaboration
    with smaller and more rural States. Last year, we were able to
    provide a modest increase for the NIH IDeA (Institutional
    Development Award) Program. This program provides funding to 23
    States, including mine, that historically received very little
    Federal research funding.
        And I'm proud of the friendship and partnership with Dr.
    John--at NIH for his leadership. The IDeA Program and the other
    NIH funding has been instrumental for Marshall University, WVU
    and other institutions in the State, developing world class
    research in neuroscience, cancer, stroke, vision, and addiction
    science.
        Dr. Bertagnolli was able to hear about West Virginia
    Clinical and Translational Science Institutes new mobile unit,
    named Maverick, purchased thanks to an NIH grant. Dr. Sally
    Hodder and her team, will use this mobile unit to give
    individuals all over the State, we know access is the issue in
    rural States, the ability to participate in clinical trials for
    new treatments, and as a prime example of how NIH investments
    can directly affect people. I do want to take a moment and the
    Chair and I are on like-minded here, to express my
    disappointment that the proposed NIH budget does not devote new
    resources specifically for Alzheimer's disease research at NIH.
        I have personally seen close hand through both of my
    parents the devastating effects that Alzheimer's can have on
    the family, the patient, and the caregivers. Nearly 7 million
    Americans are currently living with Alzheimer's in our country.
    And the national cost of caring for those with Alzheimer's and
    other dementia is estimated to reach $360 billion this year,
    that's staggering. Alzheimer's and dementia related research
    must remain a national priority.
        I'd also like to see more attention devoted to substance
    abuse. The National Institute on Drug Abuse receives only a
    nominal increase in this budget. Dr. Volkow has visited my
    State, as I mentioned, and she's seen firsthand how West
    Virginia's in the crosshairs, and as we know, every State is in
    the crosshairs of opioid and addiction crisis.
        I would like to add my voice in agreement with the Chair on
    the recovery program for those with Long COVID. And I know we
    have many in the audience today.
        [Applause.]
        Senator Capito. I know we're dealing with a tough funding
    situation this year, but investments in biomedical research are
    so important for the future of our country.
        Before I close, I would like to address Dr. Bertagnolli
    again on something that we learned last week. I want to comment
    on something that is concerning. For years, the NIH has
    leadership has taken the stance that NIH funded Gain-of-
    Function research was not happening with EcoHealth Alliance or
    the Wuhan Institute of Virology in China.
        This appears to be false based on Dr. Tabak's response to a
    house committee last week, when asked if NIH funded Gain-of-
    Function Research at Wuhan, Dr. Tabak answered, ``If you're
    speaking about the generic term, yes, we did''.
        Last year, HHS debarred the Wuhan Institute from receiving
    Federal grants for 10 years and just last week suspended all
    funding for EcoHealth Alliance and plans to debar them too. I
    think both of those should have probably been done much sooner.
        The NIH has a credibility problem here when it comes to
    Gain-of-Function research, and I strongly encourage you and Dr.
    Marrazzo in your new roles, to restore strength and research
    integrity and trust to the NIH in this area. Thank you very
    much. Look forward to your testimony.
        Senator Baldwin. Thank you, Senator Capito.
        And I will now introduce our witnesses. We have Dr. Monica
    Bertagnolli. She is the Director of the National Institutes of
    Health. We have Dr. Gary Gibbons. He is the Director of the
    National Heart Lung and Blood Institute. Dr. Richard Hodes is
    the Director of the National Institute on Aging. Dr. Jeanne
    Marrazzo is the Director of the National Institute of Allergy
    and Infectious Diseases. Dr. W. Kimryn Rathmell, is the
    Director of the National Cancer Institute. And Dr. Nora Volkow
    is the Director of the National Institute on Drug Abuse.
        Thank you all for joining us today, and I look forward to
    hearing from all of you. We'll start with Director Bertagnolli.
    You may deliver your opening remarks.

              SUMMARY STATEMENT OF DR. MONICA M. BERTAGNOLLI, M.D.

        Dr. Bertagnolli. Chair Baldwin, Ranking Member Capito, and
    distinguished members of the committee. It is an honor to
    testify before you today concerning our fiscal year 2025 budget
    request. Let me start by sincerely thanking you for the funding
    you provided to NIH in fiscal year 2024, every State receives a
    share of NIH investment.
        Each year, NIH awards over 60,000 grants supporting more
    than 300,000 researchers at more than 2,500 institutions. We're
    proud to contribute to nationwide innovation in biomedical
    research, and to support the next generation of researchers who
    will meet the challenges of the future.
        NIH is guided by the principle that our work is not
    finished when we deliver scientific discoveries. Our work is
    finished when all people are living long and healthy lives.
    Decades of sustained investment in fundamental science are
    producing exciting results. How can the brain be reprogrammed
    to relieve anxiety or depression or craving for harmful
    substances?
        How can we replace a defective gene, thereby achieving
    durable remission of a debilitating disease? How do we enlist
    the specific function of the immune response to eliminate an
    advanced cancer? Our laboratories are delivering answers to
    these questions and many more, but we still have work to do.
        Families across the country are facing high rates of
    maternal mortality, struggling to care for those suffering from
    Alzheimer's disease and losing loved ones to substance use
    disorders.
        The 2025 President's budget requests support to address
    these critical needs, including the Cancer Moonshot, Brain
    Initiative, Women's Health Research Initiative, and funding to
    promote mental health, to overcome suffering from Long COVID
    and related ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue
    Syndrome) and to achieve longer and healthier lives for people
    with Down syndrome.
        Our track record demonstrates that, with continued funding
    and support, NIH researchers will deliver progress toward
    understanding and overcoming these challenges. I call your
    attention to two overarching concerns.
        First, many are underrepresented in medical research,
    especially people who are older, uninsured, belong to minority
    groups or live in rural locations. And second, for the wealth
    of data we now collect, we still lack comprehensive, diverse
    data from the clinical care environment that can power new
    artificial intelligence approaches to improve health.
        On behalf of the 27 institutes and centers of NIH, I
    present, two new programs to address these important needs.
    First, to ensure that research discoveries benefit all who need
    them, we must partner with people across the entire Nation
    reaching them even, for instance, if they live in a rural
    location far from a major academic medical center.
        To do this, we will enlist primary care clinicians on the
    front lines, to develop ways to overcome health challenges that
    matter to the communities they serve. Care providers practicing
    in underserved communities will be the main focus, supporting
    them so that their patients and they will contribute to
    knowledge generation and also benefit from research that allows
    people to receive better care.
        Next, consider how information technology is changing our
    world and how much more efficient and inclusive our research
    would be if we could better collect data to learn from
    everyone. Artificial intelligence and machine learning are
    revolutionizing what is possible for biomedical research and
    clinical care.
        But to realize the potential of new technologies, we need
    to invest more in a secure and sustainable data sharing
    infrastructure. By engaging government, industry, and academic
    partners, we will enable health innovation on a national scale,
    supporting secure researcher access to data along with advanced
    analytics and computational power.
        And we will incorporate what we have learned from projects
    such as all of us, to obtain people's permission to use their
    health data for research and deliver results back to them,
    inviting them to be our true partners in research.
        These efforts to reach people from all locations and walks
    of life will accelerate progress and ensure that no one is left
    out. When we ask people what they need and deliver results that
    benefit them, when we are transparent and clear and respect
    their wishes, we will earn trust.
        So, NIH supported discoveries have benefited all of us, and
    we are opposed to do so much more. Your continued support of
    our mission to help all people live longer and healthy lives is
    crucial.
        Thank you for the opportunity to appear before you today. I
    look forward to your questions.
        [The statement follows:]
                 Prepared Statement of Monica Bertagnolli, M.D.
        Good morning, Chair Baldwin, Ranking Member Capito, and
    distinguished Members of the Subcommittee. I am Monica Bertagnolli,
    M.D., Director of the National Institutes of Health (NIH). Thank you
    for the invitation to appear before you today. It is an honor to lead
    the NIH, guide the work of a remarkable research community and provide
    stewardship of public resources to enhance the lives of all Americans.
        I am grateful for the committee's long-standing support for NIH.
    NIH research has made significant contributions to improving the health
    of people in the United States and around the world. NIH's successes
    would not have been possible without the investment made by this
    committee. But we still have work to do. Families across the country
    are grappling with new cancer diagnoses, managing chronic diseases, or
    struggling with ill health from Long COVID, among many other
    challenges. To tackle the most persistent and complex problems, and to
    restore trust in science and the value it brings to society, we need to
    bring more members of the public into the research enterprise as our
    partners in discovery. By linking the laboratory to the clinic and to
    diversity of communities that encompass our country, and making sure
    that the information we collect is used safely and ethically to improve
    health for all people, we can find solutions to the health challenges
    facing our communities.
        The FY 2025 President's Budget requests $50.1 billion in
    discretionary and mandatory resources for NIH Institutes, Centers, and
    Offices. This funding will allow the NIH to continue our vital work to
    support the Administration's goal to prevent more than four million
    cancer deaths by 2047, end the HIV epidemic, and make targeted
    investments in mental health, women's health research and data science
    in an environment of tight discretionary spending caps.
                        a reinvigorated cancer moonshot
        In FY 2025, the President's Reignited Cancer Moonshot Initiative\1\
    will support priority investments to advance the goal of cutting
    America's cancer death rate by 50 percent by 2047. Since it was
    established in 2016, the Beau Biden Cancer Moonshot has supported over
    300 research projects that pushed the boundaries of discovery and
    collaboration on behalf of cancer patients. The President's FY 2025
    Budget requests $716 million in discretionary funding.
    ---------------------------------------------------------------------------
        \1\ https://www.cancer.gov/research/key-initiatives/moonshot-
    cancer-initiative.
    ---------------------------------------------------------------------------
        In addition to discretionary resources, the budget also proposes to
    reauthorize the 21st Century Cures Act Cancer Moonshot program through
    FY 2026 and provide $2.9 billion in mandatory funding in FY 2025 and FY
    2026, $1.448 billion each year. In total, the budget proposes $2.164
    billion in combined discretionary and mandatory funding for FY 2025.
        To attain the goal of a 50 percent reduction in cancer mortality,
    funding for the Moonshot will continue to focus on substantially
    increasing the number and diversity of people who participate in
    National Cancer Institute-sponsored clinical trials to develop new
    prevention, diagnosis, and treatment approaches. Additionally, making
    faster progress is critical against cancers that have proven the most
    difficult to treat, such as pancreatic cancer, glioblastoma, as well as
    rare cancers and certain pediatric tumors. The FY 2025 request will
    build on research supported through the Moonshot that led to
    foundational advancements in immunotherapy, progress in childhood
    cancer research, and expanded use of proven strategies for cancer
    prevention and early detection to reduce cancer risk and disparities.
             revolutionizing mental health with precision medicine
        Scientific and clinical advances are rapidly advancing mental
    healthcare in the United States. Progress in basic science has led to
    new tools and resources that enable investigators to gain significant
    insight into the complex interactions between the brain, environment,
    and disease. This Budget increases funding for NIMH mental health
    initiatives, including $10 million to support behavioral health
    prevention implementation science, focusing on sustainable prevention
    and early intervention approaches. For example, NIMH aims to change the
    game for precision medicine in psychiatry with a groundbreaking new
    initiative. NIMH's Individually Measured Phenotypes to Advance
    Computational Translation in Mental Health (IMPACT-MH) seeks to harness
    machine learning and other data-driven approaches to integrate data
    from behavioral assessments with clinically available data, with the
    goal of generating more precise, objective clinical signatures and
    improving mental health outcomes by helping mental health providers and
    their patients make more informed decisions.
        Additionally, the President's Unity Agenda for mental health \2\
    emphasizes strategies for addressing our national mental health crisis,
    including scalable approaches for prevention and early intervention. In
    alignment with this agenda, NIMH is focused on building and
    disseminating a robust evidence base for effective preventive and
    treatment interventions for mental and behavioral disorders, driving
    this investment in the FY 2025 Budget.
    ---------------------------------------------------------------------------
        \2\ https://www.whitehouse.gov/briefing-room/statements-releases/
    2024/03/08/fact-sheet-president-bidens-unity- agenda-for-the-nation/.
    ---------------------------------------------------------------------------
                  women's health research across the lifespan
        Advancing science for women's health requires a multipronged
    approach to advance a vision in which sex and/or gender influences are
    integrated into the biomedical research enterprise; every woman
    receives evidence-based disease prevention and treatment tailored to
    her own needs, circumstances, and goals; and women in science careers
    reach their full potential. This budget directs $153.9 million in FY
    2025 to the NIH Office of Research on Women's Health (ORWH). ORWH plans
    to use the increase to support a range of new and ongoing activities to
    enhance research into women's health issues, including increasing the
    number of hubs in the Maternal and Pediatric Precision in Therapeutics
    Centers of Excellence (MPRINT) initiative to increase the knowledge,
    tools, and expertise in maternal therapeutics available to the broader
    research, regulatory science, and drug development communities;
    expanding trial capacity for the Maternal-Fetal Medicine Unit Network
    to advance specific treatment approaches to leading drivers of maternal
    morbidity and mortality, and establishing clinical trials to test
    technologies developed through the RADx-Tech Maternal Health Challenge
    based on levels of readiness of the technology in rural and remote
    locations. The funds will also support new research into important
    topics such as the intersection of menopause and diabetes, ORWH will
    continue to support cross-NIH initiatives to promote sex and gender
    equity across all domains of research.
        NIH is also playing a major role in the new White House Initiative
    on Women's Health Research, led by First Lady Jill Biden, who has long
    championed women's health, and the White House Gender Policy Council.
    In announcing this Initiative, President Biden stated: ``I have always
    believed in the power of research to save lives and to ensure that
    Americans get the high- quality healthcare they need. To achieve
    scientific breakthroughs and strengthen our ability to prevent, detect,
    and treat diseases, we have to be bold. That's why today, we're
    establishing a new White House Initiative on Women's Health Research so
    that my Administration--from the National Institutes of Health to the
    Department of Defense--does everything we can to drive innovation in
    women's health and close research gaps.'' The goal is to fundamentally
    change how our government approaches and funds women's health research,
    to improve how it is conducted and to maximize the impact of our
    investments.
                                   long covid
        For many, symptoms of COVID-19 persist long after the initial,
    acute phase of COVID-19 infection has ended. To address this growing
    public health concern, NIH's National Heart, Lung, and Blood Institute
    (NHLBI), the National Institute of Allergy and Infectious Diseases
    (NIAID), and the National Institute of Neurological Disorders and
    Stroke (NINDS), along with several other NIH Institutes and the Office
    of the Director (OD), are leading NIH's Researching COVID to Enhance
    Recovery (RECOVER) initiative,\3\ a national research program to
    understand post-acute sequelae of SARS-CoV-2 (PASC), commonly known as
    Long COVID. In 2023, the NIH RECOVER initiative launched and opened
    enrollment for phase II clinical trials to evaluate at least four
    potential treatments for Long COVID, with additional clinical trials
    planned. These trials were informed by findings from earlier RECOVER
    research and focus on several of the symptoms described as most
    burdensome by people experiencing Long COVID. With its complementary
    research efforts, RECOVER has positioned NIH to design and conduct
    trials that have the potential to provide Long COVID patients who
    experience varying symptoms with relief sooner than any individual
    study can alone. The Administration has dedicated an additional $515
    million of COVID supplemental appropriations to RECOVER over the past
    year, on top of the original $1.15 billion, to support a second wave of
    clinical trial activity, long-term patient follow-up, and further
    pathobiology and mechanistic studies, as well as electronic health
    record research and overall research infrastructure.
    ---------------------------------------------------------------------------
        \3\ https://recovercovid.org/research.
    ---------------------------------------------------------------------------
                   data sharing across the research ecosystem
        The lifeblood of a research-driven Agency is its data, and for NIH,
    this includes data spanning fundamental research (basic science)
    generated in laboratories, large healthcare systems, and individual
    communities. The FY 2025 Budget includes $30 million for the National
    Library of Medicine to serve as a focal point to support data sharing
    and use for biomedical, behavioral, and social sciences research across
    the Nation. NIH is committed to harnessing the power of artificial
    intelligence and machine learning to maximize benefits from this wealth
    of data to advance research across diverse fields, diseases, and
    scientific communities. Looking ahead, advanced scientific methods, new
    data analytics, and technologies are unlocking possibilities to
    leverage data in ways that achieve faster and more definitive results.
    These approaches are only as good as the data used to train them. For
    research extending to the clinic, this requires data that are
    comprehensive and include all communities that we serve. For example,
    NIH's AIM-AHEAD program seeks to promote broad researcher participation
    and increase the variety of data in the AI/machine learning field. NIH
    has launched innovative and ambitious initiatives to propel the fusion
    of biomedicine and artificial intelligence and machine learning, such
    as the Bridge2AI program, which aims to generate new flagship data sets
    and best practices for machine learning analysis.
        The NIH Office of Data Science Strategy will work with NLM to
    increase capacity for data hosting, development of programs, and
    infrastructure to deliver minimal cost access to open-industry data
    standards, support for broad access to advanced analytics and
    computational power, and support for education and workforce
    development, including promoting participation by population groups not
    currently represented.
        These efforts are informed by the NIH Strategic Plan for Data
    Science \4\ and the NIH Policy for Data Management and Sharing \5\
    which aim to promote responsible sharing and management of data
    collected from NIH-supported research. Implemented in January 2023, the
    data management and sharing policy reflects NIH's longstanding
    commitment to making the results of the research it supports with
    public funds available to the public by expecting that NIH-supported
    researchers maximize appropriate data sharing.
    ---------------------------------------------------------------------------
        \4\ https://datascience.nih.gov/sites/default/files/
    NIH_Strategic_Plan_for_Data_Science_
    Final_508.pdf.
        \5\  https://sharing.nih.gov/data-management-and-sharing-policy.
    ---------------------------------------------------------------------------
                            strengthening biodefense
        The FY 2025 budget will support biodefense activities across HHS
    with mandatory funding of $20.0 billion, including $2.7 billion for NIH
    research and development of vaccines, diagnostics, and therapeutics
    against high-priority viral families, biosafety and biosecurity, and
    expanding laboratory capacity and clinical trial infrastructure. NIH
    will conduct and support preclinical and clinical research on vaccines
    and vaccine platforms, monoclonal antibodies, and novel adjuvants to
    provide protection against prototype or representative pathogens. It
    will support the development and clinical trials of additional
    therapeutic candidates, including host- tissue-directed therapies, and
    develop next-generation diagnostics to fill critical gaps, such as the
    need for affordable and accessible at-home tests that are as reliable
    as lab-based PCR tests.
                            buildings and facilities
        Safe, reliable infrastructure and facilities are essential to
    pursuit the cutting-edge research within the NIH intramural research
    program. The FY 2025 request of $350 million enables NIH to continue to
    address the Backlog of Maintenance and Repairs (BMAR) which was
    estimated at $3.8 billion as of the end of FY 2023. This request
    enables NIH to continue to implement recommendations from the National
    Academies of Sciences, Engineering, and Medicine 2019 report. In
    addition to the B&F appropriation, NIH has received support for
    critical infrastructure projects in recent years from targeted
    allocations from the Nonrecurring Expenses Fund (NEF). The FY 2025
    request includes a planned allocation of $120.6 million in NEF funding
    for three critical infrastructure projects to improve electrical power
    reliability and distribution systems on the Bethesda and Research
    Triangle Park campuses.
                                   conclusion
        Turning discovery into health remains the central goal and mission
    of NIH. Improving health across the lifespan is essential to
    maintaining our country's greatest asset: its people. My life
    experiences have given me a powerful sense of the transformative
    potential of research, and of the critical importance of equity and
    access for all people to research and its benefits. One of my guiding
    principles is that our work is not finished when we deliver scientific
    discoveries; our work is finished only when all people are living long
    and healthy lives. We should celebrate our successes but remain humble
    in the face of human suffering and approach our work with great
    urgency. With your support, NIH looks forward to tackling timely public
    health challenges through rigorous and innovative science in FY 2025.
    My colleagues and I look forward to answering your questions.

        Senator Baldwin. Thank you, Dr. Bertagnolli. I am going to
    kick off a round of questions, and I want to begin with Dr.
    Marrazzo.

                                   H5N1 VIRUS

        More than a decade ago, researchers at the University of
    Wisconsin Madison studying avian flu or H5N1, warned that only
    a few mutations in the virus would enable it to transmit to
    mammals. Today, H5N1 has infected 51 dairy cattle herds across
    nine States.
        Just yesterday, a second human case of H5N1 infection was
    detected in Michigan. Fortunately, as far as we know, the virus
    has not spread to my home State of Wisconsin, but it has caused
    concern for dairy farmers in my State and across the country. I
    recently convened a round table with Federal and State agency
    leaders and dairy stakeholders in Wisconsin on the current
    state of the disease and strategies for mitigating its impact
    on human and animal health.
        Scientists still don't know how the virus is spreading, or
    how long cows remain infectious and are roughly a hundred
    thousand farm workers are at the highest risk of infection.
        So, Dr. Marrazzo please tell me about NIAID's tracking of
    the spread of H5N1 or mutations in the virus and the work that
    you're doing to develop a vaccine against it.
        Dr. Marrazzo. Thank you for that question. Chair Baldwin,
    this is an incredibly important topic, and I do want to
    acknowledge the great work that our University of Wisconsin
    colleagues have done. In fact, they have been part of one of
    the networks that I want to tell you about.
        This is a pathogen that has been on our radar for a long
    time because when it does get into human hosts, we have seen a
    mortality of about 50 percent. So, this is something we really
    do not want to happen. What we have been doing for more than 10
    years is funding a group of investigators called the Centers
    for Excellence in Influenza Research and Response of which your
    university is one.
        And what they do is to collect and characterize this virus
    in wildlife, including migratory birds, which has been, of
    course, a very big source of these viruses. And that's
    important because, as you mentioned, you do need to track the
    mutations that are occurring in the wild so that you can be
    prepared to prepare the vaccines and antivirals that you're
    going to need if those viruses get into human hosts. So, really
    important network that has been doing incredible work, and
    that's been informing us even before this current outbreak.
        With regard to the current outbreak, the good news is that
    many of the viruses that they have been identifying are very
    similar, if not almost identical to the case in the humans,
    both humans that we know about. Although the sequencing hasn't
    been done on the human case, we heard about yesterday, but we
    assume it's going to be the same one.
        So, the good news is that we're really prepared to not only
    test the current vaccines that we have in the stockpile, but
    also to really develop specific vaccines. So, I think we're in
    a very good place. We're also working closely with some of the
    other agencies that are involved in this and continuing to
    develop monoclonal antibodies, vaccines, and antiviral drugs,
    all very much a part of our remit and very much engaged right
    now in doing this.

                                OVERDOSE DEATHS

        Senator Baldwin. Thank you. Dr. Volkow, while recent CDC
    (Centers for Disease Control and Prevention) data shows a
    slight decrease from the prior year, overdose deaths, still
    claimed more than a hundred thousand lives for the third year
    in a row. These deaths are largely attributable to illicit
    fentanyl. And a NIDA study published last week shows the
    availability of illicit fentanyl continues to skyrocket. 115
    million illicit fentanyl pills were seized by law enforcement
    last year.
        We can and must do more to stop this epidemic and save
    lives. I know this is a bipartisan priority for members of this
    committee, including Senator Capito and myself. That's why we
    provided a $5 million increase for opioid research in the
    fiscal year 2024 Labor HHS bill. So, Dr. Volkow, 2 years ago,
    HHS launched a coordinated National Strategy to prevent
    overdoses. What can you tell us about the HEALing Community
    Study and what interventions it has found to be most effective
    at the local level?
        Dr. Volkow. Thanks very much for your question, and thanks
    for your interest on this very challenging issue posed by the
    overdose crisis. The HEALing Community Study aimed to actually
    empower the communities in order to give them the resources and
    the support necessary for them to respond to the local
    circumstances at which they find, because we see that the
    overdose crisis is very heterogeneous across the Nation, and we
    wanted to learn from this community.
        So, the HEALing Community Study empowers them, allowing
    them to get the data and to develop the interventions that are
    more likely to be beneficial. And as a result of that we have
    learned strategies that then can be deployed to other States,
    because this was done just in four States, and now actually are
    expanding access to data that allows the communities to see
    whether their interventions are making difference or not.
        And in the process, we've seen a significant expanded
    distribution of Naloxone and a significant expanded recruitment
    of people into medications for opioid use disorder and an
    improvement in the practices for treating patients with pain
    properly with opioids when they need it or using alternative
    treatments.
        Senator Baldwin. Thank you.
        Senator Capito.

                          ULTRASOUND SLOWING ADDICTION

        Senator Capito. Yes. Thank you. I'll stick with you Dr.
    Volkow because I know that you've seen and well aware of some
    of the research that's going on with NIH at West Virginia
    University with Dr. Rezai on his use of ultrasound potentially
    slow addiction and Alzheimer's. And I want to talk to Dr. Hodes
    about that as well.
        What do you think that work--what kind of promise does that
    work have with ultrasound to decrease some kind of cravings? I
    know there's no one solution fits all here, and that's the
    difficult part of what you deal with every single day. So, what
    do you see in terms of, on the horizon for treatment?
        Dr. Volkow. I was just saying you're seeing me smiling
    because this is a perfect example that you see where science
    has transformed the way that we can tackle problems like in
    this case, addiction. And this is possible because of our
    understanding how the brain works and what are the circuits
    affected in addiction on the one side, and through brain
    technologies developed by brain to be able to manipulate them
    in a non-intensive way very selectively.
        And that's exactly what Dr. Rezai's is doing, using a low
    intensity focus ultrasound to basically restructure the way
    that the nucleus accumbens, which is the area of the brain
    involved with reward, actually gets disrupted by drugs. And
    what he has shown, even though it's very pilot data, is quite
    dramatic. He sees that dramatic reduction in craving and
    anxiety on people with severe substance use disorder.
        And this is an intervention that's not invasive that
    requires one or two intervention and appears to have at least
    an effect that lasts 1 week, if not 4 weeks. So, we are funding
    research to try to exploit it, how to maximize its utility so
    that others can take advantage of it.
        Senator Capito. Yes. It's quite remarkable to watch and
    I've watched it myself. Dr. Hodes is also doing the same, well,
    its brain and it's interesting how all of these things can kind
    of interconnect at some point. I know you've had a long history
    of studying Alzheimer's.

                             ALZHEIMER'S TREATMENT

        So, what do you think about this as a potential
    breakthrough in combination with what we're seeing with some of
    the pharmaceuticals and other available, I don't know that
    they're full treatments, but at least improvements in how to
    handle Alzheimer's?
        Dr. Hodes. Just as you're reflecting, and as Dr. Volkow
    noted it, it's gratifying when we see convergence of
    technologies and approaches. In this case, the progress in
    these past years in Alzheimer's treatment has been quite
    remarkable with the first FDA (Food and Drug Administration)
    approval of a drug Lecanemab for treatment of mild cognitive
    impairment early stage. What we've learned from the series of
    both successful and unsuccessful trials is that the effect is
    very strongly related to the degree of decrease in amyloid that
    could be accomplished.
        And what was shown in these studies in West Virginia was
    that the use of targeted ultrasound, in combination with an
    antibody to amyloid increase, the effect in decreasing amyloid
    in the brain, preliminary data, which now will be followed up
    with promise for making more effective in combination the
    treatments that we have available.

                         NCI DESIGNATED CANCER CENTERS

        Senator Capito. It couldn't be done without NIH and without
    the innovators that we have. I'd like to move over to the NCI
    (National Cancer Institute) designations and clinical trials,
    and I don't know who wants to answer this, Dr. Rathmell or Dr.
    Bertagnolli, but there are 14 States, including my State, that
    do not have an NCI designated Cancer center. You know, you've
    seen the statistics. Our cancer statistics in our State are
    very disappointing and devastating to us.
        It goes back to my rural area question. My understanding
    anecdotally through the professionals that I've talked with is
    that in order to get this designation, you have to have $10
    million of repeating research into a center before you can
    become NCI designated. In some rural States that don't have the
    resources and other things that becomes a very big hill to
    climb.
        I'm suggesting here that have you thought about some kind
    of a carve out, or some kind of a way for access for the more
    rural States to take into consideration the certain dynamics in
    a State like that as opposed to some of these bigger medical
    centers that are around the other 36 States that have it. So, I
    don't know who wants to take that.
        Dr. Rathmell. Okay. Senator Capito. Thank you for the
    question. So, first, the Cancer Centers is only one part of the
    portfolio. And we would love to have more cancer centers and so
    I know we're working with several that are emerging and working
    toward becoming the comprehensiveness.
        But in terms of reaching out to rural America in particular
    with delivering on the discoveries to get into the hands of
    patients, which is ultimately what we all want here. First,
    I'll say that the NCI has long had dedication to this, but I
    grew up in Iowa, right? You know, I understand very much what
    it means to have great distance from wherever you are to a
    major medical center. And then was at Vanderbilt where although
    we had Nashville the surrounding area had very similar issues.
        So, I'll tell you just a couple of things that we're doing
    to try to take that on. Beyond the cancer centers, we have 2200
    sites that do clinical trials around the Nation. Our National
    Clinical Trials Network is something unique in the world in
    terms of a broad network for clinical research. I think we have
    over a hundred clinical trials in West Virginia and we also
    have the National Community Oncology Research Program, which is
    another way of engaging community oncologists, because that's
    really where most patients get their care.
        But we know that it's not enough. And so, we've engaged a
    group to work across agencies and with community centers to
    look at our capacity building opportunities. Absolutely, it's a
    huge priority for us.
        Senator Capito [presiding.] Thank you, Senator Durbin.

                             NIH FUNDING INCREASES

        Senator Durbin. Thank you, Senator Capito. And welcome to
    the NIH team. It was about 10 years ago when I met with Francis
    Collins at NIH, went through one of their spectacular tours,
    which I recommended all my colleagues, and I said to him, I can
    remember as a member of the house when Arlen Specter and Tom
    Harkin and a Congressman John Porter decided to double the
    budget of NIH. It seemed an impossible task. They achieved it,
    it made such a difference in that agency. And still, we feel
    the benefits today.
        And I asked Dr. Collins, what is it I can do or we can do
    now, doubling it is not realistic. What is realistic? He said,
    5 percent real growth each year. I'm going to pass out a chart
    here, which shows what happened after that. I came in and
    engaged Roy Blunt, who deserves credit again and again for his
    leadership on this, and my seatmate, who will be here shortly,
    Senator Murray, as well as Lamar Alexander.
        And our effort was to try to make sure that year after
    year, we continued to give 5 percent real growth to the
    National Institutes of Health. The chart will show you that we
    did a pretty good job of it. The slope that heads on up there,
    the blue slope, I would attribute to the team that came
    together, the red or orange part of it that shows is the
    deficit where we failed to reach the 5 percent real growth.
        I would just say two things. I commend to my colleagues the
    theory that this is National Security. This is National
    Defense. Ask the American people, if it's of their tax dollars,
    I'm not going to take a penny away from the Pentagon, but for
    God's sake, NIH is doing things which are going to save as many
    lives as anybody at work in the Pentagon.
        [Applause.]
        Senator Durbin. So, I encourage the creation of a new team.
    Senator Capito, you sound like from your questions, you're deep
    into this subject, and that's a good thing. So, I hope in the
    memory of Roy Blunt, that you'll join the effort as we move
    forward, and I invite others to be part of it. And again, we
    count on Senator Murray now as Chair of the full committee to
    move in that direction.

                         AMYOTROPHIC LATERAL SCLEROSIS

        Like my colleagues, I have some specific questions about
    specific maladies and illnesses which we've taken an interest
    in. This success story for the National Institutes of Health
    has had its ups and downs in given areas.
        Next week, 6,000 blue flags we placed on the National Mall,
    each flag bearing the name of a grandparent, spouse, parent,
    child, neighbor, or friend, battling ALS. One of those flags
    will bear the name of my friend and constituent Brian Wallach
    who was active in the White House under President Obama. His
    wife, Sandra Abrevaya, a true courageous individual used to
    work on my staff as a press secretary. And of course, they have
    two little daughters. They have been battling ALS for years
    with some limited success. And I had to use that word advisedly
    because I know that you hardly ever want to say that word
    around ALS.
        Dr. Collins called me at one-point years ago and said,
    we've come to the conclusion that we're heading in the wrong
    direction in our research in ALS. We're just not coming up with
    anything after years and years of effort. What is the status of
    efforts today in research on ALS?
        Dr. Bertagnolli. Thank you so much, Senator Durbin. And let
    me just say right out that this is a tragic disease, and we are
    approaching it with a great sense of urgency that it deserves.
    What has happened, among other things, the act for ALS, which
    has been really great for us, is a collaboration between NIH
    researchers and the people affected by this terrible disease.
    They worked with us to set strategic priorities for tackling
    the disease.
        And these goals encompass diagnosis, treatment, management,
    prevention, and cure. We have to use that word because that is
    what our goal is. And we're in implementation now, let me give
    you specifics of implementation.
        There is a very active partnership with FDA's Critical Path
    initiative, expanded access program for drugs that are
    experimental, which is certainly critical for hope for these
    individuals. A new accelerating medicines partnership for ALS
    that is done under the foundation for the NIH will be announced
    imminently. And then also some practical but critical things,
    data sharing, prognosis in the genetics of ALS, biomarker
    development and more new trials.

                              BLOOD BRAIN BARRIER

        Senator Durbin. Just have a few seconds left. The blood
    brain barrier seems to be a topic which I hear about more and
    more in breakthroughs in medical research.
        [Applause.]
        Senator Durbin. Can you tell me in a few sentences what
    we're finding?
        Dr. Bertagnolli. Well, we're finding that there are
    techniques this barrier prevents drugs from getting into the
    brain where they need to work. And we are finding that certain
    techniques are able to open that barrier so that drugs we need
    to get in can pass through. The details don't matter, but I can
    tell you this incredibly active area of research to bring more
    effective therapies to those affected by neurologic disease.
        Senator Durbin. My last comment, glioblastoma, is an
    example. We've lost John McCain, Ted Kennedy, and Bo Biden to
    glioblastoma, and I'm hoping even at Northwestern University,
    where there's some research breakthroughs that we can find a
    way to treat this malady in a more effective way. Thank you.
        Senator Capito. Senator Hyde Smith.

                         NCI DESIGNATED CANCER CENTERS

        Senator Hyde-Smith. Thank you, Madam Chairman, and Ranking
    Member. And I certainly appreciate our panel for being here
    today, and I'm going to direct my question to Dr. Rathmell. The
    University of Mississippi, my State, is the only academic
    medical center, much like Senator Capito, We are working to
    achieve our NCI designation, but we're not there yet. UMMC
    (University of Mississippi Medical Center) does a fantastic
    job. First lung transplant, first heart transplant in the
    entire country in the early sixties, and I'm really proud of
    that.

                         CLINICAL TRIALS INFRASTRUCTURE

        So, we're working hard to get there, but we're not there
    yet. And my question is, as we work to get there, we're talking
    about the trials and treatments and being able to participate
    in that. Can you share your thoughts on--although we don't have
    that designation yet, bringing these trials and treatments to
    Mississippi, and what that looks like and if we're eligible for
    that, and how would that change lives in Mississippi?
        Dr. Rathmell. Yes, absolutely. Thank you, Senator for the
    question. So, as I said before, we do have multiple resources
    that we use to bring clinical trials in the NCOR. The National
    Community Oncology Research Program, is actually very active in
    in your State. This group, I'll expand a little bit on the
    group that I mentioned before that we're convening.
        Actually, one of the co-chairs of the group comes from
    Baptist Healthcare Center in in Memphis. And so, his group
    really sees a lot of patients in the Mississippi area. That
    group is, as I said, working across Federal Agencies, VA Indian
    Health Service, CMS (Centers for Medicare & Medicaid Services),
    American Cancer Society, where they are, you know, grassroots
    efforts to see how we can make clinical trials more accessible
    and more desired and more available.
        And then we're doing other things as well. Smaller centers
    can't necessarily have all of the staff that they need to run
    clinical trials. And so, we've piloted a virtual clinical
    trials office, which has been really heralded as a different
    opportunity to take the clinical research nurse in virtual
    space in into these places. I think that will democratize the
    ability to bring clinical trials a lot further, and that's part
    of what this group will be looking at.
        Senator Hyde-Smith. Thank you for that, I'm certainly going
    to ask for your commitment as well at UMMC to help us get
    there. But recently, your editorial that stressed the
    importance of clinical trials infrastructure to address and
    eliminate the inequities in the healthcare system. You
    highlighted that increasing community capacity to conduct
    cancer research is the key goal.
        And we sure hope that we're part of all of that. Will this
    plan involve getting granting mechanisms and what impact would
    flat or declining budgets have such on the initiative, to help
    us all get there?
        Dr. Rathmell. I'm so glad, we're clearly on the same page
    here. And we want to work with you to be able to do more of
    these things. The flat budget makes it tougher to make new
    granting initiatives. And we have to come up with new ways to
    be able to get these initiatives out there within the budget
    constraints that we have today.
        So, that's where part of the reinvigorated Cures Act would
    bolster our infrastructure for clinical trials. We are looking
    at a future where we think that clinical trials could be much
    more available to patients everywhere where they are. And that
    takes real infrastructure.

                                  IDEA PROGRAM

        Senator Hyde-Smith. Thank you so much. I have a little time
    left. So, Dr. Bertagnolli, thank you for being here as well.
    The NIH provides support to Mississippi through the
    Institutional Develop Award, the IDeA Program. And we currently
    have 10 active IDeA Awards totaling over $17 million. And as
    you know, the IDeA Networks of Biomedical Research Excellence
    funds statewide biomedical research developments, which
    includes a network in Mississippi colleges and universities
    that are collaborating to increase this research infrastructure
    in my State.
        And this is made possible through the NIH commitment to
    that program and to expanding our national research
    capabilities. But I certainly encourage you to continue the NIH
    to commitment to the IDeA Program and the funding it provides
    to Mississippi and other States. How committed are you to
    ensuring that NIH allocates at least 1 percent of NIH funding
    to the IDeA Program under your leadership?
        Dr. Bertagnolli. So, Senator, I can't give a specific
    percent, but I can tell you this is truly among my highest
    priorities, to make sure that our research, which means our
    funding, is delivered, and distributed through communities such
    as those that are served by the IDeA Program. And even more so,
    not just the IDeA Program alone, ideas capacity building, and
    the ability to do research.
        What we are going to do now is bring the research grants
    in, the actual trials, the actual studies. So, I think States
    like yours have done a great job with this funding to develop
    the capacity. Now we're going to put that capacity to work, and
    that is going to be really exciting and I think of great
    benefit. Thank you.
        Senator Hyde-Smith. Thank you, Madam Chairman.
        Senator Baldwin [presiding.] Next I recognize the Chair of
    our full committee, Chair Murray.
        Senator Murray. Thank you very much, Chair Baldwin, and
    thank you to all of our witnesses. Thank you for the great work
    you do. You know, the fact of the matter is, NIH is fighting
    some of our Nation's most devastating adversaries: Cancer,
    Alzheimer's, Heart Disease, Opioid Addiction, Long COVID to say
    nothing of rare diseases or pandemic threats.
        The lifesaving work happening at NIH really shows that, as
    I've been reminding my colleagues, if we are serious about
    protecting our families here, then we need robust defense and
    non-defense spending.
        Unfortunately, the tough caps that are squeezing DOD are
    squeezing NIH. They're threatening to slow or derail
    breakthrough patients and families are desperately counting on
    today. That's why I have been very clear that we have to invest
    in non-defense and in defense, we need parity, and we need to
    make sure that investments like medical research, which saves
    countless lives, get their due as well.
        I'm proud to say we have a long history of bipartisan
    support for NIH. I've worked across the aisle many, many times
    to advance this important work with crucial funding increase.
    So, I hope we can all come together to support this work again,
    along with many of our other crucial domestic priorities.

                               SEXUAL HARASSMENT

        With that, Dr. Bertagnolli, I wanted to start with you
    because I have a really important question, I need to press you
    on. It's something I have been pressing on NIH for years about
    how the agency will make sure that Federal dollars are not
    supporting researchers who create a hostile work environment
    for colleagues and students.
        We have seen NIH fall short when it comes to holding
    grantees accountable, and complicit as institutions pass the
    harasser. We simply can't afford to have this agency's
    potential limited and its workers harmed by sexual harassment,
    discrimination, or bullying in the workplace. NIH is in a
    position to set a standard for a safe work environment in the
    biomedical research field. Under your leadership now, talk to
    us about what steps you are taking to make clear to
    institutions and your grantees that these behaviors will not be
    accepted and will result in the loss of Federal funding.
        Dr. Bertagnolli. Thank you so much, Chair Murray. And first
    of all, abusive behavior of any type sexual abuse, harassing,
    bullying, any type, is absolutely not to be tolerated anywhere.
    And we really thank you for your advocacy and championing this
    really important issue. So, specifics. First of all, thank you
    for your support in giving us the authorities to require that
    institutions that we fund must report to us anyone who has been
    found to exhibit this behavior, has a real finding of this
    behavior. And when that happens, their funding is withdrawn.
    That is a solid and important step forward that you provided us
    with.
        However, we still have more work to do and we need your
    help. And so, I really look forward to working with you on
    that. And I'll just say it is still possible to pass the
    harasser, if someone has been accused but has not really had a
    finding. It is possible for them to then move and get a new job
    and for us not to know what the results have been.
        Let me tell you, we've been trying to combat this as well
    by having an anonymous tip line. And we do get and follow up on
    everything we get with anonymous tip lines, but we can work
    better to close this one remaining way----
        Senator Murray. Does it need a legislative solution or do
    you have the capacity?
        Dr. Bertagnolli. I would like to work with you on that
    because I am not sure I exactly know the answer. We've been
    exploring it and I think maybe we could have a discussion and
    figure out the best way. So, thank you.

                            WOMEN'S HEALTH RESEARCH

        Senator Murray. Okay. Let's follow up on that. I also
    wanted to talk about the fact that women are half the
    population, you all know that, yet we are not near where we
    need to be when it comes to Federal investment in Women's
    Health Research. I strongly support the administration's
    efforts to tackle this problem head on, including the executive
    order that President Biden signed in March to better prioritize
    investments in women's health across the Federal research
    portfolio.
        This is really a needed step to make sure women's health is
    better understood, so women can get quality healthcare at every
    stage. There are significant gaps in what we know about
    diseases and conditions that impact women, and a lack of
    treatments available even for things as universal as menopause.
    Talk to us about what NIH is doing to advance Women's Health
    Research, including for conditions like menopause, that are so
    common and yet so misunderstood and overlooked.
        Dr. Bertagnolli. Yes, thank you. So, NIH has a long-time
    commitment to women's health in many ways. I'll just call your
    attention to the Framingham study. 75 years deep understanding
    of women's cardiovascular health. 50 percent women, for all of
    those 75 years, and we've gained a lot of knowledge over that,
    Women's Health Study Research across all of our institutes and
    centers address women's health.
        However, we absolutely can do more. The new initiative now
    gives us an opportunity to address current challenges that are
    really important to women. All you've already illustrated a
    few, maternal health, vulnerable time you know, mental health,
    postpartum depression, so many areas there that deserve more
    attention.
        Alzheimer's disease, which has an increased risk in women,
    mental health overall. The menopause transition now, normal
    time of life, but the change in hormones can be incredibly
    disruptive. And there's also long-term health effects, bone
    health, et cetera, that we still haven't really developed the
    treatments and approaches that we need. Although we've made
    some progress, we can do more.
        And then finally, what's our approach? We are taking
    instead of a bit-by-bit approach, we want to take a lifespan
    approach to women's health. A much more comprehensive and
    lifespan approach that coordinates across all our institutes
    and centers.
        Senator Murray. Well, I appreciate your attention to that
    and I think I speak on behalf of many of us that we really want
    to see what we can do to help make sure NIH is really focusing
    on it. I mentioned menopause, working with a number of women
    Senators on making sure we have the research and knowledge and
    coordinate what we're doing here and have a better focus. I
    think it was Senator Murkowski who said to us, if men went
    through menopause, we'd have an institute at NIH.
        [Laughter.]
        Senator Murray. We're not asking for that. We're just
    asking to make sure we really focus on it. So, I appreciate
    your response. Thank you.
        Dr. Bertagnolli. Thank you.
        Senator Baldwin. Vice Chair Collins.
        Senator Collins. Thank you very much, Madam Chair. I'm
    going to forego an opening statement because I have so many
    questions that I want to ask. And they really fall in four
    areas, Alzheimer's disease, Long COVID, Tickborne Illnesses,
    and Diabetes.

                              ALZHEIMER'S RESEARCH

        So, Dr. Hodes, we've talked so much over the years and this
    committee has been very generous in funding Alzheimer's
    research in the last 5 years. And I would like to hear from
    you, have we made any progress as a result of that fund?
        Dr. Hodes. Yes. Well, Senator, thank you for the support
    we've had from Congress, which has been enormously important
    and has yielded important results. In the past year, for
    example, we saw FDA approval of the first drug Lecanemab, which
    targets the underlying process of Alzheimer's. In terms of
    prevention, another important area, we've seen studies
    reporting the effect of repairing hearing deficits with hearing
    aids in those at high risk for Alzheimer's producing something
    like a 50 percent decrease in cognitive decline in that
    population.
        Early studies, but multiple of them have pointed to the
    possible role of multivitamins in reducing cognitive decline,
    as well as targeted coaching to address the individual risk
    factors. Biomarkers, for the first time giving us an
    opportunity to test by imaging, but also by blood biomarkers.
    The various components biochemically, molecularly of what
    contributes to Alzheimer's.
        So, with all the successes, some of those of which I've
    summarized these past years, where we are now, is an
    understanding that Alzheimer's is a complex disease, meaning
    multiple pathways that can occur in individual and differ
    across individuals. But most importantly, we now have
    increasingly the ability to monitor this with biomarkers, with
    studies that will identify the best treatment for individuals,
    a growing number of unique targets now in early-stage clinical
    trials, which we see as our next generation, both drugs and
    lifestyle interventions too.
        So, I think we've had great advances, and the work is only
    partially there with the increasing understanding we have of
    disease, targeting diverse approaches in these future years, I
    think is enormously promising.
        Senator Collins. Thank you very much. I'm encouraged as
    well. And I think we're going to find out that Alzheimer's is a
    multifactorial disease and that lifestyle factors play a role,
    inflammation, I think we're going to find is important as well
    as the amyloid plaque that we focused on for so many years.

                              TICK BORNE ILLNESSES

        Dr. Marrazzo, HHS recently released the National Public
    Health Strategy, to prevent and control vector-borne diseases
    in people. This was required as part of the Kay Hagan Tick Act,
    which I authored with Senator Murray and others, and it builds
    on the NIH strategic plan for tick-borne illnesses.
        This is increasingly a problem in the State of Maine. 20
    years ago, we didn't have tickss in Maine that transmitted
    these kinds of diseases like Lyme disease. Increasingly, it's
    all over the State of Maine. They're all over the United
    States, and it creates real problems. Maine had a record high
    number of Lyme disease cases in 2023, and as ticks continue to
    expand, those cases are likely to increase.
        I was pleased to see the specific goal of reducing the
    number of Lyme disease cases by 25 percent by the year 2035.
    Could you briefly update us on the progress made in Lyme and
    Tickborne disease diagnostics, treatments, and potential
    vaccines? Because one problem is there's been a real dispute in
    the medical community on how to treat Lyme disease.
        Dr. Marrazzo. Senator Collins, as someone who did my
    residency in Connecticut and worked in old Lyme for a summer,
    where I think I saw every manifestation of Lyme disease. And
    recently coming from Alabama where we saw tons of tick-borne
    illness, your comments could not resonate with me more. It's a
    really challenging infection.
        And you highlight the fact that we still 25 years after, or
    however many, we still don't even have a really good diagnostic
    test that we can use for it. The serology is very frustrating,
    it leads to a lot of misinterpretation. So, let me just say
    that we released our strategic plan, as you know, for tick-
    borne disease in 2019. And the support from this committee in
    this area has been critical in advances for both the basic, the
    diagnostic, and the vaccine and the treatment areas.
        So, in the basic area, one of the more exciting things is
    that we finished with both intramural and extramural scientists
    sequencing the Ixodes scapularis genome, which is very exciting
    because you can now go in and be more specific about genetic
    targets to try to develop some of these vaccines and figure out
    what are the antigenic components, what is stimulating this
    immune response? That probably frankly informs post-treatment
    syndrome, what was previously called chronic Lyme disease, but
    it's clearly a post-treatment, inflammatory syndrome.
        I'll jump ahead to that and just note that in 2021, I think
    we actually had a proposal out for work specifically on post-
    treatment conditions and awarded seven big grants to look at
    that, to try to figure out is that pathogen really persisting
    in these areas and how can we best address it.
        With the diagnosis, we're really looking carefully at a
    number of new serology approaches, some point of care
    diagnostics, which would help people a lot in the field,
    especially since people come to emergency rooms in the summer
    with these infections all the time.
        And then the last thing I'll mention is the vaccines. We
    have a pretty successful vaccine for dogs, right? There is a
    canine vaccine. We are figuring out why that vaccine is
    actually working, and we're trying to learn from that analogy
    to develop and refine the approaches to human vaccines, which
    has been really challenging. I'll stop there. There's more but,
    I'll stop there.
        Senator Collins. Madam Chair, I would ask that I be able to
    submit my question on diabetes. I'm concerned about the cut
    that is in the budget and surprise to see that and on Long
    COVID as well. The RECOVER initiative's been very
    controversial. The Maine medical center, I'm proud to say is
    involved in the research, but I'll submit those to for the
    record.
        Senator Baldwin. Without objection and any opening
    statement, you wish to submit, at the end, I will indicate the
    timeline we need for questions for the record but thank you.
        Senator Schatz.
        Senator Schatz. Thank you, Chair. And thanks to all of you
    for your good work. I think I speak for most of us when we'd
    say this is one of our favorite hearings. It gives us the most
    hope about the future.

            NATIVE HAWAIIAN PACIFIC ISLANDER HEALTH RESEARCH OFFICE

        Dr. Bertagnolli, I wanted to start with something close to
    home for me. With the support of this subcommittee, we secured
    $4 million last year to launch NIHs first ever native Hawaiian
    Pacific Islander Health Research office. Can you tell me--our
    worry is that this is going to take 17 months to stand up. So,
    can you reassure me that this thing is going to get stood up
    quickly? I know I'm in no position to hector you for it not
    already being up, but could you please reassure us that this is
    going to happen quickly?
        Dr. Bertagnolli. Absolutely. And we have an office of
    research in Tribal Health, and this will fall right into a very
    active program to do much more to care and engage in research
    our indigenous peoples.

                             CHRONIC PAIN TREATMENT

        Senator Schatz. Great. Dr. Volkow, my STOP Pain Act was
    enacted 8 years ago, and since then, NIH has funded hundreds of
    millions of dollars in pain management research. What have we
    learned in the last several years about chronic pain treatment?
        Dr. Volkow. Yes, and thanks very much for the budget
    because it has actually energized the whole science
    infrastructure necessary to bring treatments that are effective
    for patients that are suffering from pain. Pain is devastated.
    It's very, very prevalent, but it has been neglected. And as a
    result of that, many people with pain, ended up getting drugs
    that were very dangerous, which of course contributed
    tremendously to the overdose crisis.
        So, thanks to the resources that have come, in part through
    the HEAL Initiative, we've been able to advance several
    clinical trials and to actually uncover new treatments for pain
    that are not addictive and that are effective, completely new
    molecular targets. The resources have also enabled us to
    understand how multi-pronged approaches can be used to manage
    pain on people with chronic pain conditions and two other areas
    that we have never been able to investigate.
        Senator Schatz. Two quick questions. What do you mean by
    multi-pronged.
        Dr. Volkow. Multi-Pronged that is not just based on a
    medication, that it actually engages behavioral interventions
    and cognitive interventions to help the person live with the
    pain and like meditation, for example.
        Senator Schatz. So, how much of this is sort of, I'm not
    sure I'm using the right terminology here. How much of this is
    jumping the fence and getting into CMS and the private
    healthcare sector? That's the question I have, is that it does
    seem like over the last 3 to 5 years a lot of important
    discoveries that are not so, they're not merely suggestive,
    like we think we know some things now about pain management,
    but it doesn't seem to me that in its application, in the
    healthcare context that they've woken up to this new treatment
    modality.
        Dr. Volkow. And that's why it's so important that in all of
    these projects, we work closely with CMS so that we can ask
    them the question, what is it necessary for us to show with the
    science that will lead to its reimbursement?
        So, we work very closely and for example, acupuncture is a
    perfect example of a partnership that's being developed, if it
    shows effectiveness, you want to be able to provide it to
    patients and be reimbursed as a physician.
        Senator Schatz. So, you're not overly concerned that these
    are just two separate agencies that only talk when necessary.
        Dr. Volkow. No, there is a very proactive way of sort of
    interest and motivation to commit ourselves to make
    collaborations across agencies. Because otherwise the science
    doesn't go into the patients, it stays in the journals or in
    the laboratory issues.

                              PSYCHEDELIC RESEARCH

        Senator Schatz. This is what I worry about. So, it's time
    for my annual question about psychedelic research.
        [Laughter.]
        Senator Schatz. You know, I am cautiously optimistic about
    the revived research on psychedelics. And I think that part of
    what we have to do as a committee, but also as a Congress, is
    to draw distinctions around drug policy and a kind of move
    towards liberalization of drug policy for other reasons, for
    maybe libertarian reasons, for criminal justice reasons. And
    the question of whether or not some of these things that are
    used recreationally and sometimes abused are medicine. That is
    a separate conversation.
        I am personally for drug liberalization. I am also a son of
    a principal investigator, and I'm not prepared to call this
    medicine until all of you do the adequate research. So, where
    are we with psychedelic research and particularly, there's a
    bunch of accumulated data that seems to indicate that this
    needs supervision, and the application of the administration of
    the drug has to be combined with talk therapy and supervision.
    So, can you talk through how you see this?
        Dr. Volkow. You're absolutely correct. I mean, this is an
    area of tremendous excitement from the very pharmacology to
    actually understanding how to optimally use it on patients.
    Because the data is starting to translate in evidence that it
    could be beneficial, what has happened is that the clinicians
    are ahead of actually where the data is.
        So, it's being offered to a wide variety of patients
    without sufficient evidence, including the question that you
    ask, how do you optimally give it without producing risk and
    ensuring that you're having long-term effects? And that's where
    we need to understand how the context that which you are giving
    the psychedelic drug is going to influence your therapeutic
    response.
        It's crucial, but like anything else, what people get
    excited, they want to start of sort of believing a little bit
    in fairytales that it's magic. It's not a magic, it's very
    promising, but we need to do much more research. Thank you.
        Senator Schatz. Thank you.
        Senator Baldwin. Senator Moran.
        Alzheimer's Disease and Down Syndrome
        Senator Moran. Chairwoman, thank you very much.
        Dr. Hodes, I was very interested in your answer to Senator
    Collins question about the state of research regarding
    Alzheimer's. Let me ask an additional question. What's the
    latest in the research? What does the research show in regard
    to the connection between Alzheimer's and Down syndrome? Is
    that connection still viable and are we learning something
    about both at the same time?
        Dr. Hodes. Yes. It's a very important connection between
    two very important conditions that we need to address. And as
    many may know, individuals with Down syndrome likely related to
    the fact they have an extra copy of Chromosome 21, have as they
    age, and the good news is of course, that those living with
    Down syndrome now age into older adulthood, and a very high
    proportion developed Alzheimer's disease.
        And there's been an extremely active program designed to
    study this, a network of longitudinal studies looking at
    biomarkers to understand how disease progresses in Down
    syndrome and establish a network for clinical trials and,
    clinical trials are already in progress. For example, looking
    at the effect of a, so-called GM-CSF, it's a growth factor
    granulocyte, monocyte growth factor as therapy in those with
    Down syndrome, a preventive therapy as well as behavioral
    exercise intervention.
        So, we're working all the way from the basic science
    connecting the trisomy of Down syndrome and the relationship to
    the pathogenesis of Alzheimer's clinical trials infrastructure
    and active clinical trials.
        Senator Moran. What would be the outcome if there, if this
    connection is determined, what would change in the way that we
    would then address the issue of Down syndrome?
        Dr. Hodes. Well, certainly as Down syndrome relates to risk
    of Alzheimer's disease, this becomes similar to the rare but
    tragic early onset autosomal dominant Alzheimer's and other
    aspects where we know with high priority, high probability,
    that individuals will develop Alzheimer's. We know that years
    in advance and importantly now that we have biomarkers to track
    the presence of disease early, allows us to intervene early in
    these populations to prevent.

                    USE OF EMERGING DATA METHODS IN RESEARCH

        Senator Moran. Thank you. My following questions really are
    about process, mostly data. This could be to Dr. Hodes or to
    you, Dr. Bertagnolli. With all the data that's now available,
    in many instances, but related to Alzheimer's, electronic
    health records, diagnostic, sex, clinical treatment results,
    insurance claims, medical images. Is there a way now that NIA
    (National Institute on Aging) can harness that data, uncover
    new insights and patterns, that we can't see through individual
    research projects? Maybe that's my question. Is that being
    done?
        Dr. Hodes. I can begin. And then certainly Dr. Bertagnolli
    can amplify upon it because you're absolutely right. Real world
    data of the kinds that you mentioned are critically important
    to our fully understanding in an inclusive way what goes on
    with the health of the population, the way to maximize it.
        There have been some very important real world data studies
    already carried out around Alzheimer's disease. And
    importantly, I would say that now the promise more than ever is
    for us to leverage these real-world data initiatives in the
    context of the large data initiatives, NIH wide, and Federal
    agency wide that I think Dr. Bertagnolli can comment upon.
        Senator Moran. That really was going to be my question, how
    do we expand that?
        Dr. Bertagnolli. I'll be quick. The data we use has got to
    be good enough that we can make life altering decisions based
    on it. Right now, our real-world data is not at of that level
    of accuracy, frankly. We are working really hard with FDA and
    with partners across all of HHS to convert our current ability
    to gather real world data into one where we really can harness
    it appropriately, use it with new analytics like artificial
    intelligence, to make life altering decisions. Right now, it
    tends to be more hypothesis generating than testing, and we're
    going to fix that.
        Senator Moran. And the issue is not sufficient data. It's
    determining how to harness that data to get it in a form that
    it's valuable.
        Dr. Bertagnolli. It's not necessarily efficient. It's the
    accuracy and the interoperability. You know, you got to compare
    apples to apples, not apples to oranges. And, you know, some
    issues with how the messy data is in the clinical environment
    that can really lead to mistakes if it's not used properly.
        Senator Moran. Thank you for using a scientific term that I
    understand, apples and oranges.
        [Laughter.]
        Dr. Bertagnolli. Thank you.

                                 ARPA-H FUNDING

        Senator Moran. Finally, just maybe make a statement because
    of the shortage of time. I raised this in last years or
    previous years' hearings with Dr. Tabak. ARPA-H at one point in
    time the funding of ARPA-H was at the expense of more
    traditional and clinical research at NCI. I hope that that's
    not a pattern. I assume that you'll say that it depends on how
    much money you have, but I want to make certain that you are
    prioritizing NCI competitive cancer grants with fiscal year
    2025 funding, Dr. Bertagnolli.
        Dr. Bertagnolli. So, yes, absolutely we are, and our
    relationship with ARPA-H is that we have our team members meet
    routinely to review what's happening in our sister agency and
    make sure that there is no redundancy and, in any way, we can
    amplify, we do so.
        Senator Moran. That question was also directed to you, Dr.
    Rathmell.
        Dr. Rathmell. But that's what I would say as well.
        Senator Moran. All right. Thank you. Thank you.
        Senator Baldwin. Senator Kennedy.
        Senator Kennedy. Thank you, Madam Chair. Dr. Bertagnolli,
    I'm directing these comments to you because, you of course are
    the director of the NIH, but I could also direct to each of
    each member of this distinguished panel. Let me state a few
    things that I think most fair-minded people would agree are
    facts.
        The National Institutes of Health are more to the point,
    the men and women there are one of the most extraordinary
    collections of minds in the world, maybe in all of human
    history. Your work, their work has saved billions of lives.
    Their work, your work, has improved the quality of life for
    billions of people, not just in America, but worldwide.
        Additional fact, the National Institutes of Health is part
    of, at least in America, but I think the world as well is part
    of the Institution of Public Health.
        Another fact in my judgment. As a result of the pandemic,
    the Institution of Public Health, at least in America, and I
    think in some respects throughout the world, has been
    tarnished. And that's dangerous. That's very dangerous for
    America, for the world, if we have another public health
    crisis, I don't care to partake in who's at fault for that. Or
    depending on upon your perspective, who receives the credit for
    that?
        I'd like to suggest that we do something about it and that
    we learn from it. And I think the NIH is the perfect group of
    men and women with the requisite credibility to do that.

                           GAIN OF FUNCTION RESEARCH

        Now, here are my suggestions. Number one, the NIH needs to
    clear the air on Gain-of-Function research. I would gently
    suggest that you, I don't know, you could do it in a symposium.
    You could do it at an extended press conference, with some of
    your bright minds making presentations. Be technical, but also
    speak directly to the American people in a way they can
    understand.
        Tell them what gain-of-function research is. Tell them how
    it is funded. Tell them what research projects the American
    taxpayers are funding. Tell them what if any America's
    involvement was with the gain-of-function research at the Wuhan
    lab. Tell them the benefits of gain-of-function research.
    Explain to them the risks and be transparent. That needs to be
    done. And I think the NIH could lead it.

                              PANDEMIC PREPARATION

        Number two, at a different symposium or extended press
    conference, I would like to see the NIH take the lead in
    speaking to the world and to the American people about what we
    learned from the pandemic. What did we get right? What did we
    get wrong? Here's why we got it wrong. Here's why we got it
    right. Here's how we saved lives. Here's how we could have
    saved more lives if we'd known then what we know now.
        The American people, they don't read Aristotle every day,
    but they're too busy earning a living, but they get it, you
    know, hindsight is wonderful. I think if you would consider
    doing those two things, we could remove some of the tarnish on
    the institution of Public Health in America.
        And I'll conclude with this point. I know there are risks
    here, and I know some of you are thinking, you know, what
    planet did Kennedy just parachute in from? Why do I want to get
    mixed up in this political hot mess? Because it's important and
    it's not going away, folks. Neither one of those topics is
    going away. So, I would again gently suggest you put those
    extraordinary minds to work and consider doing those two
    things.
        [Applause.]
        Dr. Bertagnolli. So, on behalf of all of us, thank you very
    much.
        Senator Baldwin. Senator Britt.
        Senator Britt. Thank you, Madam Chairwoman, Vice
    Chairwoman. Appreciate you holding this hearing today. And
    thank each and every one of you for appearing before this
    subcommittee. I want to begin by expressing my deep gratitude
    to you, Dr. Bertagnolli. Is that right? How do you say it
    properly? Not that I'm going to be able to do it, but yes. The
    Alabama in me----
        I'm going to say Madam Director, how about we do that?
    Thank you so much for visiting Alabama this year. I am deeply
    grateful for your time and letting you come and visit with the
    incredible men and women that work there. See the work that's
    being done, figuring out how we can partner to continue to
    change lives for the better. Really, really appreciate it. And
    then also, and here we're going to have another challenge with
    how to say your name. Is it, Marrazzo?

                               MATERNAL MORTALITY

        Dr. Marrazzo, we are very proud, obviously, you having been
    at UAB (University of Alabama at Birmingham) and to see you in
    this job. Now, you obviously know what a special place UAB is,
    the tremendous work that is done there and look forward to
    working with you in your new position.
        As you both know, in Alabama, over a third of our 67
    counties are classified as maternity care deserts. Areas
    without access to birthing facilities or maternity care
    providers. Last fall, three more Alabama hospitals announced
    closures of their labor and delivery departments, leaving both
    Shelby County and Monroe County without access to labor and
    delivery services.
        Additionally, Alabama has the highest maternal mortality
    rate in the Nation. I am of the mindset, as I believe probably
    the men and women sitting at that table are as well, this is a
    crisis we should be able to fix. If you look back to 2019, NIH
    launched the implementing a maternal health and pregnancy
    outcomes vision for everyone, the IMPROVE Initiative. Madam
    Director, could you speak to the importance of this program and
    why the NIH felt so strongly that standing up the IMPROVE
    initiative was necessary even without a sustained funding
    source?
        Dr. Bertagnolli. Oh, absolutely. Thank you, Senator. You
    know, pregnancy related complications related in the deaths of
    about 1,200 women in 2021. We're still waiting to see the
    figures coming in for the last couple years, but it was just an
    enormous jump and with much higher rates in black women, which
    is also terrible.
        And so, we are really--IMPROVE is one of many efforts a
    really important one, but one of many we are looking to tackle
    this problem because it's multifactorial. It's mental health,
    so our institute mental health plays a role. Yes, it is also to
    a certain degree associated with substance use disorder as
    well, which we know, you know, all these things----
        Senator Britt. All of these things together intersect, and
    that's why it's so critically important. I just want to say
    thank you. Improving healthcare for women before, during, after
    pregnancy is truly vital. And I really am thankful for your
    leadership in this space, and I want you to know that I want to
    continue to partner.
        As you mentioned though, obviously, that this research
    funding is so important, or this research is so important, but
    really lacks a sustainable funding source. And so, last month I
    was proud to partner with Senator Laphonza Butler from
    California on the NIH IMPROVE Act, which would authorize in
    statute and provide consistent funding for this initiative.
        And so, I just want to thank all of you and the NIH staff
    for providing your offices to help us with technical assistance
    on this, to make sure that we could get this important bill out
    there.
        I am committed to continuing to work with Senator Butler to
    finding a way to getting this passed into law. As you
    mentioned, I mean, not only is Alabama the highest maternal
    mortality, it disproportionately affects the black community,
    and we need answers and we need them now. So, we're going to
    keep working on that to help with America's maternal mortality
    crisis.

                        IMPACT OF CONTINUING RESOLUTIONS

        And I want to say, I know I'm almost out of time. Two quick
    questions. When it comes to CRS (Continuing Resolutions), which
    is what we end up seeing happen here, unfortunately, and I want
    to commend Chairwoman Murray, I want to commend Vice Chair
    Collins. This committee did its work last year. We finished on
    July 27, all 12 bills out of committee. Unfortunately, we did
    not get those to the President's desk until 236 days later, 174
    days into the fiscal year. Can you speak very quickly about
    what a CR does to your agency? Oh, look at this. I get a
    reaction from the whole crowd. And can you just speak very
    quickly to that?
        Dr. Bertagnolli. I'm sure we're the same as all of
    government, anyone knows this. If you don't know how much you
    have to spend, it's very hard to plan and make all of the
    strategic decisions we need to make that don't come at the very
    end of the year. You know, we do the best we can and are
    certainly grateful for our funding, but it is challenging.
        Senator Britt. Madam Chairman, would you allow me to ask
    one more question?
        Senator Baldwin. Yes.

                                CLINICAL TRIALS

        Senator Britt. Thank you so much. Last question. In your
    visit to Alabama, you were able to see some of the research
    that we are doing there, you know, how our community, our
    diverse population in Alabama is really a great place for
    clinical trials. Could you just speak to that very quickly, as
    to why you feel like those things match up so well?
        Dr. Bertagnolli. So, it is absolutely critical that we
    serve our populations that are having many of these
    extraordinary needs that all intersect, that have to do with
    community in a very effective way with our clinical trials
    infrastructure.
        And so, that is why we are launching a new clinical trials
    network, devoted toward primary care, to do exactly that, to
    get into the communities. And doctors and clinicians on the
    front line, like the ones that we were able to visit in Alabama
    and in West Virginia and in other parts of the Nation. And
    we're excited about this. It will be all of NIH effort to work
    with these communities to get the research that they need.

                    FUTURE OF SCIENTIFIC RESEARCH WORKFORCE

        Senator Baldwin. Thank you. Senator Capito and I have a
    couple of remaining questions. So, we're going to start a
    second round, hopefully quickly. Dr. Bertagnolli, new data from
    the National Science Foundation reveals the largest drop in the
    number of postdoctoral scholars at academic institutions in
    over 40 years. Employment indicators suggests that life science
    PhDs are choosing to pursue careers in the industry instead.
        In order for America to out-innovate the rest of the world,
    we must invest in the next generation of researchers. I was
    proud to author the Next Generation Researchers Act with my
    colleague, Senator Collins, to improve opportunities for new
    and early-stage researchers. Since this bill was signed into
    law as part of the 21st Century Cures Act, NIH has increased
    funding for early-stage investigators by 63 percent. I was
    pleased to see the NIH recent plan to increase the minimum
    postdoctoral salary by 8 percent, raising it to $61,008 per
    year, and provide an additional childcare benefit.
        This is a major step in the right direction, but it falls
    short of the 70,000 minimum salary that your advisory committee
    recommended. So, Dr. Bertagnolli how is NIH tracking the impact
    of the stipend increase and why aren't Cost of Living
    Adjustments part of that equation?
        Dr. Bertagnolli. So, thank you for that. And, you know, I
    will say that this discussion, how do we better support our
    young, the next generation, the ones who are going to transform
    the world? That discussion happens every single week in our
    meetings across all of our NIH directors. We need to support
    them on so many levels.
        You hit briefly on an increase in stipend for postdocs that
    came out of a working group of the Advisory Committee to the
    director. Many other parts of that working group we are
    responding to. I think you also alluded to why haven't we gone
    farther, faster? We are left with a challenge of do we fund
    more researchers at a lower level, or do we fund smaller
    numbers at the full level that the committee asked us to do?
        You know, it was an economic calculation. We did. We have
    made a declaration that as funding allows, we will increase it
    to the full $70,000 a year. That was advised by the committee
    over the next, hopefully 3 years.
        And then finally you also talked about the early-stage
    investigator support. We do have special review criteria for
    early-stage investigators. They get a little of a less
    stringent funding rate. So, we really actively encourage--and
    we put out a challenge every year across all of our institutes
    and centers to achieve at least it used to be 1,100 new early-
    stage investigators a year. Yet last year we made 1,600. And
    I'm optimistic we'll get that this year as well. Thank you.
        Long COVIDSenator Baldwin: Dr. Gibbons, an estimated 20
    million Americans continue to suffer with the long-term effects
    of COVID-19.
        [Applause.]
        Senator Baldwin. More than 3 years have passed since
    Congress appropriated $1.2 billion to the NIH for long COVID
    research. NIH has moved slowly to enroll patients in clinical
    trials, and there are still zero FDA approved treatments for
    Long COVID. Critics of the RECOVER Initiative, fear that it may
    not deliver any meaningful treatments.
        Getting this right has massive ramifications because, it
    will dictate how doctors across the country treat their
    patients and impact people's ability to access work
    accommodations, disability benefits, and more. So, Dr. Gibbons,
    why has the pace of research been so slow? And what can you
    tell us about the status of clinical trials for Long COVID?
        [Applause.]
        Dr. Gibbons. Well, thank you for that question, Senator. As
    you know Long COVID is a debilitating disorder inflicting great
    suffering and affects nearly every organ system of the body and
    involves, quite frankly, the mission areas of many of our
    institutes. And in that regard, let me turn first to our NIH
    director, Dr. Bertagnolli for addressing your question.
        Dr. Bertagnolli. Yes. Dr. Gibbons, thank you. And Chair
    Baldwin. I am very pleased to speak on this as the NIH
    Director. Really to emphasize that this is now really
    considered as a full NIH activity. Long COVID and the similar
    condition, myalgic encephalomyelitis are terrible diseases.
        [Applause.]
        Dr. Bertagnolli. We must find better ways to treat and
    actually cure, make the--restore the lives of these people who
    are affected by this terrible. And, you know, the increase
    related from this new disease, COVID SARS-CoV-2 is just very
    tragic.
        So, what's already been accomplished, I'll be very brief
    there. What has been accomplished is to understand a new
    disease that dropped on us that we didn't understand. 15,000
    people with biospecimens, their electronic health record data,
    have allowed us to do the following. Five platform clinical
    trial structures focused on what people need us to fix.
    Autonomic dysfunction, cognitive, you know, the brain fog, the
    cognitive challenges, fatigue and exercise tolerance, sleep
    disturbances, and viral persistence.
        So, targeting those five key really disruptive areas. We
    now are--and fully admit, we are not where we want to be in
    terms of a rapid, nimble clinical trials enterprise that's
    testing promising treatments very quickly. That is our focus
    right now, moving forward, to do that.
        And finally, you know, we have launched eight trials. New
    ones are pending, but as I said, we have clinically
    characterized platforms. We are ready to go into action and
    accelerate approaching this great sense of urgency.
        And the last thing I want to say about Long COVID and ME/
    CFS, we are so grateful for our partnership with the people
    that are affected by this. They have taught us over the last 2
    years what we needed to do. Now we just need to deliver for
    them.
        [Applause.]
        Senator Baldwin. I'm going to recognize Vice Chair Capito
    for one remaining question, and then I will recognize Senator
    Shaheen. Go ahead, Senator Capito.
        Senator Capito. Yes. Thank you, Dr. Gibbons. You were
    either having your best day or your worst day because you
    hadn't gotten a question yet.
        [Laughter.]

                       RESPIRATORY SUPPORT IN RURAL AREAS

        Senator Capito. I wanted to ask a question about an NIH
    study through your institute that found higher mortality rates
    for patients on respiratory support in rural intermediate care
    units. This goes to the heart of what I talked about earlier.
    Obviously, I have a large rural population. What advice would
    you give, or what do you think can come out of this study in
    terms of helping rural intermediate care facilities be able to
    change the results of this study?
        Dr. Gibbons. Oh, thank you, Senator. You bring out the
    important aspect of your earlier comment in which we recognize
    that rural America and our systems need to focus in on where
    the burden and suffering is the greatest. And clearly when it
    comes to intensive care units there's actually a lower
    proportion per capita in rural communities.
        And we know that it is a challenge where we are hoping
    that, and we're testing strategies, many of which involve
    telehealth, in which we can ensure that the care is at the
    level where we can improve those rates of recovery in the
    context of rural communities.
        For example, one of the other elements of that challenge
    involves chronic pulmonary disease in which we know that
    pulmonary rehabilitation can actually reduce hospitalization
    rates for those with chronic obstructive pulmonary disease.
        And we've tested that in rural settings and shown that it's
    effective in the context of where patients are in rural
    communities. Similarly, we have established cohort studies
    focused in on rural communities to understand the whole
    trajectory of the development of chronic lung disease and heart
    disease. Our RURAL initiative is in Kentucky, Alabama,
    Louisiana, and Mississippi. So, we really want to be where
    individuals are to understand their risks and improve their
    care, including the use of a mobile CT scan to further
    understand those things.
        Senator Capito. Good. I was just talking to one of my West
    Virginia University doctors about a mobile unit to look more at
    heart. I just want to thank all of you, this has been, it is
    always so informative and hopeful.
        And also, my last comment would be to you Dr. Bertagnolli.
    27 Institutes, that's a lot to manage. Not just physically
    manage, but there's so much interplay between what's going on,
    and as we look at a time of dollars shrinking or not, you know,
    we got to be more efficient. So, any efficiencies, and I'm not
    asking you to speak on this, any efficiencies that can be found
    across the 27 institutes, I think you're going to reap the
    results of that. And I know that's something that you and I
    talked about earlier, so thank you all very much. Appreciate
    it. Thank you. Senator Shaheen, I haven't voted yet----
        Senator Baldwin. Senator Shaheen, you're recognized.

                            SUBSTANCE USE DISORDERS

        Senator Shaheen. I have voted. So, thank you for holding
    the hearing, and thank you all so much. Not just for being here
    today, but for the work that you do every day.
        I really want to focus my questions on the area of
    substance misuse and Dr. Volkow. You have been so helpful and
    willing to come to New Hampshire to see our challenges there.
    But while CDC data shows overdose deaths decreased somewhat
    last year, for the first time since 2018, we still lost 107,000
    Americans, 430 in New Hampshire.
        And overdose deaths continue to take a devastating toll on
    not just those affected, but their families, friends. Last year
    we discussed the important work of the HEAL Initiative, and can
    you give us an update on the development of medications for
    treating or vaccinating individuals against substance use
    disorders?
        Dr. Volkow. Thanks very much for that question. And I am
    actually keeping an eye on this problem that yes, there was a 3
    percent decrease in 2023, but if you look at certain areas,
    they are continued to increase the mortality and the numbers
    are unacceptable.
        So, there are many strategies. One of them is how is it
    that we can provide better treatment for people that otherwise
    will die because of an overdose? And vaccines, in monoclonal
    antibodies has been one of the targeted, we have actually
    completed a trial on phase two for the monoclonal antibody
    against methamphetamine.
        And I want to note that the number of people dying from
    methamphetamine has continued to increase. We are not seeing
    reductions, and we have no treatment whatsoever. Unfortunately,
    the outcome did not reach the one that was set up by the FDA,
    so the company is withdrawing, unfortunately.
        We are in the stages of starting clinical trials with
    fentanyl monoclonal antibody. And we are in the last pre-
    clinical stages for a fentanyl vaccine. So, we are advancing,
    and the HEAL funding has enabled us to accelerate that
    research.
        There are many challenges, but we have multiple potential
    treatments, if the results come forward, we will have better
    interventions for reversing overdoses and better interventions,
    not just for treating opioid use disorder, but we have no
    medications for stimulant use disorder, which, as I said, the
    mortality has continued to increase. So, we need to continue to
    do this in order to be able to bring the treatments to the
    people.

                                 DRUG OVERDOSES

        Senator Shaheen. I appreciate that. And we are certainly
    seeing that in New Hampshire that the number of cases of people
    overdosing on meth has gone up. And as you point out, there's
    no treatment. One of the challenges that we're seeing in New
    Hampshire, is that so much of our funding and programs have
    been tied to specific drugs. And we need more flexibility in
    what those programs can do to address other drugs other than
    just opioids. Would you agree with that, that it would be
    helpful to see more flexibility in funding?
        Dr. Volkow. A hundred percent. And in fact, what the
    science is telling us is that the problem that we have in
    overdoses is polysubstance use, is very rare to see someone
    dying with just one substance. It's also very rare to have a
    person that has a substance use disorder that only consumes one
    drug.
        So, the strategy now--and genetically, you inherit genes
    that make you vulnerable for addiction in general. So, the
    strategy now is how do we do interventions that are going to be
    beneficial for any type of addiction regardless? And certainly,
    in terms of how we deploy care and how we fund it, there should
    not be distinguishes, categorical distinguish these or the
    other because it's not the way that the cases are presenting
    themselves.
        Senator Shaheen. Thank you. Madam Chair, I hope as we're
    looking at the funding in the budget, we can look at that issue
    and try and ensure that we're not directing funding just at one
    substance.

                                    DIABETES

        My other question has to do with diabetes and Dr.
    Bertagnolli, I think I'm going to direct this to you. As I
    understand, the last year I asked Dr. Tabak about beta cell and
    stem cell derived islet replacement therapies, cutting edge
    technologies. We're seeing companies, a new company in New
    Hampshire that's working on that. It has tremendous potential
    for curing, and I say that directly, curing diabetes.
        I have a granddaughter with type 1, so we know very
    directly the challenges. Can you talk about where NIH is and
    plans to address investments in diabetes focused cell
    therapies?
        Dr. Bertagnolli. Absolutely. This is a very exciting area,
    there's great hope. We have three wins that's come out of the
    special diabetes program.
        The first is, the first drug that can delay the onset of
    type 1 diabetes severe symptoms by almost 3 years. So, that's a
    win. The second you've already referred to the cadaveric eyelet
    cell transplants, where we're finally starting to know how to
    protect these precious eyelets from destruction by the immune
    system. And you know, this is one of those things where you get
    first proof of concept, then you can really expand and do
    better.
        And then finally, there's also good technology and new
    artificial pancreas technology and a lot of--so much better
    testing insulin control. I just want to raise one issue though,
    since I think we both really care about this disease, we've
    still got a long way to go with underserved people, minorities,
    very young people. We we're getting some advances, we got to
    make sure everybody gets them.
        Senator Shaheen. I couldn't agree more with that. And
    Senator Collins and I co-chair the Diabetes Caucus, we have
    legislation. We're working with some of our other colleagues to
    not only cap the out-of-pocket cost of insulin until we get
    these cures, but also to cover uninsured who definitely are
    experiencing more of the negative effects of the disease. So,
    thank you very much for what you're doing.
        Thank you, Madam Chair.
        Senator Baldwin. Thank you, Senator Shaheen, thank you to
    Director Bertagnolli, and the entire panel we have today of
    Institute directors. We really appreciate your presence and
    your work.

                         ADDITIONAL COMMITTEE QUESTIONS

        The record is going to stay open for 1 week for additional
    questions.
        [The following questions were not asked at the hearing, but
    were submitted to the Department for response subsequent to the
    hearing:]
             Questions Submitted to Dr. Monica M. Bertagnolli, M.D.
                  Questions Submitted by Senator Tammy Baldwin
    Focal segmental glomerulosclerosis (FSGS)
        Question. What is the current status of NIH research and investment
    into FSGS?
        What actions is the NIH able to take to increase activities
    relating to FSGS?
        What resources would NIH need to better support research on FSGS?
        Answer. The National Institutes of Diabetes and Digestive and
    Kidney Diseases (NIDDK) supports a robust research program on focal
    segmental glomerulosclerosis (FSGS) and other rare kidney diseases.
    Projects to better understand their causes and improve their treatment
    include the NIDDK-led Nephrotic Syndrome Study Network (NEPTUNE) and
    Cure Glomerulonephropathy Consortium (CureGN), both long-term studies
    of rare glomerular kidney diseases, are playing key roles in advancing
    FSGS research. Currently, 850 children and adults with FSGS are
    participating in these research programs, which are exploring disease
    mechanisms, biomarkers, and candidate treatment targets. Importantly,
    seminal research at NIDDK identified a genetic kidney disease risk
    mediator, APOL1, and found that individuals with high-risk APOL1
    genotypes--primarily people of West African descent--have a greater
    risk for FSGS and kidney failure. Current research therefore seeks to
    clarify the role of APOL1 in aggravating outcome disparities in FSGS
    and other kidney diseases, and to identify better treatment and
    prevention approaches for people with these genetic variants. Other
    ongoing NIDDK-supported research also aims to better understand FSGS
    disease mechanisms and markers of risk for recurrence after kidney
    transplant, with the goal of improving therapy for all people with the
    disease.
        NIDDK is investing in the future of research on kidney diseases
    such as FSGS by expanding its support for training programs through a
    new initiative known as KUH FAMILY, which is coordinating training
    programs for junior researchers in kidney, urologic, and hematologic
    research (K, U, and H). To better engage trainees and retain them in
    the KUH research community, the program will provide opportunities for
    trainees to: (1) connect with other trainees across the nation via a
    national peer-to-peer network; and (2) access the growing number of
    novel, modernized career development resources generated by the KUH
    FAMILY and previous training programs. In addition, the KUH FAMILY will
    provide support to ongoing institutional training programs, coordinate
    annual meetings and large-scale program evaluations, and promote
    continuous improvement activities. The NIDDK continues to encourage new
    research proposals from FSGS investigators to increase our
    understanding and treatment of this disease and other rare kidney
    diseases.
    All of Us Research Program and the BRAIN Initiative
        Question. Dr. Bertagnolli, back in March, I had a chance to sit
    down with you and Dr. Josh Denny to discuss how the All of Us Research
    Program's rich diverse dataset is now a vital resource for medical
    researchers across the whole of NIH and at other institutions around
    the country. All of Us has over 800,000 diverse Americans from all 50
    states and U.S. territories which provides researchers access to the
    world's largest and most diverse dataset of its kind. I'm very proud
    that institutions in my state of Wisconsin such as the Marshfield
    Clinic and the University of Wisconsin in Madison have played a
    critical part in advancing the program and enrolling many of these
    participants.
        Likewise, the BRAIN Initiative supports breakthrough research to
    revolutionize our understanding of the human brain and develop new ways
    to treat, cure, and even prevent brain disorders. The Cures Act
    provides dedicated funding to the All of Us and BRAIN Initiative
    programs in FY25, but due to annual fluctuations in Cures Act funding,
    they face a $280 million decrease. Combined with the $678 million
    decrease Cures Act programs saw in FY24, I'm concerned these program
    are facing dramatic cuts that could endanger much of the progress we've
    seen since these unique programs were launched. They could face an up
    to 71% cut in FY25 unless this mandatory funding is restored.
        What happens to programs like All of Us and the BRAIN Initiative in
    a scenario where 30-70% of their funding is cut? What is the impact on
    the scientific breakthroughs that we hoped would come from them?
        Answer. The All of Us Research Program is an ambitious, visionary
    effort to put the United States at the forefront of personalized
    medicine, which is possible because of the diversity of our nation. The
    scientific breakthroughs we are beginning to see with personalized
    medicine are only possible when the program has the funding to engage
    and enroll participants that have been traditionally underrepresented
    in biomedical research. But due to the $184 million reduction of Cures
    Act funding in FY 2024, All of Us had to reduce funding significantly
    for all awards for the Program,\1\ diminishing many program activities
    and functions and resulting in an estimated 600-800 staff layoffs
    across the nation-wide consortium of partners. For example, the All of
    Us Wisconsin consortium's budget was cut 83 percent, resulting in a 78
    percent reduction in staff; the University of Alabama in Birmingham's
    award was cut from $12 million to $3.2 million; and the Program's
    newest regional medical center, the Heartland Consortium led by the
    University of Kansas, saw their award reduced from $6 million to $2.8
    million. These partners all contribute to the Program's ability to
    engage with individuals in rural communities. Additionally, All of Us
    planned to support two to three new enrollment awards focused on
    enrolling children in response to a Research Opportunity Announcement
    OTA-22-006,\2\ but we cannot make those additional awards and will not
    launch pediatric enrollment this year.
    ---------------------------------------------------------------------------
        \1\ allofus.nih.gov/news-events/announcements/all-us-ceo-keeping-
    our-momentum-amidst-funding-uncertainties.
        \2\ sam.gov/opp/69da7ceff0e4456b9fad4b15f074d4de/view.
    ---------------------------------------------------------------------------
        If the Cures Innovation Fund decrease is not addressed in FY 2025,
    the Program's funding level will be cut by 71 percent in two fiscal
    years, resulting in additional layoffs estimated at 1,500 to 2,000
    across the nation-wide All of Us consortium of partners. Under that
    scenario, All of Us will prioritize the security of the biosamples and
    the data already provided by the 800,000+ existing participants (as of
    May 2024), requiring the Program to stop all in-person enrollment at
    physical locations nationwide. This effort will curb the recruitment of
    underrepresented populations, impacting the study's diversity,
    representativeness, and usefulness of the data, potentially skewing
    research findings and undermining efforts to understand health
    disparities. Research aimed at understanding the optimal treatments for
    chronic diseases such as diabetes, heart disease, and cancer could be
    severely delayed. Currently the data have been accessed by more than
    10,000 researchers asking questions across some of our most critical
    disease areas. Cuts this significantly will impede the development of
    personalized treatments that can significantly improve patient outcomes
    and reduce healthcare costs, reducing efforts to achieve equity in
    healthcare access and effectiveness across different demographic
    groups. More funding cuts in FY 2025 will limit genomic sequencing
    efforts, delaying breakthroughs in genetic therapies and understanding
    genetic predispositions to diseases. Furthermore, the comprehensive
    data from All of Us supports the identification of biomarkers for
    disease, which in turn aids in developing targeted therapies. With
    reduced funding, fewer resources will be available for biomarker
    discovery and validation, slowing the development of new, more
    effective drugs. Another critical area affected by funding cuts is the
    genetic return of individual results to participants, including
    information on an individual's risk for certain diseases and potential
    responses to commonly used drugs. With further funding cuts, fewer
    genetic findings will be returned to participants, limiting
    opportunities to impact the health of those who have already enrolled
    or would enroll in a longitudinal program like All of Us. Finally, this
    will cause the program to further delay enrollment of children, which
    can accelerate discoveries and deepen our knowledge regarding risk
    factors, effective preventions, and therapeutic approaches during
    childhood and throughout the lifespan.
        NIH's The BRAIN Initiative was launched in 2014 with the goal of
    revolutionizing our understanding of the human brain, the most complex
    organ in the body whose very complexity leaves us vulnerable to
    devastating diseases. To date, the BRAIN Initiative's intentional focus
    on technology and resource development has built and cultivated a rich
    ecosystem of inclusive, open, and ethical research that is rapidly
    advancing the field in three fundamentally important ways: (1) by
    bringing novel technology-driven treatments to the clinic today for
    devastating neurological, mental, and substance use disorders, (2) by
    laying the basic science foundation for future cures through the
    development of large scale experimental and data resources, and (3) by
    changing the culture of science, building highly effective multi-
    disciplinary teams to solve problems outside the grasp of traditional
    disciplines. The BRAIN Initiative undergirds brain research relevant to
    the missions of all NIH Institutes, Centers, and Offices (ICs) and
    supports projects that would not be possible within a single Institute.
    Simply put, these are projects that would not be funded by any one IC
    at the scale, depth, and breadth required to yield the impact that
    BRAIN-funded projects are currently providing.
        Because of fluctuations in the Cures Act authorizations and the
    reduction of base appropriations to the BRAIN Initiative in FY 2023,
    the current $402 million FY 2024 appropriation for the BRAIN Initiative
    reflects a $278 million or 40 percent decrease relative to FY 2023's
    $680 million top-line appropriation. This has forced a 50 percent
    reduction in funds available to support new awards in FY 2024, creating
    numerous lost opportunities in innovation, discovery, and treatments
    for human brain disorders. If not resolved, a further $81 million
    reduction in FY 2025 Cures Act funds would lead to a devastating
    situation, in which the Initiative could fund only 20 percent of new
    awards in FY 2025 compared to previous years, leaving even more
    lifechanging research on the table. Together these year-over-year
    reductions will have a severe impact on the ability of the BRAIN
    Initiative to fulfill its mission and delay desperately needed
    treatments, cures and preventions to those living with brain disorders,
    such as Alzheimer's disease, Parkinson's disease, debilitating
    depression and other mental disorders, substance use disorder and more.
    Women's health research
        Question. NIH currently spends 10 percent of its overall funding on
    women's health research. The President's Budget proposes a $76 million
    increase for the Office of Research on Women's Health, doubling its
    budget. What activities would these additional funds support?
        Answer. The mission of the NIH Office of Research on Women's Health
    (ORWH) is to: enhance research related to diseases, disorders, and
    conditions affecting women; help ensure that women are appropriately
    represented in biomedical research supported by the NIH; and improve
    the advancement of women in biomedical careers. In FY 2025, ORWH plans
    to use a requested budget increase to fund a range of new and ongoing
    activities to enhance research into women's health issues. The increase
    will also allow ORWH to support cross-NIH initiatives aligned with the
    newly issued 2024-2028 NIH-Wide Strategic Plan for Research on the
    Health of Women,\3\ key objectives highlighted below, to promote sex
    and gender equity across all domains of research.
    ---------------------------------------------------------------------------
        \3\ orwh.od.nih.gov/sites/orwh/files/docs/ORWH_NIH-
    Wide%20Strategic%20Plan_FY2024-2028-508C.pdf.
    ---------------------------------------------------------------------------
      --Expand research to address additional critical contemporary women's
            health issues such as high rates of hypertension and
            cardiometabolic diseases and the greater prevalence of multiple
            chronic diseases, including mental health and autoimmune
            diseases, among others, in women.
      --Support Interdisciplinary and Innovative Women's Health Research to
            catalyze and accelerate the translation of science advances to
            practical benefits on midlife health of women, menopause, and
            chronic diseases.
      --Support research aimed at reducing the prevalence and impact of
            mental health disorders, substance use disorders, chronic
            stress, cardiopulmonary diseases, common metabolic disorders
            (e.g., diabetes), and cancer.
      --Support data science infrastructure and big data methods (e.g.,
            data standardization, access and sharing, artificial
            intelligence) to accelerate collaboration, innovation, and
            interdisciplinary advances for diagnosis, treatment, and
            prevention of complex diseases that cannot be answered by one
            discipline alone.
      --Expand existing training and mentoring support for programs by
            increasing the cadre of women's health researchers and
            connecting them to settings to meet the growing needs of
            getting evidence-based women healthcare to people faster for
            maternal and postpartum health through innovative approaches
            and models, improving continuity of care, engaging communities,
            developing the workforce, and increased partnerships.
                                     ______

                Questions Submitted by Senator Joe Manchin, III
        Question. Dr. Bertagnolli, thank you for joining Senator Capito and
    I while visiting West Virginia University (WVU)'s Health Science Center
    and its leaders this past March to learn more about the unique health
    issues impacting West Virginians and to see firsthand how WVU is using
    NIH funding to support research that addresses health disparities
    across the state and within Appalachia. While WVU and other colleges
    and universities in the state are making inroads, West Virginia
    continues to rank high in incidences of disease, injury, and poor
    health behaviors--ranking first for cardiovascular disease, diabetes,
    obesity; deaths related to cancer and opioid overdose; and with the
    second lowest life expectancy and fourth highest infant mortality.
        What can NIH do to help expand the medical research footprint in
    rural states like West Virginia so we can tackle high disease burdens
    and low life expectancy?
        Answer. The National Institute of General Medical Sciences (NIGMS),
    through the Congressionally mandated Institutional Development Award
    (IDeA) program, supports research capacity building in states and
    jurisdictions that historically have had low levels of NIH funding,
    including many rural states. In particular, the IDeA Clinical and
    Translational Research Networks (CTR-N) program funds statewide
    networks that build capacity for clinical and translational research in
    IDeA states, with a focus on health issues relevant to each state.\4\
    The West Virginia Clinical and Translational Science Institute (WVCTSI)
    is one example of a successful CTR-N that has established a highly
    collaborative, statewide research infrastructure to address the
    substantial health disparities in West Virginia such as addiction and
    resulting emerging epidemics (such as hepatitis C), cancer,
    cardiovascular disease, and chronic lung disease. Since FY 2020, the
    program has required CTR-Ns to work with community clinics and primary
    care physicians affiliated with Practice-Based Research Networks (PBRN)
    in their state(s) to better engage patients throughout the state,
    including those in more rural areas. WVCTSI has expanded its PBRN 22
    percent over the past year to include 131 clinics across the state.
    ---------------------------------------------------------------------------
        \4\ nigms.nih.gov/Research/DRCB/IDeA/Pages/idea-ctrp.aspx.
    ---------------------------------------------------------------------------
      --One difficulty with engaging rural clinics in clinical and
            translational research is access to technology that would
            facilitate local clinical trial participation. To address this
            issue, NIGMS has been funding Supplements to Advance the Use of
            Electronic Health Records for Research. Many CTR-Ns, including
            WVCTSI, have used this funding to upgrade software at rural
            community clinics to help their patients become ``findable''
            for clinical research participation. In addition, with support
            from NIGMS funding, WVCTSI is set to launch a mobile clinical
            trials unit to expand clinical trial participation in rural
            communities by taking the research to the people.
      --Another challenge for clinical research in IDeA states lies in the
            training and resources to expand clinical trial availability.
            NIGMS funded the IDeA States Consortium for Clinical Research
            (ISCORE), a partnership between nine CTR-Ns and two IDeA state
            CTSAs, to serve as a clinical research resource center for all
            of the CTRs, as well as other institutions in IDeA states.\5\
            The ISCORE Resource Center, based at West Virginia University,
            will help CTR-Ns develop collaborations with clinical trial
            sponsors and build a cohort of clinical research coordinators
            to manage clinical trials so that CTR-Ns can better address
            health conditions with high prevalence among medically
            underserved populations in IDeA states.
    ---------------------------------------------------------------------------
        \5\ iscorerc.org.
    ---------------------------------------------------------------------------
        Question. I noticed with great interest of the recent announcement
    that NIH will support Network Research Hubs to Integrate Clinical
    Research into Primary Care settings. Can you explain how you envision
    these hubs will work and how would their efforts would help medically
    underserved and disadvantaged populations?
        Answer. Many communities across the United States are
    underrepresented or historically underserved in clinical research and
    are often disproportionately impacted by illness and disease. As a
    result, clinical studies frequently do not sufficiently produce results
    that are applicable to these communities. Communities Advancing
    Research Equity for HealthTM (CARE for HealthTM)
    will allow us to connect with patients and providers, earning trusted
    partnerships and engaging with community-guided opportunities to
    integrate the research we do into the routine clinical care patients
    receive. The program's Network Research Hubs will leverage existing
    research networks and partnerships with clinical sites to support
    clinical research in primary care settings. Participating sites will be
    able to select and collaboratively design the studies they want to
    offer their patients, directly driving research to best meet community-
    identified needs. We hope that by enhancing access to research
    opportunities, particularly among those historically underrepresented
    and underserved in research, we will have a meaningful impact on health
    treatment and outcomes.
        Question. Doctors of Osteopathic Medicine (DOs) are trained and
    licensed to provide osteopathic manipulative medicine (OMM), a hands-on
    treatment used to diagnose and treat illness and injury that can be
    used to treat structural and functional issues in the bones, joints,
    tissues and muscles of the body. OMM is a non-pharmacological solution
    to pain management that requires more research. Every year, the West
    Virginia School of Osteopathic Medicine (WVSOM) holds an annual Student
    Osteopathic Manipulative Medicine Clinic for residents of Lewisburg and
    surrounding areas.
        As you know, the opioid epidemic has ravaged West Virginia like no
    other state. Every family in our state has been affected by this
    horrible epidemic and we must continue to address this crisis so that
    our communities can continue to recover. That is why I have been
    supportive of legislation that ensures non-opioid treatments are used
    whenever possible.
        What are the NIH's plans to increase and expand research into the
    use of osteopathic manipulative medicine as a non-addictive alternative
    to opioids for pain management?
        Answer. Research into non-pharmacologic and non-addictive
    techniques for pain management is a very important area of science
    supported by the NIH. The Helping to End Addiction Long-term
    Initiative, or the NIH HEAL Initiative, supports a number of programs
    focused on reducing opioid prescribing, improving pain management, and
    treating opioid-use disorders. The National Center for Complementary
    and Integrative Health (NCCIH) focuses solely on non-pharmacologic
    treatments and devotes approximately 40 percent of its budget to pain
    research.
        Physicians with a Doctor of Osteopathic Medicine (D.O.) degree
    represent an important component of the medical community. They
    straddle the complementary, integrative health, and allopathic medical
    practices and have historically been connected to NCCIH through the
    practice of osteopathic manipulation. Osteopathic manipulation is a
    full-body system of hands-on techniques to alleviate pain, restore
    function, and promote health and wellbeing. This and other manual
    therapies are of interest to NCCIH. In 2022, NCCIH in partnership with
    the National Institute of Neurological Disorders and Stroke (NINDS)
    launched three new research networks focused on studying the effects of
    mechanical forces on the human body. These exciting research networks
    bring together scientists that study neural systems with clinicians who
    use force-based manipulations--such as massage therapy, spinal
    manipulation or acupuncture--to treat health problems. These span basic
    research through dissemination and implementation science. However,
    NCCIH does not receive many applications from D.O.s or Colleges of
    Osteopathic Medicine. In the last 5 years, NCCIH has received 2,738
    scientific grant applications; of those only six applications have been
    from D.O.s or Colleges of Osteopathic Medicine. This suggests that the
    most impactful way to expand research into the use of osteopathic
    manipulative medicine is to increase the number of grant applications
    submitted from D.O.s or Colleges of Osteopathic Medicine.
        NIH is making efforts to increase the number of applications for
    osteopathic research through conversations with organizations
    representing osteopathic physicians and specific funding opportunities
    for clinician-scientists, which includes D.O.s. Examples of such
    programs include but are not limited to: Mentored Clinical Scientist
    Research Career Development Awards, Clinical Scientist Institutional
    Career Development program, Academic Research Enhancement Award
    program, Mentored Patient-Oriented Research Career Development Award,
    and the Loan Repayment Program. In addition to these efforts, NCCIH has
    launched one and plans to launch an additional Research Across
    Complementary and Integrative Health Institutions (REACH) Center. The
    idea of these Centers is to foster institutional partnerships between
    large research institutions and smaller complementary and integrative
    health institutions, including Schools of Osteopathic Medicine, to
    perform the necessary administrative functions related to writing and
    submitting a competitive grant application and conducting research.
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
    NIH Proposal on Promoting Equity Through Access Planning RFI
        Question. Is this policy proposal intended to be complimentary to
    the NIST March In Rights proposal or separate?
        Public comments are due on July 22, 2024. Do you have an expected
    timeline for finalizing a proposal?
        Answer. All NIH activities are driven by the principle that our
    work is not finished when we deliver scientific discoveries; our work
    is finished when all people are living long and healthy lives. To
    advance this aim, NIH is seeking comment on a policy proposal that
    would require licensees that succeed in bringing products based on
    certain NIH-owned inventions toward market submit a plan outlining
    steps they intend to take to promote patient access to those products.
    This proposal, if implemented, would affect inventions developed by
    government scientists at the NIH Intramural Research Program, and makes
    it clear that access is of paramount importance in providing a return
    on taxpayers' investment in biomedical research. At this time, NIH is
    seeking comments on this proposal through mid-July and those comments
    will be critical in informing the nature of any final policy or
    timelines for implementation.
        While NIH's access planning efforts are complementary to the USG
    efforts to make products available to patients, this work is distinct
    from review of the use of march-in authority as laid out in the Bayh-
    Dole Act. However, both endeavors reflect NIH's commitment to efforts
    to improve the health of all Americans and advance innovation
    consistent with the interests of the American public.
    Osteopathic Research and Representation at NIH
        Question. What will the NIH do this year to increase utilization of
    osteopathic researchers to improve primary care and preventative
    research?
        Answer. The National Institutes of Health (NIH) is dedicated to
    strengthening and diversifying the biomedical research workforce,
    including for physician scientists. As part of this effort, NIH
    continues to address recommendations described in a 2014 report focused
    on the physician-scientist workforce from the NIH Advisory Committee to
    the Director (ACD).\6\ NIH agrees with the report's conclusion that
    ``findings which lead to advances in practice are driven largely by the
    work of investigators with a variety of degrees, of whom those with
    clinical training contribute essential knowledge and skills.''
    Physician-scientists represent vital investment in research discovery
    and innovation. These researchers help transform clinical observations
    into hypotheses and research findings into medical advances.
    ---------------------------------------------------------------------------
        \6\ acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf.
    ---------------------------------------------------------------------------
        Though there are no plans to release funding opportunities specific
    for osteopathic research, osteopathic medical schools (and their
    principal investigators) are welcome to review and apply for any NIH
    funding opportunities in the same way other organizations seeking NIH
    support do. Osteopathic medical schools could also consider referencing
    their medical principles in their grant applications in response to
    current funding opportunities to highlight how these principles help
    strengthen the scientific and technical merit of the proposed research.
    NIH would also recommend interested osteopathic medical schools and
    Doctors of Osteopathic Medicine (D.O.s) follow the NIH Guide for Grants
    and Contracts to learn about new biomedical and behavioral research
    grant policies, guidelines, and funding opportunities. They should also
    contact appropriate program staff at NIH to discuss potential funding
    opportunities, as well as participate in planned webinars and other
    outreach activities available to all organizations to learn more about
    NIH programs and policies (some of which are promoted through the NIH
    Extramural Nexus newsletter).
        NIH recognizes that strengthening the future workforce includes
    fostering opportunities for physician-scientists with osteopathic
    medical degrees. Physicians with a D.O. degree represent an important
    component of the medical system at the intersection of the
    complementary, integrative health, and allopathic medical communities.
    These physicians practice osteopathic manipulation, a full-body system
    of hands-on techniques to alleviate pain, restore function, and promote
    health and wellbeing.
        This promising approach is of interest to the National Center for
    Complementary and Integrative Health (NCCIH), and the Center makes
    every effort to ensure that D.O.s have representation on its advisory
    council. NCCIH currently has two members with D.O. degrees on its 18-
    member council.\7\ Though they have historically been connected to the
    NCCIH, D.O.s have also been designated on applications submitted to and
    awarded from other NIH Institutes and Centers. Similarly, D.O.s also
    serve in other peer review capacities across NIH Institutes and Centers
    in addition to NCCIH.
    ---------------------------------------------------------------------------
        \7\ nccih.nih.gov/about/naccih-member-roster.
    ---------------------------------------------------------------------------
        Table 1 lists the total funding and number of awards (both
    competing and non-competing) NIH made to osteopathic medical schools in
    fiscal years (FYs) 2020 to 2023.
        Table 1. Number of NIH Research Project Grant Awards and Funding to
    Osteopathic Medical Schools: FYs 2020-2023

    ------------------------------------------------------------------------
                                                                    Total
                      Fiscal Year                      Awards      Funding
    ------------------------------------------------------------------------
    2020..........................................           71  $42,618,974
    2021..........................................           58  $35,426,785
    2022..........................................           72  $43,408,636
    2023..........................................           69  $39,161,807
    ------------------------------------------------------------------------

        Table 2 shows the success rate for competing research project grant
    \8\ applications submitted by investigators in osteopathic medical
    schools between FYs 2020 and 2023. The success rate is an application-
    based metric that is calculated by dividing the number of awards made
    in a FY by the number of applications.\9\ NIH receives few applications
    from osteopathic medical schools, but their success rates are generally
    in line with overall NIH success rates.\10\ Again, NIH encourages
    osteopathic medical schools to review and apply for funding
    opportunities that are also available to the entire research community.
    ---------------------------------------------------------------------------
        \8\ grants.nih.gov/grants/glossary.htm#ResearchProjectGrant(RPG).
        \9\ nexus.od.nih.gov/all/2022/03/07/fy-2021-by-the-numbers-
    extramural-grant-investments-in-research/.
        \10\ report.nih.gov/nihdatabook/report/201.
    ---------------------------------------------------------------------------
        Table 2. Success Rate for Competing Research Project Grant
    Applications from Osteopathic Medical Schools: FYs 2020-2023

    ------------------------------------------------------------------------
                                                                   Success
               Fiscal Year            Applications     Awards        Rate
    ------------------------------------------------------------------------
    2020............................           119           20        16.8%
    2021............................            70           18        25.7%
    2022............................           144           25        17.4%
    2023............................           120           22        18.3%
    ------------------------------------------------------------------------

        NCCIH and other NIH ICs have specific opportunities for clinician-
    scientists, including D.O.s, who conduct research across a wide range
    of complementary and integrative health approaches. Osteopathic medical
    schools and D.O.s should consider applying for these and other funding
    opportunities. Examples of such programs include, but are not limited
    to:
      --Communities Advancing Research Equity (CARE) for Health \11\
      --HEAL Prevention and Management of Chronic Pain in Rural Populations
            program \12\
      --Mentored Clinical Scientist Research Career Development Awards \13\
      --Clinical Scientist Institutional Career Development program \14\
      --Academic Research Enhancement Award program \15\
      --Mentored Patient-Oriented Research Career Development Award \16\
      --Loan Repayment Program \17\
    ---------------------------------------------------------------------------
        \11\ nih.gov/news-events/news-releases/nih-launches-30-million-
    pilot-test-feasibility-national-primary-care-research-network.
        \12\ heal.nih.gov/research/clinical-research/chronic-pain-rural-
    populations.
        \13\ researchtraining.nih.gov/programs/career-development/K08.
        \14\ researchtraining.nih.gov/programs/career-development/k12.
        \15\ grants.nih.gov/grants/funding/r15.htm.
        \16\ researchtraining.nih.gov/programs/career-development/K23.
        \17\ lrp.nih.gov/.
    ---------------------------------------------------------------------------
                                     ______

                  Questions Submitted by Senator John Kennedy
        Question. Director Bertagnolli, the NIH has long resisted moving
    their chimpanzees from the Alamogordo Primate Facility to Chimp Haven
    in Louisiana, despite a clear congressional mandate to do so. These
    chimpanzees have remained in the same facility where they underwent
    experimental research for decades. According to your own agency, these
    chimpanzees are anticipated to live for many more years, justifying the
    need for annual revaluations.
        With this in mind, why does the NIH continue to refuse to relocate
    these chimps?
        Answer. NIH has already moved 494 chimpanzees to Chimp Haven
    between 2005 (when the sanctuary opened) and May 2024, including 75
    chimpanzees from the Alamogordo Primate Facility (APF); some of these
    chimpanzees had chronic health issues, but their disease progression
    was not at levels that would compromise successful relocation,
    introduction, and integration into new social groups. In contrast, the
    transport and integration of the remaining chimpanzees at APF would not
    be safe. Their health status puts them at high risk of dying during the
    transport or integration process. Since it is the responsibility and
    obligation of NIH to protect the health and welfare of the chimpanzees,
    we are unwilling to risk having them die in transport or shortly
    thereafter. As of May 23, 2024, twenty-four chimpanzees remain at APF
    and are in health category V, which consists of animals that have been
    diagnosed with life-threatening, systemic disease that poses a constant
    threat and could result in abrupt death. More details about this health
    category can be found at Chimpanzee Health Categorization Framework:
    Harmonized Across NIH-supported Facilities.\18\
    ---------------------------------------------------------------------------
        \18\ orip.nih.gov/sites/default/files/
    ChimpanzeeHealthCategorizationFrameworkFinal_508.pdf.
    ---------------------------------------------------------------------------
        In Humane Society of the United States, et al. vs. National
    Institutes of Health, et al., No. 8:2021cv00121, NIH stated that it
    reads the Court's December 13, 2022, Decision to hold that the ``CHIMP
    Act mandates the transfer of all APF Chimpanzees to Chimp Haven,'' ECF
    No. 54 at 13, unless a chimpanzee is ``moribund.'' ECF No. 70 at 3. NIH
    further stated that, ``[s]ince before this litigation began, NIH has
    used that term [moribund] to refer to chimpanzees placed in Class V on
    the rating scale NIH created after a lengthy scientific process--those
    animals with `life-threatening, systemic disease that poses a constant
    threat and could result in abrupt death.' Id. NIH has categorized each
    remaining APF Chimpanzee as being in Class V, and thus as `moribund'
    based on the agency's understanding of that term. Id. NIH plans to
    annually reevaluate each of the APF Chimpanzees, as urged by Congress,
    to consider whether they continue to be ``moribund'' or if they are no
    longer ``moribund'' and can be safely transported to Chimp Haven.'' Id.
        Question. Also, why does the NIH continue to express this position
    when in 2022 a Federal judge ruled that your agency was in violation of
    Federal law by refusing to move these chimps?
        Answer. On December 13, 2022, in its decision, the Court declined
    to direct NIH to transfer the chimpanzees at Alamogordo to Chimp Haven.
    In doing so, the Court stated: ``NIH has unique expertise regarding the
    transfer and care of the APF Chimpanzees that must also be taken into
    account when considering whether to [order a transfer] ECF No. 54 at 3-
    4, 12. Notably, Congress has afforded discretion to NIH to make
    decisions about how best to safely accomplish the transfer of the APF
    Chimpanzees. These considerations . . . caution against the Court
    imposing a deadline, or other directives, on NIH regarding the timing
    and method of the transfer of the APF Chimpanzees. Indeed, as the Court
    observed in its December 13, 2022, Decision, `the Court recognizes and
    appreciates the difficult policy and practical considerations that NIH
    must confront in determining how best to ensure the health and safety
    of the frailest APF Chimpanzees, when transporting these chimpanzees to
    the Federal sanctuary system.' ECF No., 53 at 12. [A transfer order]
    would improperly supplant NIH's discretion in this regard.'' ECF No. 73
    at 7.
        Question. In response to my colleague Senator Lujan's question
    during your confirmation hearing, you wrote in your written response
    that ``. . .I am committed to carrying out the goals of the CHIMP Act
    to ensure that these chimpanzees get the sanctuary and care they
    deserve.'' I would like an update on NIH's work to carry out your
    commitment to get these chimpanzees to Chimp Haven.
        Answer. As noted in prior filings with the district court (ECF 55
    at 6, ECF 70 at 3), NIH plans to re- evaluate each chimpanzee on an
    annual basis to determine whether they can be safely transported to
    Chimp Haven, taking into account each chimpanzee's health conditions
    and the unavoidable and inevitable stresses that result from transport
    and transfer of animals from one facility to another. Annual reviews by
    NIH will begin in summer/fall 2024. NIH remains fully committed to
    complying with the relevant animal welfare laws and policies and
    ensuring the safety and care of all NIH-owned and -supported
    chimpanzees.
        The APF has been and will remain a chimpanzee care facility; no
    biomedical research has been or will be conducted at APF since NIH took
    over management of the facility in 2001. NIH will continue to monitor
    the chimpanzee care program at APF to ensure that chimpanzee care is
    provided at the highest standards expected by the NIH.
        Question. Colleges of Osteopathic Medicine (COMs) are critically
    underrepresented and underfunded by the NIH, despite educating a
    quarter of U.S. medical students. DO medical schools receive only $62
    million in NIH grants compared to $23 billion for MD schools, and DO
    representation is almost nonexistent on NIH study councils and study
    sections. Congress raised these concerns in the FY22, 23 and 24 omnibus
    appropriations bills (Public Laws 117-103; 117-328; and 118-47) and in
    a 2022 letter, yet the NIH has taken no overt action to address the
    concerns raised by Congress.
        What will NIH be doing this year to address the agency's chronic
    underfunding of osteopathic research and underrepresentation of
    osteopathic scientists?
        Answer. The National Institutes of Health (NIH) is dedicated to
    strengthening and diversifying the biomedical research workforce,
    including for physician scientists. As part of this effort, NIH
    continues to address recommendations described in a 2014 report focused
    on the physician- scientist workforce from the NIH Advisory Committee
    to the Director (ACD).\19\ NIH agrees with the report's conclusion that
    ``findings which lead to advances in practice are driven largely by the
    work of investigators with a variety of degrees, of whom those with
    clinical training contribute essential knowledge and skills.''
    Physician-scientists represent vital investment in research discovery
    and innovation. These researchers help transform clinical observations
    into hypotheses and research findings into medical advances.
    ---------------------------------------------------------------------------
        \19\ acd.od.nih.gov/documents/reports/PSW_Report_ACD_06042014.pdf.
    ---------------------------------------------------------------------------
        Though there are no plans to release funding opportunities specific
    for osteopathic research, osteopathic medical schools (and their
    principal investigators) are welcome to review and apply for any NIH
    funding opportunities in the same way other organizations seeking NIH
    support do. Osteopathic medical schools could also consider referencing
    their medical principles in their grant applications in response to
    current funding opportunities to highlight how these principles help
    strengthen the scientific and technical merit of the proposed research.
    NIH would also recommend interested osteopathic medical schools and
    Doctors of Osteopathic Medicine (D.O.s) follow the NIH Guide for Grants
    and Contracts to learn about new biomedical and behavioral research
    grant policies, guidelines, and funding opportunities. They should also
    contact appropriate program staff at NIH to discuss potential funding
    opportunities, as well as participate in planned webinars and other
    outreach activities available to all organizations to learn more about
    NIH programs and policies (some of which are promoted through the NIH
    Extramural Nexus newsletter).
        NIH recognizes that strengthening the future workforce includes
    fostering opportunities for physician-scientists with osteopathic
    medical degrees. Physicians with a D.O. degree represent an important
    component of the medical system at the intersection of the
    complementary, integrative health, and allopathic medical communities.
    These physicians practice osteopathic manipulation, a full-body system
    of hands-on techniques to alleviate pain, restore function, and promote
    health and wellbeing.
        This promising approach is of interest to the National Center for
    Complementary and Integrative Health (NCCIH), and the Center makes
    every effort to ensure that D.O.s have representation on its advisory
    council. NCCIH currently has two members with D.O. degrees on its 18-
    member council.\20\ Though they have historically been connected to the
    NCCIH, D.O.s have also been designated on applications submitted to and
    awarded from other NIH Institutes and Centers. Similarly, D.O.s also
    serve in other peer review capacities across NIH Institutes and Centers
    in addition to NCCIH.
    ---------------------------------------------------------------------------
        \20\ nccih.nih.gov/about/naccih-member-roster.
    ---------------------------------------------------------------------------
        Table 1 lists the total funding and number of awards (both
    competing and non-competing) NIH made to osteopathic medical schools in
    fiscal years (FYs) 2020 to 2023.
        Table 1. Number of NIH Research Project Grant Awards and Funding to
    Osteopathic Medical Schools: FYs 2020-2023

    ------------------------------------------------------------------------
                                                                    Total
                      Fiscal Year                      Awards      Funding
    ------------------------------------------------------------------------
    2020..........................................           71  $42,618,974
    2021..........................................           58  $35,426,785
    2022..........................................           72  $43,408,636
    2023..........................................           69  $39,161,807
    ------------------------------------------------------------------------

        Table 2 shows the success rate for competing research project grant
    \21\ applications submitted by investigators in osteopathic medical
    schools between FYs 2020 and 2023. The success rate is an application-
    based metric that is calculated by dividing the number of awards made
    in a FY by the number of applications.\22\ NIH receives few
    applications from osteopathic medical schools, but their success rates
    are generally in line with overall NIH success rates.\23\ Again, NIH
    encourages osteopathic medical schools to review and apply for funding
    opportunities that are also available to the entire research community.
    ---------------------------------------------------------------------------
        \21\ grants.nih.gov/grants/glossary.htm#ResearchProjectGrant(RPG).
        \22\ nexus.od.nih.gov/all/2022/03/07/fy-2021-by-the-numbers-
    extramural-grant-investments-in-research/.
        \23\ report.nih.gov/nihdatabook/report/201.
    ---------------------------------------------------------------------------
        Table 2. Success Rate for Competing Research Project Grant
    Applications from Osteopathic Medical Schools: FYs 2020-2023

    ------------------------------------------------------------------------
                                                                   Success
               Fiscal Year            Applications     Awards        Rate
    ------------------------------------------------------------------------
    2020............................           119           20        16.8%
    2021............................            70           18        25.7%
    2022............................           144           25        17.4%
    2023............................           120           22        18.3%
    ------------------------------------------------------------------------

        NCCIH and other NIH ICs have specific opportunities for clinician-
    scientists, including D.O.s, who conduct research across a wide range
    of complementary and integrative health approaches. Osteopathic medical
    schools and D.O.s should consider applying for these and other funding
    opportunities. Examples of such programs include, but are not limited
    to:
      --Communities Advancing Research Equity (CARE) for Health\24\
      --HEAL Prevention and Management of Chronic Pain in Rural Populations
            program\25\
      --Mentored Clinical Scientist Research Career Development Awards\26\
      --Clinical Scientist Institutional Career Development program\27\
      --Academic Research Enhancement Award program\28\
    ---------------------------------------------------------------------------
        \24\ nih.gov/news-events/news-releases/nih-launches-30-million-
    pilot-test-feasibility-national-primary-care-research-network.
        \25\ heal.nih.gov/research/clinical-research/chronic-pain-rural-
    populations.
        \26\ researchtraining.nih.gov/programs/career-development/K08.
        \27\ researchtraining.nih.gov/programs/career-development/k12.
        \28\ grants.nih.gov/grants/funding/r15.htm.
    ---------------------------------------------------------------------------
      --Mentored Patient-Oriented Research Career Development Award \29\
    ---------------------------------------------------------------------------
        \29\ researchtraining.nih.gov/programs/career-development/K23.
    ---------------------------------------------------------------------------
      --Loan Repayment Program \30\
    ---------------------------------------------------------------------------
        \30\ lrp.nih.gov/.
    ---------------------------------------------------------------------------
                                     ______

                  Questions Submitted by Senator John Boozman
        Question. Arkansas is currently struggling with the highest
    maternal mortality rate in the country, and the entire state has come
    together over the last year to find ways to improve the crisis. I am
    intrigued by the work NIH is doing in the maternal health space,
    including the launch of the IMPROVE Initiative, and was pleased to see
    a geographically diverse group of institutions chosen as the centers of
    excellence.
        Will any of the research be focused on rural areas and the unique
    set of factors impacting outcomes for women in rural areas?
        Answer. NIH is committed to improving health for all pregnant and
    postpartum women, which includes addressing the unique needs of women
    in rural areas who may not have access to specialized healthcare or
    technologies. This commitment is built into the IMPROVE initiative,
    including the Maternal Health Research Centers of Excellence, which
    focus on populations with known health disparities, including tribal
    communities, and those living in underserved and rural areas. These
    centers are working to develop and implement community-driven
    interventions, as well as supporting training and professional
    development of maternal health researchers, including those from
    underrepresented backgrounds.
        Another component of the IMPROVE initiative is the Rapid
    Acceleration of Diagnostics Technology (RADx Tech) for Maternal Health
    Challenge. It prioritizes the development of home-based or point-of-
    care diagnostic devices, wearables, and other remote sensing
    technologies in order to improve postpartum outcomes for those living
    in areas lacking maternity care access. Ten teams have advanced to the
    final Technology Assessment Phase and are developing solutions related
    to blood pressure monitoring, mental health, hemorrhage, urinary tract
    infections (UTIs), and anemia.
        Question. NIH's Draft Intramural Research Program Policy released
    May 22nd includes requirements for Access Plans that include an
    ``affordability'' component that could include ``committing to keep
    prices in the U.S. equal to those in other developed countries.'' I am
    concerned that this proposal could encumber NIH inventions with
    requirements that would not be associated with non-NIH inventions.
        Would this make it more difficult to license these inventions, and
    put taxpayer-funded inventions at a competitive disadvantage in the
    innovation ecosystem?
        Did NIH consider its November 2021 analysis that found the
    ``reasonable pricing'' policy implemented from 1989 to 1995 drove
    industry away from potentially beneficial collaborations in issuing
    this draft?
        Answer. NIH is seeking comment on a policy proposal that would
    require licensees that succeed in bringing products based on certain
    NIH-owned inventions toward market submit a plan outlining steps they
    intend to take to promote patient access to those products. Access can
    take on many forms, including product affordability, availability,
    acceptability, and sustainability. Accordingly, NIH is currently
    seeking input on this proposal to consider the range of activities that
    could be considered and strategies to mitigate access challenges and
    expand the reach, and benefit, of drugs, biologics, vaccines, and
    devices stemming from NIH inventions.
        NIH seeks to drive effective partnerships that foster a shared
    commitment to transforming knowledge into improved health for all. NIH
    continues to explore a variety of approaches currently employed by
    technology transfer communities, such as the access planning model, as
    well as evaluate data generated from prior policy initiatives, such as
    the reasonable pricing efforts in the 1990s. We will continue to work
    with patients, industry partners, technology transfer and licensing
    professionals, research institutions, and other interested individuals
    to craft an approach forward that advances the NIH mission and drives
    biomedical innovation.
                                     ______

                   Questions Submitted by Senator Marco Rubio
        Question. In a recent hearing of the Select Subcommittee on the
    Coronavirus Pandemic, NIH principal deputy director Lawrence Tabak
    confirmed on the record that American taxpayer dollars were used to
    fund gain-of-function research at the Wuhan Institute of Virology in
    China in the years leading up to the COVID-19 pandemic. The American
    people, of course, have known this fact for some time, yet Federal
    officials have avoided giving a direct answer to prevent blame for the
    pandemic from being traced to Federal investment in untrustworthy
    Chinese labs. There were many drastic errors in research oversight
    here, including grantees knowingly failing to report that their
    modified coronaviruses were altered to become 10,000 times more
    infectious. Accountability is the first step to ensuring a global
    health and security crisis of this magnitude will never happen again.
    The American people deserve to know what happened, how their hard-
    earned money was egregiously invested, and how the agency is improving
    its transparency and communication.
        Could you define gain-of-function research as the NIH understands
    it?
        Can you confirm that U.S. taxpayer dollars were indeed granted to
    the Wuhan Institute of Virology to carry out gain-of function research?
        Does the NIH intend to reinstate its relationship with the
    EcoHealth Alliance and the Wuhan Institute of Virology once their
    funding bans have lifted?
        As an act of building greater trust in public health agencies,
    would the NIH provide all of its documentation to Congress, and the
    public, regarding its internal and external correspondence about the
    NIH funded grant to the EcoHealth Alliance and the Wuhan Institute of
    Virology to carry out coronavirus gain-of-function research?
        What steps has the NIH taken/will take to ensure grantees engaging
    in research with infectious pathogens are complying with NIH rules and
    will not produce dangerous products?
        Will the NIH commit to ceasing all distribution of Federal funds
    toward research institutions domiciled in the People's Republic of
    China or otherwise directed or controlled by the Chinese Communist
    Party?
        Answer. NIH does not define the term gain-of-function, and current
    USG, HHS, and NIH policy do not define or operationalize these terms.
    Official Federal definitions pertaining to research that requires
    additional review and oversight are outlined in the following official
    USG and HHS policies: the 2017 Recommended Policy Guidance for
    Departmental Development of Review Mechanisms for Potential Pandemic
    Pathogen Care and Oversight (OSTP P3CO Policy Guidance) \31\ issued by
    the White House Office of Science and Technology Policy, the HHS
    Framework for Guiding Funding Decisions about Proposed Research
    Involving Enhanced Potential Pandemic Pathogens (HHS P3CO
    Framework),\32\ the United States Government Policy for Oversight of
    Life Sciences Dual Use Research of Concern \33\ and the United States
    Government Policy for Institutional Oversight of Life Sciences Dual Use
    Research of Concern \34\ (collectively the USG DURC Policies). These
    oversight frameworks are part of a robust U.S. biosafety and
    biosecurity oversight system comprised of multiple, complementary
    regulations, policies, and guidelines to minimize potential risks and
    preserve benefits of critical life sciences research for the American
    people.
    ---------------------------------------------------------------------------
        \31\ phe.gov/s3/dualuse/Pages/ppp-oversight-recommendations.aspx.
        \32\ phe.gov/s3/dualuse/Pages/
    p3co.aspx#::text=The%20Department%20of%20Health%20and,
    PPPs%20resulting%20from%20the%20enhancement.
        \33\ phe.gov/s3/dualuse/Documents/us-policy-durc-032812.pdf.
        \34\ phe.gov/s3/dualuse/documents/durc-policy.pdf.
    ---------------------------------------------------------------------------
        Information on research projects that have completed review in
    accordance with the HHS P3CO Framework since its adoption in 2017 is
    publicly posted on HHS's website.\35\ Research with pathogens,
    including research that may fall under the USG DURC policies and P3CO
    framework, is necessary to understand their function and helps us
    identify, understand, and develop strategies and effective
    countermeasures against rapidly evolving pathogens that pose threats to
    our public health, economic, and national security. The EcoHealth
    Alliance (EHA) application did not propose research to enhance
    coronaviruses to be more transmissible or virulent in humans and thus
    did not fall under these policy frameworks or definitions.
    ---------------------------------------------------------------------------
        \35\ phe.gov/s3/dualuse/Pages/ResearchReview-PPP.aspx.
    ---------------------------------------------------------------------------
        On May 6, 2024, OSTP released an expanded and unified USG Policy
    for Oversight of Dual Use Research of Concern and Pathogens with
    Enhanced Pandemic Potential.\36\ This new USG-wide policy, which will
    be effective on May 6, 2025, combines the current DURC and P3CO
    oversight frameworks, and expands the scope of research requiring
    additional review. NIH staff are evaluating the recently released
    policy and will work with our HHS counterparts towards updating and
    establishing policies and oversight procedures, as needed, during the
    1-year implementation period to ensure consistent implementation. The
    policy states that OSTP and NSC staff, in consultation with relevant
    departments and agencies, will coordinate a process for identifying
    countries posing risks in which the U.S. government should not fund
    DURC or research involving pathogens with enhanced pandemic potential
    (as defined therein). At the time of release of the policy, the Federal
    government will not fund such research in the following countries: the
    Democratic People's Republic of Korea (DPRK), the Islamic Republic of
    Iran, the Russian Federation, the People's Republic of China (along
    with the Special Administrative Regions of Hong Kong and Macau, for the
    purposes of this policy), Cuba, Syria, and Venezuela. NIH will adhere
    to the requirements articulated in this new USG policy, including with
    respect to definitions, the assessment of risks and benefits and the
    development of risk mitigation plans. NIH notes that the term gain-of-
    function also is not defined in this policy.
    ---------------------------------------------------------------------------
        \36\ whitehouse.gov/ostp/news-updates/2024/05/06/united-states-
    government-policy-for-oversight-of-dual-use- research-of-concern-and-
    pathogens-with-enhanced-pandemic-potential/.
    ---------------------------------------------------------------------------
        NIH has not made any awards to the Wuhan Institute of Virology
    (WIV). Rather, NIH awarded a grant to the EcoHealth Alliance (prime
    recipient), who in turn made a subaward to WIV. Information on prime
    awards from NIH are available on the NIH RePORTER system,\37\ and
    subaward information made by prime recipients is available on
    USASpending.gov.\38\ On July 17, 2023, the DHHS Suspension and
    Debarment Office (SDO) officially suspended WIV and proposed debarment
    of WIV due to its failure to turn over requested records to EHA. On
    September 19, 2023, WIV was debarred until July 2033. And on May 15,
    2024, DHHS took action to suspend and propose for debarment of EHA. NIH
    awaits the SDO's findings.
    ---------------------------------------------------------------------------
        \37\ reporter.nih.gov/.
        \38\  usaspending.gov/.
    ---------------------------------------------------------------------------
        NIH takes our stewardship over the Nation's investment in
    biomedical research very seriously. NIH actively manages and
    administers NIH awards in a manner to ensure that Federal funding is
    expended and associated programs are implemented in full accordance
    with the U.S. Constitution, Federal Law, and public policy
    requirements. Furthermore, the NIH follows all United States Government
    laws, policies, and guidance in distribution of Federal funds to
    research institutions in foreign countries. NIH remains committed to
    transparency with Congress and the public and will continue to produce
    internal and external documentation about research funded by NIH.
        Question. The NIH has long been a leader in supporting research and
    development to tackle our nation's greatest public health challenges.
    However, I remain concerned that the NIH is distorting priorities and
    constructing barriers that prevent qualified, needed researchers from
    accessing Federal grants in the name of promoting ``DEI.'' The NIH's
    policy of requiring grantees to submit a ``Plan for Enhancing Diverse
    Perspectives'' or PEDP mandates that researchers prioritize spending
    their precious time and capital to check the diversity box. The NIH
    should trust that researchers will hire the most qualified personnel
    and focus on partnering with entities that maximize the quality of
    their research, rather than seeing essential research as a laboratory
    to impose radical social mandates. At the end of the day, the NIH
    should care most about ensuring that taxpayer funded investments will
    yield results for the American people, not that they are appeasing to
    left-wing advocates.
        How many NIH initiatives and sub agencies are currently requiring
    applicants to submit PEDPs as a portion of their application?
        How did the NIH develop their criterion within their PEDP?
        How do the peer reviewers weigh an applicant's PEDP against the
    rest of their application?
        Are there additional avenues available for applicants who do not
    include a PEDP in their application?
        Is there an option for an applicant to appeal if they are denied
    based on their PEDP?
        Have any scientists refused to serve on an NIH peer review panel
    because of the directive to mandate inclusion of PEDPs in grant
    applications?
        Answer. The Plan for Enhancing Diverse Perspectives (PEDP) in NIH
    grant applications is a summary of actionable strategies to advance the
    scientific merit of proposed projects through diverse perspectives. The
    NIH recognizes that teams comprised of investigators with diverse
    perspectives working together and capitalizing on innovative ideas and
    distinct viewpoints outperform homogeneous teams. To support the best
    science, the NIH encourages inclusivity in research guided by the
    consideration of diverse perspectives. Broadly, diverse perspectives
    can include but are not limited to the educational background and
    scientific expertise of the people who perform the research; the
    populations who participate as human subjects in research studies; and
    the places where research is done. More information on the
    implementation of PEDPs is available on the NIH Grants site.\39\ NIH
    does not require that all funding opportunities include a PEDP as a
    part of the application submission process.
    ---------------------------------------------------------------------------
        \39\ grants.nih.gov/policy/plan-for-enhancing-diverse-
    perspectives.htm.
    ---------------------------------------------------------------------------
        The NIH developed PEDP criteria through consultations with
    scientific experts from across the NIH, with input from the research
    community, and a review of relevant literature. Peer reviewers,
    individuals that are themselves comprised of scientists from the
    extramural research community, evaluate PEDPs as part of the Overall
    Impact score of an application, focusing on how these plans help to
    advance the scientific merit of the proposed project. This evaluation
    is integrated with other critical components of the application, such
    as significance, innovation, and approach. Consistent with Federal law,
    the race, ethnicity, or sex (including gender identity, sexual
    orientation, or transgender status) of a researcher, award participant,
    or trainee will not be considered, even in part, during the application
    review process or when making funding decisions. Applicants that do not
    have their applications approved for funding may utilize the long-
    standing process of appeal developed by NIH.
        The review community has been very receptive to the goals of the
    PEDP. While a reviewer may recuse themselves from reviewing any
    application should they feel uncomfortable with its contents, to date
    no reviewer has reported that they recuse themselves from reviewing an
    application because of the inclusion of a PEDP.
        By fostering diverse perspectives, the NIH aims to support high-
    quality science and maximize the impact of taxpayer-funded research,
    ensuring that the results benefit the broadest possible audience.
        Question. As you know, the NIH is currently in the process of
    updating its mission statement. However, as I and Senator Duckworth
    previously communicated to you in January, I remain concerned about the
    NIH's proposed removal of the goal to ``lengthen life'' from the
    agency's mission statement, without any justification. As U.S. life
    expectancy is now lower than it was fifteen years ago and nations are
    increasingly embracing physician assisted suicide, it is critical that
    the NIH continues to emphasize an approach to biomedical research that
    affirms the value and dignity of every human life.
        At what stage is the NIH in the process of reviewing and publishing
    its final mission statement?
        Answer. NIH has analyzed the hundreds of responses to the Request
    for Information (RFI) \40\ inviting feedback on a proposed update to
    the NIH mission statement. NIH Director Bertagnolli intends to provide
    an update on the progress during her Director's Report of the NIH
    Advisory Committee to the Director (ACD) meeting on June 13, 2024.\41\
    The RFI results, which will be posted in a public report in the coming
    weeks, have indicated that more input is needed to better understand
    all perspectives before finalizing a new mission statement.
    ---------------------------------------------------------------------------
        \40\ grants.nih.gov/grants/guide/notice-files/NOT-OD-23-163.html.
        \41\ acd.od.nih.gov/meetings.html.
    ---------------------------------------------------------------------------
        Question. Is the NIH concerned by evidence suggesting that false
    stereotypes and biases regarding people with disabilities could lead to
    discrimination in how doctors recommend physician-assisted suicide to
    their patients?
        Answer. NIH would be deeply concerned if false stereotypes and
    biases regarding people with disabilities led to discrimination.
        Question. When does the NIH intend to publish its final mission
    statement?
        Answer. As noted above (3a), analysis of the RFI results has
    indicated more input is needed. NIH intends to publish its final
    mission statement following additional public engagement over the
    coming months.
        Question. Does the NIH pledge to continue supporting research and
    innovation that will lengthen life?
        Answer. NIH intends to continue supporting research and innovation
    to help all people live long and healthy lives.
                                     ______

                Questions Submitted by Senator Susan M. Collins
        Question. Dr. Bertagnolli, despite a proposed increase of more than
    $1 billion across NIH, I am concerned about the proposed decrease for
    the National Institute of Diabetes and Digestive and Kidney Diseases
    (NIDDK), which is the primary Federal agency responsible for conducting
    research for the prevention and treatment of diabetes. This proposal
    comes at a time when rates of diabetes are skyrocketing, particularly
    among our youth. According to the CDC, the number of young people under
    age 20 with diabetes in the United States is likely to increase more
    rapidly in future decades. This expected upward trend may lead to as
    many as 220,000 young people having type 2 diabetes in 2060--a nearly
    700% increase. The number of young people with type 1 diabetes could
    increase by as much as 65% in the next 40 years. Even if the rate of
    new diabetes diagnoses among young people remains the same over the
    decades, type 2 diabetes diagnoses could increase nearly 70% and type 1
    diabetes diagnoses could increase 3% by 2060. Given the cost and burden
    of diabetes, why is the NIH proposing a decrease at the NIDDK?
        Answer. The National Institute of Diabetes and Digestive and Kidney
    Diseases (NIDDK) sincerely thanks the Committee for the budget increase
    we received through the FY 2024 appropriations. Because the President's
    Budget was released prior to the enactment of FY 2024 appropriations,
    this increase was not considered in the process of budget development,
    which was based on the FY 2024 Continuing Resolution. There was no
    intent to propose a budget decrease in discretionary funding at NIDDK
    in FY 2025. NIH is committed to supporting diabetes research that will
    advance effective prevention and intervention approaches for all,
    including children and young people. The skyrocketing rates of diabetes
    in youth are especially alarming as NIH-supported studies have shown
    that type 2 diabetes is much more difficult to treat and progresses
    more rapidly when it occurs in young people than in those who develop
    it in middle age or later. Studies have also shown that type 2 diabetes
    in youth disproportionately impacts underrepresented populations. NIDDK
    is supporting a new study, called DISCOVERY, that will follow a cohort
    of youth at risk for developing type 2 diabetes to better understand
    diabetes progression in youth and adolescents and to discover factors
    that may help predict diabetes onset and progression. To combat the
    rising rates of type 1 diabetes, NIDDK-funded research, including The
    Environmental Determinants of Diabetes in the Young (TEDDY) study
    supported by the Special Diabetes Program, is working to identify what
    environmental factors may contribute to type 1 diabetes onset. These
    projects, as well as others in NIDDK's diabetes portfolio, aim to
    understand and curb these alarming increases.
        Question. In March, I led reauthorization of the Special Diabetes
    Program (SDP) through December 31, 2024, at an annual rate of
    approximately $160 million per year--a roughly $10 million increase
    from current funding levels. This is the first funding increase for SDP
    in 20 years. The Special Diabetes Program has made significant
    scientific progress toward the goal of preventing, treating, and
    ultimately curing type 1 diabetes. Can you discuss some of the advances
    that have come from this program and how the funding increase and
    extension under consideration at the end of the year would help further
    advance these important goals?
        Answer. The Special Diabetes Program (SDP) has led to
    groundbreaking progress that is improving the health and quality of
    life of people with type 1 diabetes. For example, decades of SDP-
    supported foundational research and clinical trials culminated in
    recent U.S. Food and Drug Administration (FDA) approvals of the first
    drug (teplizumab) that can delay onset of type 1 diabetes diagnosis in
    people at high risk for developing the disease; the first cellular
    therapy (islet transplantation) to treat adults with type 1 diabetes
    who have recurrent episodes of dangerously low blood glucose levels;
    and hybrid artificial pancreas devices that have greatly eased the
    burden of type 1 diabetes management. Other successes stemming from the
    Program include the paradigm-shifting understanding of how type 1
    diabetes progresses in distinct stages from normal glucose levels to
    clinically overt disease, and clinical trial results that have
    transformed the treatment of diabetic retinopathy and diabetic macular
    edema worldwide.
        The recent SDP renewal and historic funding increase are critical
    for building on the progress made by the Program's ongoing landmark
    research consortia and networks, as well as to support new and emerging
    research opportunities. These opportunities include exploring the use
    of sodium-glucose co-transporter-2 inhibitors (SGLT2i)--drugs that
    protect heart and kidney health in people with type 2 diabetes--as a
    treatment for type 1 diabetes; understanding the neurocognitive impact
    of type 1 diabetes in children to inform strategies to mitigate the
    risk of developing neurocognitive complications in later life;
    identifying mechanisms that promote the development of cardiovascular
    disease (CVD) in people with type 1 diabetes toward developing CVD
    prevention and treatment strategies for this population; identifying
    factors that restore awareness of hypoglycemia in adults with type 1
    diabetes and impaired awareness of hypoglycemia toward tailoring
    treatment approaches for these individuals; and developing next-
    generation hybrid artificial pancreas systems. New type 1 diabetes
    research opportunities will also be discussed at a November 2024
    meeting of the statutory Diabetes Mellitus Interagency Coordinating
    Committee. The FY 2025 President's Budget proposes a further increase
    to the SDP, with a level of $260 million in FY 2025 and $270 million in
    FY 2026.
        Question. Four years after the start of the COVID pandemic, we
    still have many questions surrounding how to identify and treat Long
    COVID. In 2021, NIH launched the RECOVER Initiative to study Long COVID
    and look for treatments across different types of research studies. I
    have discussed the RECOVER Initiative both with those involved in the
    research, who defend its complexity, and others who are more critical
    due to the time spent defining the symptoms and a delayed emphasis on
    therapeutics. I believe in the NIH's ability to translate research into
    results patients feel on the ground, but I also understand the
    frustration that no ``cure'' or even real treatment has been found. Do
    you have any NIH-wide strategies to help RECOVER continue to work
    better given how varied the symptoms and treatments are?
        Answer. NIH RECOVER is an agency-wide priority that involves many
    parts of NIH, including the National Heart, Lung, and Blood Institute
    (NHLBI), the National Institute of Neurological Disorders and Stroke
    (NINDS) and the National Institute of Allergy and Infectious Diseases
    (NIAID). Many of the investments made and structures created thus far
    were designed for the long haul. Given the challenge that infection-
    associated conditions have been thus far--with little evidence that
    advances our understanding or treatments, we knew tackling Long COVID
    was neither going to be quick or easy. Some of the learnings to date
    include better understanding of how the numerous symptoms cluster, how
    different types of people (adults, children, pregnant people, etc.) and
    communities are affected, and the effect the virus has on tissue and
    organ systems. These learnings are enabling us to identify potential
    therapeutic targets that can bring potential relief to those
    experiencing the greatest burden from clusters of specific symptoms. In
    addition, longer term follow-up with individuals remains critical for
    NIH to understand how Long COVID behaves in patients over time.
        The NIH strategy is to tackle Long COVID on many fronts.
    Understanding the pathology and how the virus effects specific organs
    and tissues has shown to be pivotal to evolving hypotheses surround
    therapeutic targets. Continuing to leverage data technologies and
    enable greater exploration of the data from others will similarly yield
    consideration of promising interventions. The clinical trials approach
    enables multiple potential therapies to be tested at the same time,
    with the expectation that additional interventions and therapeutics
    will be added to these platforms in the future. Finally, NIH is
    listening to the numerous ideas that are coming to us through various
    channels and from various communities of patients, caregivers,
    clinicians, policy makers, and of course, researchers with knowledge in
    infection associated conditions. It is our hope that this strategy will
    allow NIH to find therapeutics and hopefully a treatment for this
    debilitating disease.
                                     ______

      Questions Submitted to Dr. W. Kimryn Rathmell, M.D., Ph.D., M.M.H.C.
                Questions Submitted by Senator Joe Manchin, III
        Question. Dr. Rathmell, West Virginia tops the fifty states in
    cancer risk. West Virginia University (WVU) is committed to reducing
    the risk of cancer for West Virginians through strengthening research.
    They are making great strides, evidenced by their growing cancer
    research portfolio. WVU is working to accelerate its progress by
    building a National Cancer Institute-designated cancer center with
    access to all NCI-sponsored cancer trials. I am 100% supportive of that
    goal as studies show patients treated at NCI-Designated Cancer Centers
    have higher survival and recovery rates.
        I understand there are three basic types of Cancer Centers:
    Comprehensive Cancer Centers, Clinical Cancer Centers, and Basic
    Laboratory Cancer Centers. NCI creates strict guidelines for what
    criteria a facility must meet to become a cancer center, but NCI has
    yet to consider facilities that serve large rural populations, or
    conduct research predominately in rural areas.
        Will NCI consider adding a new category for Cancer Center Support
    Grants (CCSGs) awards for cancer centers that are primarily providing
    care to rural and disadvantaged populations?
        Answer. The National Cancer Institute (NCI) Cancer Centers Program
    \42\ represents a substantial commitment to supporting research on
    breakthrough approaches to preventing, diagnosing, and treating all
    types of cancers for patients in communities across the United States.
    The program currently supports 72 NCI-Designated Cancer Centers, in 36
    states and the District of Columbia. NCI supports the research
    infrastructure for designated cancer centers to advance scientific
    goals and foster cancer programs that draw together investigators from
    different disciplines. The NCI Office of Cancer Centers \43\ (OCC)
    consults on a regular basis with cancer centers such as West Virginia
    University (WVU) planning a first-time application for NCI designation.
    The timeline for attainment of the designation varies greatly,
    depending on the status of the center at the time of initial contact
    with OCC. The OCC is pleased to continue working with WVU on this
    process and recognizes the opportunity that WVU has to improve services
    for medically underserved, rural populations in their catchment area.
    ---------------------------------------------------------------------------
        \42\ cancer.gov/research/infrastructure/cancer-centers.
        \43\ cancercenters.cancer.gov/Home.
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        NCI recognizes that the remarkable advances in cancer prevention,
    treatment, and survivorship made in recent decades are not experienced
    equitably across all populations in the United States. Patients living
    in rural areas are among those individuals who are less likely to have
    access to cutting-edge cancer care. It has been a longstanding goal of
    NCI to ensure that any person with a cancer diagnosis, or at risk of
    developing cancer, has an opportunity to participate in cancer
    research--and take advantage of the latest therapies and prevention
    strategies. NCI-designated Cancer Centers, through their Community
    Outreach and Engagement (COE) efforts, create programs catered to their
    catchment area that have increased the reach to rural communities. This
    is one of many key NCI-supported initiatives focused on rural areas
    across the country, including the NCI Community Oncology Research
    Program (NCORP), NCI's Virtual Clinical Trials Office, ongoing research
    focused on rural cancer control, and the recently created Working Group
    in Support of Efforts to Enhance Community Cancer Research and Quality
    Care.
      --NCORP is part of NCI's National Clinical Trials Network (over 2,200
            sites across the United States) that brings cancer clinical
            trials and care delivery studies to people in their own
            communities. NCI-supported trials are available in every state,
            not limited to NCI- designated centers. NCI clinical trials
            networks reach across the country and make this possible, with
            a specific focus on bringing cancer clinical trials to rural
            populations. More than 100 NCI-supported trials are available
            in West Virginia, including at WVU--this includes pediatric
            trials through NCI's Children's Oncology Group.\44\
    ---------------------------------------------------------------------------
        \44\ cancer.gov/research/participate/clinical-trials-search/
    r?lcnty=United%20States&loc=2&lst= WV&rl=2.
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      --In February 2024, NCI launched the Virtual Clinical Trials Office
            Pilot Program, which aims to address clinical trials staffing
            shortages by providing remote support staff.\45\The ultimate
            goal of the program is to make it easier for community sites to
            support enrollment in clinical trials, particularly in rural
            and other underserved areas. NCI is optimistic that by
            providing support through a centralized team of remote support
            staff--including research nurses, clinical research associates,
            and clinical data specialists--eventually all clinical
            practices, regardless of their scope, patient population, or
            location, will benefit from the lessons learned during this
            pilot. Six institutions across the United States with various
            geographical settings and clinical practice characteristics
            have been selected to receive virtual clinical trials staffing
            from NCI for the initial phase of the pilot program.
    ---------------------------------------------------------------------------
        \45\ cancer.gov/MajorInitiatives/
    virtual_clinical_trials_office_pilot_program.htm.
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      --NCI supports ongoing research focused on cancer control in rural
            areas, including recent funding opportunities focused on
            improving the reach and quality of cancer care in rural
            populations \46\ and social and behavioral intervention
            research to address modifiable risk factors in rural
            populations.\47\ These funding opportunities supported 12
            research projects focused on rural populations, including a
            project providing high-quality technology-based supportive care
            resources to patients with metastatic cancer living in rural
            Pennsylvania and rural West Virginia,\48\ as well as a project
            leveraging community pharmacists to enhance provision of
            smoking cessation services for people who smoke in rural
            Appalachia.\49\
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        \46\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-19-064.html.
        \47\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-20-051.html.
        \48\ reporter.nih.gov/search/ztocNZSo1EOhnbaYLRlgUQ/project-
    details/10850646.
        \49\ reporter.nih.gov/search/McpeUAVT1U21vZJJlUXWoA/project-
    details/10701777.
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      --Also in February 2024, NCI established the Working Group in Support
            of Efforts to Enhance Community Cancer Research and Quality
            Care through NCI's Board of Scientific Advisors. The Working
            Group includes experts from across the country, including other
            Federal agencies, and is charged with providing guidance on
            ways to increase community capacity to conduct cancer research
            and provide high-quality cancer care--across every community
            oncology clinic and every patient across the nation. One of the
            things this group will do is look at best practices of
            institutions that participate in the National Clinical Trials
            Network and NCORP.
        NCI remains committed to ensuring cancer research advances reach
    all communities, including rural communities, and that cancer research
    efforts, including clinical trials, are conducted in rural communities.
    NCI will continue to pursue these opportunities through a variety of
    appropriate research mechanisms, including NCI-designated cancer
    centers, NCI clinical trials networks, rural cancer control research
    projects, and other emerging research opportunities.
                                     ______

                  Questions Submitted by Senator John Boozman
        Question. As you know, the University of Arkansas for Medical
    Sciences is working on getting designated as an NCI cancer center. If
    they're able to do so, it'll be the first and only NCI-designated
    cancer center in the state--which would be significant. However, this
    goal may still take several more years to accomplish, and in the
    meantime, I think it is vital that Arkansans can participate in cancer
    clinical trials--especially without having to travel long distances to
    do so, given the rural nature of the state.
        What is NCI doing to support clinical trial capacity at the
    community level?
        How do we ensure that Americans, regardless of where they live, can
    participate?
        Answer. The National Cancer Institute (NCI) Cancer Centers Program
    \50\ represents a substantial commitment to supporting breakthrough
    approaches to preventing, diagnosing, and treating all types of
    cancers. The program currently supports 72 NCI-Designated Cancer
    Centers, in 36 states and the District of Columbia; there are 57
    Comprehensive Cancer Centers, 8 Clinical Cancer Centers, and 7 Basic
    Laboratory Cancer Centers. The NCI-Designated Cancer Centers are
    recognized for their scientific leadership in laboratory and clinical
    research, in addition to serving their communities and the broader
    public by integrating training and education for biomedical researchers
    and healthcare professionals. These centers dedicate significant
    resources toward developing research programs, faculty, and facilities
    that will lead to better and innovative approaches to cancer
    prevention, diagnosis, and treatment. NCI supports the research
    infrastructure for designated cancer centers to advance scientific
    goals and foster cancer programs that draw together investigators from
    different disciplines.
    ---------------------------------------------------------------------------
        \50\ cancer.gov/research/infrastructure/cancer-centers.
    ---------------------------------------------------------------------------
        The NCI Office of Cancer Centers \51\ (OCC) consults on a regular
    basis with cancer centers such as the University of Arkansas for
    Medical Sciences (UAMS) planning a first-time application for NCI
    designation. The timeline for attainment of the designation varies
    greatly, depending on the status of the center at the time of initial
    contact with OCC. If the center needs to both build the research base
    and address other essential characteristics prior to application, the
    process may easily take a decade or more, depending on resources
    available, leadership, and other factors. If it already has significant
    cancer research funding, and needs only to refine its organizational
    capabilities, the process may take only a few years. The OCC is pleased
    to continue working with UAMS on this process and recognizes the
    opportunity that UAMS has to improve services for medically
    underserved, rural populations in their catchment area.
    ---------------------------------------------------------------------------
        \51\ cancercenters.cancer.gov/Home.
    ---------------------------------------------------------------------------
        NCI remains committed to providing access to cancer clinical trials
    to communities throughout the United States, including those with rural
    and underserved populations. In addition to the NCI-Designated Cancer
    Centers, the NCI Community Oncology Research Program (NCORP) is a
    national network that brings cancer clinical trials and care delivery
    studies to people in their own communities. NCORP is part of NCI's
    National Clinical Trials Network (over 2,200 sites across the United
    States) and is comprised of 7 Research Bases and 46 Community Sites,
    one of which serves Arkansas by providing access to NCI-supported
    cancer clinical trials and research studies. Fourteen of these
    community sites are designated as Minority/Underserved (M/U) Community
    Sites. NCORP covers 41 states, as well as the District of Columbia,
    Puerto Rico, and Guam. NCI-supported trials are available in every
    state, not limited to NCI-designated centers.
        NCI clinical trials networks reach across the country and make this
    possible, with a specific focus on bringing cancer clinical trials to
    rural populations. More than 150 NCI-supported trials are available in
    Arkansas, including at the University of Arkansas for Medical
    Sciences.\52\
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        \52\ cancer.gov/research/participate/clinical-trials-search/
    r?lcnty=United%20States&loc=2&lst= AR&rl=2.
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        Activities to increase access to cancer screening and treatment in
    rural regions are also often part of NCI-Designated Cancer Centers'
    Community Outreach and Engagement (COE) efforts, depending on the
    catchment area of the Cancer Center. COE activities are evaluated as
    part of Centers' applications for NCI designation. NCI's Center to
    Reduce Cancer Health Disparities (CRCHD) supports several initiatives
    to improve research capacity and cancer care among traditionally
    underserved populations, including those in rural areas.
        In February 2024, NCI also launched the Virtual Clinical Trials
    Office Pilot Program to address the decline in participation in NCI-
    funded clinical trials that is due, in part, to clinical trials
    staffing shortages that were exacerbated by the COVID-19 pandemic. NCI
    is optimistic that by providing support through a centralized team of
    remote support staff--including research nurses, clinical research
    associates, and clinical data specialists--eventually all clinical
    practices, regardless of their scope, patient population, or location,
    will benefit from the lessons learned during this pilot. Six
    institutions across the United States with various geographical
    settings and clinical practice characteristics have been selected to
    receive virtual clinical trials staffing from NCI for the initial phase
    of the pilot program.
                                     ______

            Questions Submitted to Dr. Jeanne Marrazzo, M.D., M.P.H.
              Questions Submitted by Senator Shelley Moore Capito
    Rural Access to Infectious Disease Clinical Trials
        Question. The national clinical trials infrastructure often
    excludes health facilities that serve communities that are typically
    underrepresented in studies, including individuals in rural and
    sparsely populated areas. What more needs to be done to increase access
    to infectious diseases clinical trials in rural communities?
        Answer. The National Institute of Allergy and Infectious Diseases
    (NIAID) conducts and supports basic and applied research to better
    understand, treat, and prevent infectious, immunologic, and allergic
    diseases, including in communities underrepresented in clinical
    studies. NIAID's rural health-related research and activities support
    this mission. Many of these activities aim to increase access to care
    for rural residents and help improve the quality of their lives. For
    example, NIAID--in collaboration with other National Institutes of
    Health (NIH) Institutes and Centers--has helped establish and maintain
    the national clinical trials infrastructure needed to serve communities
    that are typically underrepresented in HIV research.
        In support of the Department of Health and Human Services (HHS)
    Ending the HIV Epidemic in the U.S. (EHE) initiative, NIAID in
    collaboration with the National Institute of Mental Health (NIMH)
    supports implementation science research that focuses on expanding and/
    or improving engagement and re-engagement in HIV prevention, testing,
    treatment, and care services. A major component of this activity
    involves deploying innovative community-based prevention strategies
    directed toward populations at an increased likelihood of HIV largely
    unreached by current programs, including people living in rural or
    medically underserved areas, or people and communities experiencing
    clusters and outbreaks. These research projects, supported through
    administrative supplements to the NIH Centers for AIDS Research (CFARs)
    and NIMH AIDS Research Centers (ARCs), focus on 57 priority geographic
    areas, including seven states (Alabama, Arkansas, Kentucky,
    Mississippi, Missouri, Oklahoma, and South Carolina) with a substantial
    number of HIV diagnoses in rural areas.
        To date, NIAID and NIMH have funded over 45 projects in these
    states, with several projects explicitly focusing on addressing
    barriers to engaging rural populations. NIAID funds two CFARs located
    in these seven states: the University of Alabama at Birmingham (UAB)
    CFAR and the new Midwest Developmental CFAR (D-CFAR) at Washington
    University in St. Louis, Missouri. Both CFARs have established
    scientific working groups to address the needs of their rural
    communities. The UAB ``Ending HIV in Alabama Scientific Working Group''
    was created in 2017 to promote interdisciplinary research through: (1)
    the development of novel approaches to improve outcomes in HIV
    prevention, testing, linkage to care, retention in care, and viral
    suppression; (2) implementation of evidence-based interventions through
    coordination of interdisciplinary teams; and (3) recruitment and
    mentoring of trainees and early stage investigators in epidemiologic
    and implementation science research aimed at eliminating HIV in
    Alabama. Investigators at the UAB CFAR also are working to identify
    counties in Alabama at greatest risk for an HIV outbreak among persons
    who inject drugs in order to inform implementation strategies to
    integrate person-centered HIV, harm reduction, and addiction services.
    The ``Neglected Populations Scientific Working Group'' at the Midwest
    D-CFAR aims to establish a collaborative community involving academics,
    regional partners, and community-based partners. This collaboration
    will conduct pragmatic, community-engaged, and stakeholder-embedded
    research targeted towards neglected populations affected by HIV. The
    overall goal of these working groups is to improve health services for
    underserved communities.
        In addition, the NIAID-funded North American AIDS Collaborative
    Cohort on Research and Design (NA-ACCORD) added clinical sites to
    assess the disproportionate burden of HIV infection and HIV-related
    morbidity and mortality rate of HIV in the South. These sites, which
    highly represent the sex, race/ethnicity, and HIV transmission risk
    groups, enroll urban, suburban and rural residents. In total, NA-ACCORD
    now features seven sites considered in the ``Deep South'' which
    markedly enhances the ability to assess the HIV epidemic in this
    increasingly important region.
        NIAID will continue to conduct and support clinical research to
    better understand, treat, and prevent infectious diseases, including
    HIV, affecting underrepresented communities such as those in rural
    areas. NIAID also is committed to working with NIH Institutes, Centers,
    and Offices to help maintain the robust national clinical trials
    infrastructure needed to increase access to clinical trials in rural
    communities.
                                     ______

                Questions Submitted to Dr. Nora D. Volkow, M.D.
                Questions Submitted by Senator Joe Manchin, III
        Question. In 2023 alone, 109,000 Americans died from drug related
    overdoses and more than 76,000 of those deaths involved illicit
    fentanyl and other synthetic opioids. We have lost more Americans to
    drug overdoses since 1999 than the number of American lives lost in
    wars or conflicts since the Civil War, and it is absolutely
    heartbreaking.
        Dr. Volkow, you have been to West Virginia, visited the West
    Virginia University's Rockefeller Neuroscience Institute, and have seen
    first-hand the work being done to study and find treatments for
    substance use disorder.
        How can NIDA continue to support research institutions that are
    studying the science of substance use disorder and working on
    treatments for substance use disorder, especially those working with
    rural populations?
        What are other ways that we can better expand access to substance
    use disorder treatment in rural America, particularly in West Virginia,
    where the overdose rates continue to be some of the highest in the
    nation?
        Answer. Through a variety of NIH funding mechanisms, The National
    Institute on Drug Abuse (NIDA) continues to fund meritorious
    applications submitted by researchers from diverse institutions to
    maximize its support of research, including researchers who work with
    underserved rural populations. There are also multiple NIH mechanisms
    geared toward increasing research infrastructure. For example, the
    congressionally mandated Institutional Development Award program builds
    research capacity at institutions in states with historically low
    levels of NIH funding, including West Virginia.\53\ NIDA also uses
    novel approaches to bring more institutions that work with rural
    populations into the research enterprise. For example, with funding
    from the NIH Helping to End Addiction Long-term, or the NIH HEAL
    Initiative, NIDA expanded its Clinical Trials Network (CTN) by adding
    five additional research nodes, including the Appalachian Node, a
    collaboration between West Virginia University, University of
    Pittsburgh, and Penn State University.\54\ NIDA is also currently
    participating in two NIH funding opportunities to further increase the
    diversity, breadth, and geographic locations of research
    programs.\55,56\ Together, these efforts aim to encourage research that
    includes underserved rural populations and increases the scientific
    value and impact of research.
    ---------------------------------------------------------------------------
        \53\ nigms.nih.gov/Research/DRCB/IDeA/Pages/default.aspx.
        \54\ heal.nih.gov/research/research-to-practice/enhancing-clinical-
    trials-network.
        \55\ grants.nih.gov/grants/guide/pa-files/PAR-23-122.html.
        \56\ grants.nih.gov/grants/guide/pa-files/PAR-23-144.html.
    ---------------------------------------------------------------------------
        NIDA acknowledges the vital need to ensure rural access to
    evidence-based interventions and supports substance use research in
    rural communities. The Rural Opioid Initiative (ROI), which is in the
    process of concluding, was a collaboration of NIDA with the Appalachian
    Regional Commission, the Substance Abuse and Mental Health Services
    Administration (SAMHSA), and the Centers for Disease Control and
    Prevention (CDC). The researchers supported under this initiative
    worked with state and local health departments to fill data gaps
    regarding the opioid epidemic (including polysubstance use) and
    supported the development and testing of locally focused interventions
    to address overdose and expand access to evidence-based services. These
    efforts included peer-based efforts to increase access to treatment for
    drug use disorders and Hepatitis C, development of local infrastructure
    for harm reduction, and establishment of mobile drug use and Hepatitis
    C services. To continue this important work, NIDA recently released a
    funding opportunity in collaboration with SAMHSA focused on drug use
    prevention in rural areas.\57\ Applications are under review now.
    ---------------------------------------------------------------------------
        \57\ grants.nih.gov/grants/guide/rfa-files/RFA-DA-24-036.html.
    ---------------------------------------------------------------------------
        Telehealth approaches are promising tools to increase access to
    services for people in rural areas. NIDA's Clinical Trials Network has
    conducted research to test ways to expand medications for opioid use
    disorder in rural settings, including a study that tested adding
    telemedicine components to opioid treatment in rural primary care
    clinics.\58\ Additionally, the increased flexibilities in telehealth
    prescribing and take-home doses of medications for opioid use disorder
    during the COVID-19 pandemic allowed research opportunities to
    understand the benefits and risks of expanded telehealth treatment
    access. Studies from NIDA, CDC, and other researchers have shown that
    these enhanced flexibilities were not associated with increases in
    methadone- or buprenorphine-involved overdose deaths and were
    associated with reduced risk for fatal overdose and increased retention
    in treatment.\59,60,61\ NIDA is also funding the development of new,
    longer acting forms of medication for substance use disorders, such as
    once-weekly oral methadone,\62\ that would benefit those in rural areas
    with limited access to treatment clinics.
    ---------------------------------------------------------------------------
        \58\ ncbi.nlm.nih.gov/pmc/articles/PMC10718290/.
        \59\ pubmed.ncbi.nlm.nih.gov/35830198/.
        \60\ pubmed.ncbi.nlm.nih.gov/36662523/.
        \61\ pubmed.ncbi.nlm.nih.gov/36988913/.
        \62\  reporter.nih.gov/project-details/10455129.
    ---------------------------------------------------------------------------
        With funding from the NIH HEAL Initiative, NIDA supports large
    research programs in real-world settings in collaboration with a
    diverse range of partners to ensure that the strategies being studied
    are sustainable and scalable, including studies focused on rural
    populations. The HEALing Communities Study is investigating the impacts
    and challenges of implementing evidence-based strategies to reduce
    opioid-related overdose deaths, increase uptake of medications for
    opioid use disorder, and reduce high risk opioid prescribing in 67
    communities across four states, including in rural areas highly
    affected by the overdose crisis. The Harm Reduction Research Network is
    testing the effectiveness, implementation, and impact of harm reduction
    approaches in rural areas and other communities. As part of the HEAL
    Integrative Management of chronic Pain and opioid use disorder (OUD)
    for Whole Recovery (IMPOWR) program, one study is developing and
    testing interventions for co-occurring chronic pain and OUD to meet the
    needs of people in rural and Black communities.\63,64\ Another HEAL-
    funded NIDA study is focused on disrupting social determinants of
    health to improve substance use and mental health outcomes for parents
    in rural regions.\65\ Findings from these studies will provide valuable
    insights into how specific rural communities can increase access to
    interventions for substance use disorder through tailored approaches
    that meet individual and community needs.
    ---------------------------------------------------------------------------
        \63\ heal.nih.gov/research/clinical-research/integrative-
    management-chronic-pain.
        \64\ reporter.nih.gov/project-details/10378923.
        \65\ reporter.nih.gov/search/vlx60WJV9UKmf-cEMTrRlg/project-
    details/10892474.
    ---------------------------------------------------------------------------
                                     ______

              Questions Submitted by Senator Shelley Moore Capito
    Smoking Cessation
        Question. According to NIDA, addiction to nicotine in tobacco
    remains the most deadly substance use disorder, resulting in more than
    480,000 deaths each year from tobacco-related diseases including lung
    cancer. What role do you see for new safe and effective smoking
    cessation therapies to help patients be more successful in their quit
    attempts? Do we need new tools in the smoking cessation toolkit?
        At a Cancer Moonshot event at the White House last year, you asked
    Dr. Califf what more could be done to bring forward new, more effective
    smoking cessation treatments. What role do you see for product
    innovation to advance more effective smoking cessation therapies for
    patients?
        Smoking cessation products have been on the market for decades. Why
    are patients not more successful in their quit attempts with the
    current FDA approved methods? What do we need to do to change that?
        Answer. There are effective treatments that support tobacco
    cessation, including both behavioral therapies and FDA-approved
    medications; however, fewer than one in ten adults who smoke cigarettes
    succeed in quitting each year.\66\ This is due in part to
    underutilization of existing treatments.
    ---------------------------------------------------------------------------
        \66\ cdc.gov/tobacco-surgeon-general-reports/reports/2020-smoking-
    cessation/index.html.
    ---------------------------------------------------------------------------
        Although most people who smoke cigarettes make a quit attempt each
    year, less than one-third use FDA-approved cessation medications or
    behavioral counseling to support their attempts.\6\ In the recently
    published HHS Framework to Support and Accelerate Smoking
    Cessation,\67\ several primary goals aim to address this issue by
    strengthening cessation services and supports and increasing access to
    comprehensive evidence-based cessation treatments. This framework
    provides a unifying vision for the agency to help drive progress
    towards cessation, especially in populations that experience smoking-
    and cessation-related disparities.
    ---------------------------------------------------------------------------
        \67\ hhs.gov/sites/default/files/hhs-framework-support-accelerate-
    smoking-cessation-2024.pdf.
    ---------------------------------------------------------------------------
        Beyond existing treatments, supporting the development of new safe
    and effective strategies for tobacco cessation is an important priority
    for the National Institute on Drug Abuse (NIDA) to increase the number
    of people who are able to stop smoking. Current NIDA-funded research is
    focused on developing and testing innovative therapeutics and
    behavioral interventions for tobacco cessation to expand the evidence-
    based options available to help people. A multi-site randomized
    clinical trial is underway testing psilocybin for smoking
    cessation.\68\ Another study is following up on promising preclinical
    data to examine the effects of a ketamine infusion on craving and
    tobacco cessation in people who smoke.\69\ NIDA-funded researchers are
    also conducting a study using transcranial magnetic stimulation to
    modulate brain circuitry in people with co-occurring tobacco use
    disorder and schizophrenia and test if this treatment helps people to
    decrease or quit smoking.\70\ NIDA has developed a standardized
    research electronic cigarette (SREC) to facilitate clinical research on
    e-cigarettes,\71\ which is allowing high quality studies to be done on
    the impacts of switching from cigarettes to SRECs on use behaviors,
    chemical exposures, and biological effects across a range of
    populations and will inform our understanding of the value of e-
    cigarettes as potential cessation interventions.\72,73,74,75\
    ---------------------------------------------------------------------------
        \68\ reporter.nih.gov/search/ggAdH7ElMU-dTkJCgGg8zA/project-
    details/10491336.
        \69\ reporter.nih.gov/search/UWMVimJmYUiKO6pI49-iRQ/project-
    details/10371688.
        \70\ reporter.nih.gov/search/xxJjtoaLJkSZ7VmE4C-Ouw/project-
    details/10775767.
        \71\ nida.nih.gov/research/research-data-measures-resources/nida-
    drug-supply-program-dsp/nida-drug-supply-program-dsp-ordering-
    guidelines/nida-standardized-research-electronic-cigarette-srec-for-
    clinical-research.
        \72\ reporter.nih.gov/search/MSUv_jmK2k2w0_j2RFALgA/project-
    details/10811935.
        \73\ reporter.nih.gov/search/tozXm3VREkyB2cyj4EuvPw/project-
    details/9752505.
        \74\ reporter.nih.gov/search/49YSVOqdu0KVzL4TkoabjA/project-
    details/9788397.
        \75\ reporter.nih.gov/search/49YSVOqdu0KVzL4TkoabjA/project-
    details/9688221.
    ---------------------------------------------------------------------------
        Research is also needed to develop cessation therapies for youth,
    since there are currently no FDA-approved tobacco cessation medications
    for this population. To help address adolescent nicotine vaping, NIDA
    is funding a clinical trial testing varenicline to determine if it can
    help adolescents who vape nicotine and want to quit.\76\ NIDA is also
    funding a project developing a brief behavioral activation mobile app
    to help adolescents stop vaping nicotine.\77\ NIDA and the National
    Cancer Institute (NCI) have developed a funding opportunity,
    ``Advancing Adolescent Tobacco Cessation Intervention Research,'' \78\
    to support research that will develop, test, implement, and evaluate
    behavioral tobacco cessation interventions for adolescents, with a
    focus on the critical developmental risk period of mid- to late
    adolescence (approximately 14--20 years old). This funding opportunity
    aims to address the critical need for empirically validated tobacco
    cessation interventions for adolescents.
    ---------------------------------------------------------------------------
        \76\ reporter.nih.gov/project-details/10689064.
        \77\ reporter.nih.gov/search/7QIGg_2Dd0iXuyF V6s4w/project-details/
    10250714.
        \78\ grants.nih.gov/grants/guide/rfa-files/RFA-CA-22-043.html.
    ---------------------------------------------------------------------------
                                     ______

                Questions Submitted to Dr. Gary H. Gibbons, M.D.
              Questions Submitted by Senator Shelley Moore Capito
    Pulmonary Fibrosis Research
        Question. Pulmonary fibrosis results in the deaths of 40,000
    Americans each year, how is the NHLBI working to strengthen the
    pipeline of pulmonary fibrosis investigators to ensure that there is
    ongoing, robust research into this devastating disease.
        Answer. The National Heart, Lung, and Blood Institute (NHLBI)
    supports a robust portfolio of basic, translational, and clinical
    research focused on understanding the causes of pulmonary fibrosis
    (PF), and improving early detection, diagnosis, and treatment outcomes
    across the lifespan.
        NHLBI is harnessing data science and machine learning to drive
    precision medicine for heart, lung, blood, and sleep conditions
    including pulmonary fibrosis. This information will enable us to
    discover new targets for interventions that may improve health outcomes
    for diseases such as pulmonary fibrosis, that has historically had poor
    prognosis. NHLBI's Trans-Omics for Precision Medicine (TOPMed) program
    has assembled one of the world's largest, most diverse collections of
    genomic and multi-omic data, derived from participants in NHLBI-funded
    studies including the Women's Health Initiative, Framingham Heart
    Study, Jackson Heart Study and others.\79\ Through TOPMed, 2,180 cases
    of idiopathic pulmonary fibrosis (IPF), the most common type of PF
    which has no known cause, were sequenced and data was tested for
    association focused on the combined effect of rare variants within
    genes or regions. Researchers identified individual rare variants
    within the TERT and RTEL1 genes as high risk factors for IPF and as
    potential new therapeutic targets.\80\ Continued utilization of the IPF
    TOPMed data will yield additional discoveries to advance diagnosis,
    treatment and prevention of this disease.
    ---------------------------------------------------------------------------
        \79\ topmed.nhlbi.nih.gov/.
        \80\ ncbi.nlm.nih.gov/pmc/articles/PMC10161759/.
    ---------------------------------------------------------------------------
        An NHLBI-supported multicenter clinical trial testing the drug
    Setanaxib in patients with IPF holds the potential to shift future PF
    clinical trial design more towards meaningful patient outcomes. This
    drug inhibits nicotinamide adenine dinucleotide phosphate (NADPH)
    oxidase (NOX) isoforms, known to play an important role in the
    development of IPF. The trial represents the bedside application of a
    series of NOX translational and basic studies and discoveries, over
    several years, supported by NHLBI. Treatment with Setanaxib could
    result in significant benefit for PF, which currently has limited
    treatment options.
        NHLBI is committed to strengthening a diverse pipeline of future
    researchers in PF to guarantee the future of research in this disease.
    The Institute's workforce development programs offer a myriad of
    mechanisms geared at all careers levels including high school and
    undergraduate level, postbaccalaureate, graduate, doctoral and
    postdoctoral levels, along with early career, mid-career and
    established investigators. Similarly, NHLBI's workforce training
    programs encompass a variety of career development and training
    opportunities.
        The Institute prioritizes support for early-stage investigators
    (ESI's) with initiatives such as the BioData Catalyst Fellows program,
    which provides ESI's with funding opportunities to support research on
    novel and innovative data-science and data-focused research
    programs.\81\ The Institute's Stimulating Access to Research in
    Residency Transition Scholar Career Development program (StARRTS) and
    Mentored Research Scientist Career Development Award support career
    development opportunities for ESI's to accelerate the transition to
    independent careers across heart, lung, blood and sleep
    research.\82,83\
    ---------------------------------------------------------------------------
        \81\ biodatacatalyst.nhlbi.nih.gov/fellows/program/.
        \82\ nhlbi.nih.gov/grants-and-training/training-and-career-
    development/limited-competition-stimulating-access-research.
        \83\ nhlbi.nih.gov/grants-and-training/training-and-career-
    development/mentored-research-scientist-career- development.
    ---------------------------------------------------------------------------
        NHLBI's T32 Training Program for Institutions that Promote
    Diversity, which provides research capacity development at institutions
    that do not receive substantial NHLBI funding.\84\
    ---------------------------------------------------------------------------
        \84\ nih.gov/grants/guide/rfa-files/RFA-HL-22-001.html.
    ---------------------------------------------------------------------------
    Heart Disease and Maternal Health
        Question. Cardiovascular disease is the leading cause of maternal
    death, how is the NHBLI addressing maternal health in its research to
    protect women's heart health before, during, and after pregnancy?
        Answer. The maternal mortality rate in the United States is higher
    than in any developed country in the world. In 2021 more than 1,200
    women died of causes related to pregnancy in the United States.\85\ The
    National Heart, Lung, and Blood Institute (NHLBI) has taken a lead role
    in research to reduce the nation's alarming rates of maternal mortality
    and morbidity. Black women have a three-times greater risk for death
    during pregnancy or childbirth compared to White women.\86\ American
    Indian, Alaska Native, Native Hawaiian, and other Pacific Islander
    populations also experience increased risk. NHLBI recognizes that
    addressing maternal morbidity and mortality requires a life-course
    approach that focuses on improving women's heart health before, during,
    and after reproductive age.
    ---------------------------------------------------------------------------
        \85\ cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-
    mortality-rates-2021.htm#:%7E:
    text=In%202021%2C%201%2C205%20women%20died,20.1%20in%202019%20(Table).
        \86\ pubmed.ncbi.nlm.nih.gov/33216690/.
    ---------------------------------------------------------------------------
        NHLBI is the second largest funder of maternal health studies at
    NIH. Some key programs NHLBI leads and/or has strong involvement in
    include:
      --Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be
            Heart Health Study (nuMoM2b) studies the effects of pregnancy
            complications on future cardiovascular health, including links
            between social factors that correlate with the future heart
            health of new parents, especially in communities of color.\87\
    ---------------------------------------------------------------------------
        \87\ numom2b.org/.
    ---------------------------------------------------------------------------
        --Women with adverse pregnancy outcomes, such as gestational
                hypertension, gestational diabetes, preeclampsia, and
                preterm delivery were more likely to:
          -- Have higher blood pressures, glucose, insulin, and obesity in
                the first trimester.
          -- Have higher risk of hypertension 2-7 years after delivery.\88\
    ---------------------------------------------------------------------------
        \88\ pubmed.ncbi.nlm.nih.gov/33619977/.
    ---------------------------------------------------------------------------
      --Early Intervention to Promote Cardiovascular Health of Mothers and
            Children (ENRICH), which works directly with communities that
            have a high burden of cardiovascular disease (e.g., low-
            socioeconomic status communities, tribal nations, low- resource
            areas).\89\
    ---------------------------------------------------------------------------
        \89\ hvenrich.org/ENRICH_Main.asp.
    ---------------------------------------------------------------------------
      --Implementing a Maternal health and PRegnancy Outcomes Vision for
            Everyone (IMPROVE), which was designed to understand and reduce
            health disparities among populations disproportionately
            affected by maternal morbidity and mortality, including African
            American, American Indian, Alaska Native, Asian American,
            Pacific Islander, Hispanic/Latina, very young women, older
            women, and women with disabilities.\90\
    ---------------------------------------------------------------------------
        \90\ nichd.nih.gov/research/supported/IMPROVE.
    ---------------------------------------------------------------------------
      --Maternal Health Community Implementation Program (MH-CIP), a
            community-driven initiative studying how evidence-based
            interventions, such as regular blood pressure readings, can
            work to improve women's heart health and reduce maternal
            mortality.\91\
    ---------------------------------------------------------------------------
        \91\ nihceal.org/programs/maternal-health-community-implementation-
    program.
    ---------------------------------------------------------------------------
      --MH-CIP funds four regional coalitions, in areas with high maternal
            morbidity and mortality, to conduct community-engaged research
            testing implementation strategies to increase uptake and
            adoption of proven interventions to improve maternal health and
            address maternal health inequities.\92\
    ---------------------------------------------------------------------------
        \92\ reporter.nih.gov/project-details/10258683.
    ---------------------------------------------------------------------------
      --Chronic Hypertension in Pregnancy (CHAP), which examined the safety
            of treating mild hypertension during pregnancy, found that
            treatment for mild chronic hypertension leads to better
            pregnancy outcomes and has no negative effect on fetal growth.
            Due to this study, the American College of Obstetricians and
            Gynecologists changed their clinical practice
            guidelines.\93,94\
    ---------------------------------------------------------------------------
        \93\ chap.obgyn.uab.edu/index.php/study-details/.
        \94\ acog.org/clinical/clinical-guidance/practice-advisory/
    articles/2022/04/clinical-guidance-for-the-integration-of-the-
    findings-of-the-chronic-hypertension-and-pregnancy-chap-study.
    ---------------------------------------------------------------------------
      --Implementing a Maternal health and PRegnancy Outcomes Vision for
            Everyone Community Implementation Program (IMPROVE-CIP), the
            community-engagement arm of IMPROVE, which addresses underlying
            factors associated with health disparities (e.g., substance
            use, mental health, social determinants of health).\95\
    ---------------------------------------------------------------------------
        \95\ nihceal.org/programs/implementing-maternal-health-and-
    pregnancy-outcomes-vision-everyone-community.
    ---------------------------------------------------------------------------
        NHLBI will continue to prioritize and advance research efforts in
    pursuit of tackling the current public health crisis in maternal
    health.
                                     ______

                Questions Submitted by Senator Susan M. Collins
        Question. Four years after the start of the COVID pandemic, we
    still have many questions surrounding how to identify and treat Long
    COVID. In 2021, NIH launched the RECOVER Initiative to study Long COVID
    and look for treatments across different types of research studies. I
    have discussed the RECOVER Initiative both with those involved in the
    research, who defend its complexity, and others who are more critical
    due to the time spent defining the symptoms and a delayed emphasis on
    therapeutics. I believe in the NIH's ability to translate research into
    results patients feel on the ground, but I also understand the
    frustration that no ``cure'' or even real treatment has been found. Dr.
    Gibbons, can you describe what research gains RECOVER has made and
    update us on clinical trial efforts?
        Answer. For many, Long COVID is a long-lasting and life-altering
    experience. It presents with hundreds of heterogeneous symptoms that
    vary across the lifespan and demographic groups. The millions of adults
    and children currently struggling with debilitating symptoms of Long
    COVID urgently need proven tools for diagnosis, treatment, and care.
    Within a year of receiving supplemental appropriations for the study of
    Long COVID, NIH designed and launched RECOVER--the world's most
    comprehensive and diverse patient-centered research study to
    understand, treat, and prevent Long COVID. RECOVER is a multi-faceted
    research initiative that includes longitudinal observational studies,
    electronic health record (EHR) studies, pathobiology and tissue
    pathology studies, a mobile health platform, and clinical trials.
    RECOVER created a network of nearly 300 research sites (universities,
    hospitals, clinics) where hundreds of Long COVID researchers across the
    nation are working with nearly 90,000 adult and pediatric research
    participants, conducting medical tests and collecting data and then
    analyzing and sharing the data and results broadly with the research
    community, physicians, patients, and the public.
        RECOVER has already established a comprehensive set of adaptive
    clinical trial platforms that focus on potential causes as well as the
    symptoms deemed most burdensome by Long COVID patients, which are
    collectively testing 13 active interventions for Long COVID. The
    adaptive nature of this platform approach enables the evaluation of
    multiple treatments simultaneously. This advanced methodology enables
    the best treatments to get to patients quicker than traditional trials.
    Interventions not showing promise can be ended and quickly allow for
    more nimble pivots to test new interventions as needed. Three RECOVER-
    sponsored clinical trials have started enrolling patients: RECOVER-
    VITAL (viral persistence and immune dysregulation) began enrolling in
    July 2023; RECOVER-NEURO (neurologic/cognitive dysfunction, such as
    ``brain fog'') in September 2023; and RECOVER-AUTONOMIC (autonomic
    dysfunction, such as racing heart, dizziness, fatigue) in March 2024,
    and two additional platform protocols were released this spring,
    RECOVER SLEEP (sleep disorders, such as excessive sleepiness or
    disrupted sleep) and RECOVER ENERGIZE (exercise intolerance or
    fatigue). The first two of these trials (VITAL and NEURO) are nearing
    completion of enrollment.
        Over the past 2 years, we have learned crucial information about
    Long COVID that is helping patients by informing diagnosis, monitoring,
    and preventive measures, including:
      --The incredibly broad range of clinical symptoms in adults and
            children, and how these symptoms cluster;
      --Risk factors for developing Long COVID;
      --The impact of viral variants on the risk for and severity of Long
            COVID;
      --The impact of vaccination on Long COVID;
      --The risk of developing new-onset conditions and/or worsening of
            pre-existing conditions; and
      --Health disparities in Long COVID.
        As of May 2024, 54 scientific papers have been published or
    accepted for publication, 16 are under journal review, and another 77
    reports are in preparation. Importantly, RECOVER is making its data
    publicly available to other authorized researchers with the hope of
    accelerating discoveries with greater data analyses. In April 2024, the
    first set of secure, deidentified data from RECOVER observational
    research was made publicly available on BioData Catalyst \96\ to
    authorized researchers. The addition of RECOVER data to BioData
    Catalyst, NHLBI's cloud-based data repository, can help investigators
    identify and explore Long COVID connections that may benefit from or
    inform future studies.
    ---------------------------------------------------------------------------
        \96\ biodatacatalyst.nhlbi.nih.gov/recover.
    ---------------------------------------------------------------------------
        This large and complex research enterprise is aimed at leaving no
    stone unturned for discoveries in Long COVID. Given the history of
    post-infection conditions, the enormous challenges these conditions
    pose, and the lack of progress for them, the RECOVER Initiative and its
    associated research assets aim to ensure meaningful advances for this
    post-infection condition, and likely others as well.

                             CONCLUSION OF HEARINGS

        Senator Baldwin. And now, the subcommittee will stand in
    recess.
        Dr. Bertagnolli. Thank you.
        [Whereupon, at 11:45 a.m., Thursday, May 23, the hearings
    were concluded, and the subcommittee was recessed, to reconvene
    subject to the call of the Chair.]

           LIST OF WITNESSES, COMMUNICATIONS, AND PREPARED STATEMENTS

                                  ----------
                                                                       Page

    Baldwin, Senator Tammy, U.S. Senator From Wisconsin:
        Opening Statements of

        Questions Submitted by

    Becerra, Hon. Xavier, Secretary, Office of the Secretary,
      Department of Health and Human Services........................     1
        Prepared Statement of........................................     6
        Questions Submitted to.......................................    43
        Summary Statement of.........................................     5
    Bertagnolli, Dr. Monica M., M.D., Director, National Institutes
      of Health, Department of Health and Human Services.............   323
        Prepared Statement of........................................   330
        Questions Submitted to.......................................   357
        Summary Statement of.........................................   328
    Boozman, Senator John, U.S. Senator From Arkansas, Questions
      Submitted by

    Britt, Senator Katie, U.S. Senator From Alabama, Questions
      Submitted by

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

        Statements of

    Cardona, Hon. Miguel, Secretary, Office of the Secretary,
      Department of Education........................................    99
        Prepared Statement of........................................   107
        Questions Submitted to.......................................   129
        Summary Statement of.........................................   106
    Collins, Senator Susan M., U.S. Senator From Maine, Questions
      Submitted by

    Durbin, Senator Richard J., U.S. Senator From Illinois, Questions
      Submitted by...................................................   152

    Gibbons, Dr. Gary H., M.D., Director, National Heart, Lung, and
      Blood Institute, Department of Health and Human Service........   323
        Questions Submitted to.......................................   378
    Graham, Senator Lindsey, U.S. Senator From South Carolina,
      Questions Submitted by

    Hodes, Dr. Richard J., M.D., Director, National Institute on
      Aging, Department of Health and Human Service..................   323
    Hyde-Smith, Senator Cindy, U.S. Senator From Mississippi,
      Questions Submitted by

    Kennedy, Senator John, U.S. Senator From Louisiana, Questions
      Submitted by...................................................   363

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

    Marrazzo, Dr. Jeanne, M.D., M.P.H., Director, National Institute
      of Allergy and Infectious Diseases, Department of Health and
      Human Services.................................................   323
        Questions Submitted to.......................................   374
    Merkley, Senator Jeff, U.S. Senator From Oregon, Questions
      Submitted by...................................................   236
    Moran, Senator Jerry, U.S. Senator From Kansas, Questions
      Submitted by...................................................    75
    Murray, Senator Patty, U.S. Senator from Washington, Questions
      Submitted by

    Rathmell, Dr. W. Kimryn, M.D., Ph.D., M.M.H.C., Director,
      National Cancer Institute, Department of Health and Human
      Services.......................................................   323
        Questions Submitted to.......................................   372
    Reed, Senator Jack, U.S. Senator From Rhode Island, Questions
      Submitted by...................................................   303
    Rubio, Senator Marco, U.S. Senator From Florida, Questions
      Submitted by

    Schatz, Senator Brian, U.S. Senator From Hawaii, Questions
      Submitted by...................................................    51
    Shaheen, Senator Jeanne, U.S. Senator From New Hampshire,
      Questions Submitted by

    Su, Hon. Julie, Acting Secretary, Office of the Secretary,
      Department of Labor............................................   253
        Prepared Statement of........................................   259
        Questions Submitted to.......................................   287
        Summary Statement of.........................................   258

    Volkow, Dr. Nora D., M.D., Director, National Institute on Drug
      Abuse, Department of Health and Human Services.................   323
        Questions Submitted to.......................................   375

                                 SUBJECT INDEX

                                  ----------

                            DEPARTMENT OF EDUCATION

                            Office of the Secretary

                                                                       Page

    Achieving Academic Excellence....................................   108
    Additional Committee Questions...................................   128
    Antisemitism.....................................................   125
        and Civil Rights Enforcement.................................   114
    Bipartisan Safer Communities Act.................................   116
    Boldly Improving Learning Conditions.............................   109
    Career and Technical Education...................................   101
    Charter Schools..................................................   103
    Chronic Absenteeism..............................................   117
    College Campus Protests and Antisemitism

    Creating Pathways For Global Engagement..........................   109
    Debt Burden......................................................   121
    Department of Education Topline Request and Baseline.............   108
    Education Research, Assessment, and Statistics...................   111
    Elementary and Secondary Education...............................   101
    Enforcement of Civil Rights Laws.................................   111
    Fostering Diverse Schools Program................................   118
    Free Application for Federal Student Aid

        and Farm Assets..............................................   124
    Impact of Title IX Regulations on Females........................   123
    Making Postsecondary Education Inclusive and Affordable..........   110
    Mental Health

    Postsecondary Education..........................................   100
    Public Service Loan Forgiveness..................................   120
    Regulations......................................................   105
    Rural Education Achievement Program..............................   106
    Schools Sharing Gender Status with Parents.......................   123
    Student Loan Financial Literacy

    Title IX

        Regulations..................................................   106
                                   __________

                    DEPARTMENT OF HEALTH AND HUMAN SERVICES

                         National Institutes of Health

    A Reinvigorated Cancer Moonshot..................................   330
    Additional Committee Questions...................................   357
    Alzheimer's:
        Research.....................................................   343
        Treatment....................................................   335
    Amyotrophic Lateral Sclerosis....................................   337
    ARPA-H Funding...................................................   348
    Blood Brain Barrier..............................................   338
    Buildings and Facilities.........................................   333
    Chronic Pain Treatment...........................................   345
    Clinical Trials..................................................   351
        Infrastructure...............................................   339
    Data Sharing Across the Research Ecosystem.......................   332
    Diabetes.........................................................   356
    Drug Overdoses...................................................   356
    Future of Scientific Research Workforce..........................   352
    Gain of Function Research........................................   349
    H5N1 Virus.......................................................   333
    IDeA Program.....................................................   340
    Impact of Continuing Resolutions.................................   351
    Long COVID.......................................................   331
    Maternal Mortality...............................................   350
    Native Hawaiian Pacific Islander Health Research Office..........   345
    NCI Designated Cancer Centers

    NIH Funding Increases............................................   337
    Overdose Deaths..................................................   334
    Pandemic Preparation.............................................   349
    Psychedelic Research.............................................   346
    Respiratory Support in Rural Areas...............................   354
    Revolutionizing Mental Health with Precision Medicine............   331
    Sexual Harassment................................................   341
    Strengthening Biodefense.........................................   332
    Substance Use Disorders..........................................   355
    Tick Borne Illnesses.............................................   343
    Ultrasound Slowing Addiction.....................................   335
    Use of Emerging Data Methods in Research.........................   347
    Women's Health Research..........................................   342
        Across the Lifespan..........................................   331

                            Office of the Secretary

    988 Implementation...............................................    20
    Abortion

    Additional Committee Questions...................................    43
    Advancing:
        Health in Indian Country.....................................    10
        Science to Improve Health....................................    11
    Alzheimer's Disease..............................................    40
    ARPA-H...........................................................    28
    Behavioral Health................................................    23
    Cardiovascular Disease...........................................    33
    Child Care.......................................................    26
    CMS Program Management...........................................    35
    Enhancing Long-term Care in All Settings.........................     9
    Expanding Coverage and Lowering Health Care Costs................     7
    HHS employees....................................................    30
    HRSA.............................................................    23
    Improving the:
        Customer Experience for the American Public..................    12
        Well-being of Children, Families, and Older Adults...........     9
    Insulin..........................................................    36
    Jessica Grubb's Legacy Act.......................................    21
    Maternal Health

    Medicare Advantage...............................................    31
    Opioid Epidemic..................................................    13
    Overdose Prevention..............................................    15
    Preparing for Future Public Health Threats.......................    10
    Provider Relief Funds............................................    41
    Return to Work...................................................    29
    Rural Health

    Strengthening Maternal Health Outcomes and Reproductive
      Healthcare Access..............................................     9
    Suicide Prevention...............................................    16
    Supporting Program Operations and Mission-Critical Infrastructure    11
    Telehealth.......................................................    34
    Title X..........................................................    37
    Transforming Behavioral Health...................................     8
    Youth Homelessness...............................................    27
                                   __________

                              DEPARTMENT OF LABOR

                            Office of the Secretary

    Additional Committee Questions...................................   287
    Advancing Equity.................................................   262
    Apprenticeship Programs..........................................   257
    Child Labor:
        Laws.........................................................   271
        Penalties....................................................   274
    EBSA and Mental Health Services Enforcement......................   278
    Employee Benefits Security Administration........................   255
    Enforcing Child Labor Laws.......................................   258
    Environmental, Social, and Governance Rule.......................   282
    ESG Investment Rule..............................................   256
    Healthcare Workers & Workforce Violence..........................   264
    Highlights of DOL's Budget Request...............................   287
    H-2B Visa Program

    ILAB's Mission...................................................   263
    Importance of Skilled Labor......................................   272
    Investing in Workforce Training Programs.........................   254
    Joint Employer Rule, The.........................................   283
    Lack of Senate Confirmed Secretary at DOL........................   280
    New:
        Emergency Response Standard..................................   270
        Overtime Rule................................................   281
        Rules Impacting Independent Contractor Status................   256
    Occupational Safety and Health Administration....................   255
    Overtime Rule Compliance Timeline................................   265
    Overtime Rule, The...............................................   265
    Presidential Line of Succession..................................   280
    Proposed Changes to National Apprenticeship Systems..............   269
    Registered Apprenticeship Program................................   254
    Salary Imparities in Rural Areas.................................   268
    Schedule A Occupation List.......................................   285
    Sexual Harassment:
        at FDIC

        in Federal Government........................................   277
    Strengthening Community College Training Grant Programs..........   274
    Summary Statement of Hon. Julie Su...............................   258
    U.S. Workforce Reduction Impacts & WARN..........................   263
    Wage:
        and Hour Division............................................   255
        Theft Prevention.............................................   271
    WARN Act.........................................................   264
    Women's Bureau...................................................   275
    Workforce:
        Protection...................................................   259
        Training Services for VETS...................................   255

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