subcommittee will come to order i recognize myself for five minutes for purposes of making making an opening statement today the subcommittee is meeting to mark up for important pieces of legislation one is h r thirteen forty three the health centers renewal act of two thousand and seven introduced by my good friend mr green the vice chair of our wrists subcommittee and also mr pickering and i i have to tell you that mr green has been i don't know how to put it i'm not in a negative way but pestering us repeatedly for the last six months to move on this legislation and rightly so because it is so important the second bill is r five six six nine the poison control center support enhancement and awareness axelrod said by mr townsend mr cherry and the third bill is h r fifteen fifty three the concord childhood cancer act price and mr van hollen and lastly is h r three one one to the prenatal or prenatally diagnosed condition awareness act of two thousand and seven sponsored by mr sensenbrenner each of these bills is vitally important to protecting the public health and improving access to health care services for millions of americans and next week actually marks cover the uninsured week a time of year in which we try to come together and highlight the fact that for far too many americans  they simply have no basic health coverage and are unable to access the health care services they need while we can agree that our country is facing a growing crisis when it comes to the uninsured we tend to see things differently when we talk about how to reach the goal of affordable and stable health care for all but one program that has received broad bipartisan support for its efforts in addressing the needs of the uninsured is the community health centers program for the past forty years there's been one place that americans have been able to go to regardless of their ability to pay and receive the medical treatment that they deserve and those are our nation's community health centers since the mid one nine hundred sixty s community health centers have served as a first line of defense to provide quality preventive and primary health care services during the hearing the subcommittee held on the health centers program last year we heard about what an important role the centers play in medically underserved communities we heard from a steven miracle of georgia mountain health services who talked about the success they have experienced in providing health services to the medically needy as well as the persistent challenges they continue to face in the in light of our strained health care system as more and more americans join the ranks of the uninsured because of the economic downturn the demands on our state's health centers are growing exponentially increased demand coupled with aging facilities and difficulties in recruitment and retention of health professionals has placed tremendous strain on these health centers accordingly action by the subcommittee today to reauthorize this program will strengthen our community health centers and help them so still the role they play in guaranteeing access to high quality health services and again i want to thank mr green for sponsoring this important bill he's been a steadfast advocate for the health centers program there's no doubt in mine mind that because of his efforts that we were able to act on this bill today no question in addition to the health centers renewal act the subcommittee will also mark up the poison center support enhanced been an awareness fact introduced by mr townson and mr terry poison control centers our nation's primary defense against injury and deaths from poisoning the centers are on call twenty four hours a day to help providers in the public w possible exposures to poison in addition poison centers by the central follow up care professional health care provider education nationwide data collection and poisoning as well as a number of other services the centers are of tremendous value to our communities and i want to thank mr towns and mr terry for working together to reauthorize this important program h r fifteen fifty three the concord childhood cancer act of two thousand and seven as i said was introduced by representatives deborah price and chris van ho both of whom have been tireless advocates for beating back cancers that inflict children this legislation which strengthen federal investment in pediatric cancer research by advancing medical research and treatments into pediatric cancers ensuring patients and families have access to current treatments and information regarding pediatric cancers and promoting public awareness of pediatric cancer although the five year survival rate for children with cancer is steadily increasing cancer remains the number one disease killer of america's children more believe it or not insisted fibrosis muscular dystrophy asthma and aids combined some hopeful the passage of this bill will help us win the fight against childhood cancer and finally the subcommittee will mark up r three one one to the prenatally diagnose awareness act of two thousand and seven introduced by mr sensenbrenner and this legislation when the choice of the pregnant women or mothers of newborns with a prenatally diagnosed condition have timely access to updated scientific information about the life expectancy intellectual and functional development and treatment options for their child in addition this bill would provide families with referrals to support services improve our nation's epidemiology understanding of prenatally diagnosed conditions and support health care providers who provide the results of prenatal or postnatal tests to patients i want to thank all of my colleagues for their hard work on these bills especially for their willingness to work in a bipartisan fashion to ensure that the subcommittee considers these bills and now recognizes to deal purpose of making an opening statement thank you mr chairman i want to thank you for holding this mark up so that we can move these important bills another step closer to becoming law i'd like to drop ticket our attention to h r thirteen forty three the health centers are neil act of two thousand and seven community health center program has been a great success and they are an integral part of our country's health care delivery system health centers provide quality health care service to people in communities that would not otherwise have access to care and i want to thank mr green and mr alone for their willingness to work with me and some of the members on our side of the aisle to resolve some outstanding issues concerning the program have long supported the reforming the program in order to ensure that health centers can meet their staffing needs during times of emergency i was concerned by the stories we heard during the hearings about some health center employees who wanted to help following hurricane katrina and rita but unfortunately they learned they would not have a law billet the protection at the gulf coast states facilities and thus could not provide their services mr bones manager's amendment addresses this situation by incorporating language originally championed by the late mr paul gilmore of our committee also believe volunteers complained important role of health centers and i'm glad mr murphy's language to provide federal tort claims act protection to those who volunteer their services at health centers has been included in the manager's amendment is my understanding that many physicians would be more willing to volunteer their time at a health center if they knew they would be protected from frivolous lawsuits these changes should help the health centers program continue to be a tremendous success as it is today  services medically underserved communities throughout the country he was chairman of matter what congress and the next congress or even two congresses are now do with a national health care plan community health centers is literally a down payment so we will have these in expand this critical care will help close this gap that's why i'm happy to see that we're taking up thirteen forty three this bill is essential to provide health services to low income communities across america certainly our health care safety net would look very damaged without these community health centers i'm also pleased today that the manager's amendment includes a critical demonstration program that is part of another bill h r fifty five forty four the patients and public health partnership two thousand and eight introduced by myself and congressman stupak the chairman of the subcommittee on oversight investigations this demonstration program would provide grant money to health clinics that operate within an integrated delivery system and serve a largely  population that is largely uninsured oftentimes these academically or faith oriented hospital systems provide millions of dollars in free health care each year this demonstration will provide will provide us as policymakers with essential information about how we can improve the safety net for some of our most vulnerable americans and also provide the financial tools for many of these health networks to expand their charitable mission within their communities i thank congressman stupak and his staff for their work on this bill and i also want to acknowledge the the very competent assistance we had from committee staff particularly william garner and catherine martin working with my staff on this important priority as we move forward on h r thirteen forty three believe we will crowd craft the best legislation possible i know some have concerns over the large increase in authorization for the health center program over time but certainly we can resolve some of these issues as we move this bill to the full committee and to the full house mr chairman primary care plays a crucial role in effective paid patient care the federal money authorized in h r thirteen forty three will serve as a down payment for expanding such primary care to higher primary care doctors let patients know these doctors are available and allow for the coordination and the continuity here today and his statement be inserted into the record as well and i'll yield back thank you next to recognize the chairman of the full committee mr dingell strieber i thank you i commend you both for the hearing today and the markup and also for your remarkable leadership for worthwhile pieces of legislation today i want to say a word of praise both for the staff control center and the committee owes a thanks to mr towne who is a senior member of the subcommittee for his hard work in bringing the bill before us the third bill strengthens the federal investment in pediatric cancer research we commend our good friend and colleague for her dedication and leadership on this issue finally the fourth bill helps to ensure that pregnant women are receiving a positive diagnosis for down syndrome or other prenatal conditions have timely access to scientific scientifically sound information and adequate support services i am pleased to report that the majority and minorit sides have worked together very well to reach bipartisan consensus on the bills before us today i support the bipartisan amendments to have been worked i urge my colleagues to join us supporting these important public  thank you chairman dingell to recognize the gentleman from pennsylvania mr pitts for an opening statement gentleman from gentleman from illinois thank you mr chairman i look forward today to supporting all of these important public health bills with over two hundred forty bipartisan co sponsors the health centers renewal act has very broad support in this congress and for good reason for more than forty years health centers have played a critical role in providing a safety net for medically underserved populations including medicaid beneficiaries and the uninsured i want to thank mr green for what i learned today was his pestering in a really good way to make this happen as fast as it has for their health centers are able to provide culturally competent quality care to the communities they serve while remaining one of the top rated federal programs i'm very pleased to see this reauthorization progress through our committee and look forward to giving it my support i'm also eager to reauthorize the poison control centers program another very successful program that serves communities across the country served them well by providing a national toll free number for boys in emergencies and national media campaign to promote the use of poison centers and a poison prevention grant program in my home state of illinois a practice approximately fifty one percent of the calls handled at the state poison center involve children under five years old i shudder to think what families would do without this tremendous resource i would also like to mention my support for the concord childhood cancer act of which i am a co sponsor although mortality as a client for many childhood cancers some cancers such as brain tumors and a neuro blastoma treatments remain seriously inadequate h r fifteen fifty three would reinforce our hope for better cures by advancing medical research and treatments for pediatric cancer additionally i support prenatally diagnosed conditions awareness act which will help ensure the patient that patients receiving a prenatal diagnosis of down syndrome in spite of as a cystic fibrosis or other can general conditions we see the timely accurate and current information and support services they need and deserve again i'd like to thank the chairman for bringing these critical health bills before a subcommittee today and thank the sponsors of these bills for their leadership  these important issues and i yield back thank you recognize the gentleman from indiana mr bush passes the gentleman from california mis thank you mr chairman and i'll try to be brief mr chairman i want to thank you for convening the markup i also am in support of all of the bills before us but in particular the reauthorization of the community health centers the community health centers play a vital role in our health care safety net and i'm proud to be a co sponsor of h r thirteen forty three in california alone sixty six percent of the health care centers serve patients who are of hispanic descent there are many of the under served individuals who depend on this very vital resource for medical care and for educational and preventive services i'm pleased to have several community health centers that serve my district one in particular the east valley community health center provide fifty now that fifty nine thousand medical visits to more than twenty one thousand individuals every year we also have these is a clinic the roybal health clinic also in east l a and the majority of patients that are seen are working poor and ninety percent are uninsured i hope that we can continue to protect and strengthen our community health care cent i'm also a co sponsor of the conquer childhood cancer act this important legislation encourages an expansive port for pediatric cancer research within the national cancer institute there are disparities in pediatric cancer care and i believe we have an opportunity to reduce that through this legislation i'm pleased to have provided language which my understanding is that both the minority and majority staff will take a look at and hopefully help us in achieving this goal and i look forward to working with my colleagues to resolve any concerns regarding the language so we can be considered during the full committee markup passage of the bill will result in increased numbers of childhood cancer survivors the issue of childhood cancer survivors is an important one and i'm pleased to have introduced a chart forty four fifty the pediatric adolescent and young adult cancer survivorship and quantity quality of life back which my colleague representative mary bono mack is also supporting a diagnosis of cancer is the only beginning of a lifelong battle for a child with cancer childhood cancer survivors especially children from under served communities face tremendous health challenges the bill which i introduced has been endorsed by the alliance for childhood cancer which will improve an expanded delivery of medical and psycho social care to serve five years of childhood cancer i hope the committee will consider taking action on the important bipartisan legislation and i yield back the balance of my time these bills to do touch many lives in tennessee and us and to consider them to be important to our constituent community health centers play an important role in ensuring the adequate health care to almost two hundred fifty thousand people across ten are see particularly those that are lacking health insurance and these centers provide access to care in places where a shortage of health care remains a consistent problem in their cost of care rank among the lowest and they reduce the number of expensive emergency room and inpatient visits saving billions of dollars for taxpayers and for society my district is home to multiple centers including three rivers community health centers servicing piri hickman counties lifespan and harden and wind county chester canning and the memphis health center site in fayette county in addition i am pleased to announce that hardiman county community health center recently received c m s grant funding to provide discounted medical services to rural west tennessee clarksville tennessee is home to the newest help center in my district the matthew walker comprehensive health center recently opened a new clarksville clinic projected to serve nine thousand six hundred eighty patients by the end of this year i'm pleased that the president provided critical funding to expand community health centers in tennessee which continue to provide truly an invaluable service and really feel a need that is in our communities tennessee is also a leader in childhood cancer research and treatment the state is home to five children's oncology group hospitals throughout our state including st jude and vanderbilt children's hospital i'm pleased to support the efforts of these hospitals by co sponsoring the conquering childhood cancer while little is named about what causes childhood cancer more dass result from childhood cancer than the other leading childhood diseases combined with scarce research funds available it is critical that our tiniest patients have the opportunity to seek a cure i look forward to passing these bills at our subcommittee today i thank you mr chairman for the good work of our staff and i yield the balance of my time thank you gentlewoman from colorado thank you very much mr chairman i'm delighted that we are considering all of these important bills today i just want to talk about the community health center reauthorization bill which is really important to support vital component of our health care safety net i'm i'm happy mr chairman that you've included in the bill today the liability protection bill that i introduced last year with all of our dear friend congressm gilmore and this is kind of one of his legacies i think that will live on what this bill does is it provides liability protections for employees contractors and licensed volunteer practitioners who provide health services  designated emergency areas congressman gilmore and i developed this bill to address concerns that arose after hurricanes katrina and rita where license but out of state health center practitioners came in to provide emergency services and they were not afforded the same federal liability protections for their services that public health service employees were which seemed kind of crazy to us because they were really doing a wonderful job trying to do treat with those areas of great tragedy and so i'm just really happy mr chairman that you've included this this in the underlying bill and i'm glad to see the murphy thank you chairman paul own and ranking member deal and the sponsor of this legislation representing gene green for including a bill that i introduced h r six hundred twenty six the family health care accessibility act legislation that i introduced as part of the health senator renewal act of two thousand and seven at a time when our nation wonders of congress can come together to accomplish anything and please we able to work together in a bipartisan fashion to include my bill which is improve the underlying legislation the estimated number of uninsured in this country have been by the census bureau about forty five to forty seven million but when you subtract the individuals that are unaware they're come by medicaid the many millions of individuals who can afford health care but choose not to purchase it typically these are the younger folks in eighteen and twenty six or people with incomes above fifty to seventy five thousand you end up with ten to fifteen million people who have no insurance can't afford it but don't qualify this group is not old enough for medicare and not poor enough for medicaid this is where community health centers come in to help they provide critically important care to this group of the eleven hundred community health center of this country they employ six thousand physicians who provide this important affordable primary health care to more than sixteen million people nationwide and nearly seventy percent of all the patients treated the community all centers are members of the working poor have family incomes at or below poverty level and more than thirty percent of the uninsured what happens however when we try and provide expanded services for people who do not have other health care insurance we find the community health centers are straining to give those services there's huge vacancy rates for psychiatry family physicians obstetricians nurse practitioners physicians assistants nurse midwives and dentist at these centers on fortune one of the problems that occurs is if one wants to volunteer at one of these centers to provide support medical services without pay they cannot ironically of someone to get paid or to free clinic they can't either but here in this bill what we're providing assistance for is that doctors who wish to volunteer at these clinics they will be able to do that couple because they'll be covered under the federal tort claim act this is very very important because otherwise these medical practitioners simply would not be able to afford the medical malpractise insurance to provide these services for example let's say you have an o b g y n who wishes to volunteer some time because he or she is coming back into practice here and like to give some time if they were to have to pay for their own individual medical malpractise insurance it may cost them tens twenties i mean perhaps one hundred thousand dollars a year by volunteering it's a fraction of that and it is something the clinic can afford it is very very cost effective it saves money and it is something the community health centers have been asking for for a long time i'm pleased that chairman polonia make member deal and represent green have all worked hard on this bill i look forward to changing the law of the land so the doctors can be good samaritans and offer their time their services and their expertise to help our communities the health of our citizens and to help the uninsured and with that i yield back thank you gentleman from new york mr towns recognize for an opening statement thank you very much mr chairman let me begin by thanking center as well you know sometimes we talk about how important health care is and we do very little you know to point that out to demonstrate the importance of it so i want to salute to mr chairman for demonstrating in terms of how important it is by moving mean things would really be worse and i think that whatever we can do to enhance them and to be supportive of them i think we should should do it the prenatally diagnosed conditions awareness act of two thousand and seven is also a much needed voting in support of these bills because i think they are very important thank you to you back thank you ms eshoo recognize for an opening statement i'll put my full statement  the record mr chairman i just want to thank you all of the members from both sides of the aisle certainly the staff that have worked on these bills just a word about the community health interests this is as everyone can hear a real winner in the country the president supports them i think he brought that support to the white house saying how well they worked in his communities in the state where he was  governor and in the needs that were met and how important they are and the role that they play so there's a full recognition of this i'm very glad that we have the bill that they're being brought up not only this one but the others please to support them we have a long ways to go on the research dollars for all of the cancers and i think as one member of this committee that we need to step that effort up  so thank you for taking these bills up i look forward to their unanimous passage through this committee going through the full committee to the floor and i think we will have done something and really important for the country thank you thank you thank you for those comments i totally agree with you particularly with regard to the research dollars can next is the gentlewoman from oregon ms hooley recognized for an opening statement of utah waves and i think that concludes our opening statement on both sides so well now the subcommittee will now consider h r thirteen forty three and the clerk will report the title h r thirteen forty three a bill to amend the public health service act of provide additional authorizations of appropriations for the health centers program under section three thirty of such act with an objection the bill is considered as read and open for amendment at any point and the chair recognizes himself for the purpose of offering a memon in the nature of a substitute the clerk will report the a man and then in the nature of a substitute teacher thirteen forty three offered recognize myself for five minutes or less actually in support of the amendment the amendment in the nature of a substitute update the authorization levels for fiscal year two thousand and eight to track with what was appropriated for the current fiscal year the authorization levels for fiscal year nine and through fiscal year twelve remain the same as those included in h r thirteen forty three as introduced by mr green i mentioned in my opening statement that while health centers have enjoyed tremendous success over the years they continue to struggle to provide primary and preventative care services to a burgeoning medically needy population that's why over the past two years mr deal and i have led an effort to increase the amount of annual appropriations for the health centers program these authorization levels will allow us to continue our investment in the health centers program and improve access to care for millions of americans now secondly the m m n includes a language proposed by mr murphy that would extend the federal tort claims act coverage to licenses ition and either licensed or certified health care practitioners for any civil action that may arise due to services provided on a volunteer basis at a community health center and this language is designed to address a persistent problem for health care centers around the country a primary workforce shortage in under served communities we heard this of course during the hearing it was  part of the focus of the hearing on the spill but i've also heard from a number of my physicians back in new jersey who would be more than willing to volunteer and offer their services at a community health center if it were not for the lack of liability overage and this provision will hopefully help ensure that health centers have an adequate number of physicians and other providers to deliver the care that their patients need also the amendment would extend the federal tort claims act coverage for health centers and their employees when they travel offsite to provide health services at a center located in area impacted by a public health emergency or natural disaster of course we think of hurricane katrina and rita where we saw how important it was to have community  mobilize and provide lifesaving services however not every health center was able to provide assistance in those cases with those two hurricanes because of unclear rules regarding f t c a coverage during emergency situations so this  will hopefully provide clarity said sure so that during the next emergency health centers can quickly participate in the response effort and i want to thank diana de gette for her sponsorship of the legislation from which this language was drawn and basically we included your bill in this manager's amendment finally the amendment would establish a new three year demonstration project proposed by congressman stupak and burgess and this demonstration would provide grants for integrated health systems to expand access to primary and preventive care for the medically underserved let me just state in closing that i'm aware of several outstanding issues that we were not able to resolve in time for today's markup however i am committed to resolving these issues before the full committee i want to thank mr deal and and for all the those on the republican side who are working with the democrats to come to a consensus today and i would urge my colleagues on the subcommittee to support underserved we have some that actually need more and i would hope we would do that by legislative intent and working with her so even after this becomes law we hope so again thank you for your work as chair on the on the manager's amendment and the courage of option thank you mr green any other member on the substitute ok do we have any amendments to the substitute if not if no other member wishes to be recognized on the amendment seeing  on the question now occurs on agreeing to the polo substitute all in favor say aye all opposed say no appear to have its eyes have it and the amendment is agreed to  but we need to move the bill forward to the full committee does any other member wish to be recognized ok seeing on the question now occurs on forwarding the bill as a as a member to the full committee all in favor say aye all opposed say no as appear to have as eyes have it and the bill is forwarded to the full committee the subcommittee will next consider h r five six six nine and the clerk will report the ti h r five six six nine a bill to amend the public health service act to reauthorize the poison center national toll free number national media campaign and grant program to provide assistance for poison prevention sustain the funding of poison centers and enhance the public health people of the united states without objection the bill is considered as read and open for amendment at any point we don't expect any amendments to the bill so will just reauthorize the poison center national toll free number of national media campaign and state grant programs to provide assistance for the nation's network of poison control centers to support poison prevention sustain the finding a that enhanced the public health people of the united states particularly under served there are currently sixty one poison control centers nationwide each poison controls and is a medical support facilit by toxicologist nurses and other professionals operating twenty four hours a day seven days a week to provide a free but critical medical service in two thousand and seven more than four million calls were managed by these  son control centers these calls include accidental and intentional chemical biological and radiological and nuclear exposure and adverse reaction to descriptions and non prescription drugs and household products medicines pesticide plant bites and stings food and alcohol poisoning fumes and other poisonous hazardous substances the department of health and human services estimates that in any given year there will be between three million and five million poison exposures sixty percent of these exposures will involve children under the age of six who are exposed to toxins in their home poisoning is the second most common form of unintentional death in the united states poisoning accounts for two and eighty five thousand hospitalizations one point two million days of acute hospital kiev and more than twenty six thousand fatalities in two thousand and five the economic cost is also considerable and of course one's about twenty six billion in medical expenses and the year two thousand the most valuable resource this country has in fighting death and the own this caused by p the sanctity gentleman with any other member wish to be recognized on this bill seeing we will proceed of forward the bill to the to the full committee the question now occurs on forwarding the bill to the full committee all in favor say aye all opposed say no appear to have it as have it and the bill is forwarded to the full committee and our next village consideration of cancer ensure patients and families have access to the current treatments and information regarding pediatric cancer is establishing a population base national childhood cancer database and promote public awareness of pediatric cancers without objection the bill is considered as read and open for amendment at any point and the chair recognizes and self for the purpose of offering a memon in the nature of a substitute the clerk will report that amendment of the amendment this amendment to h r fifteen fifty three has been worked out on a bipartisan basis between the majority and the minority again i want to thank mr deal it makes a series of technical and conforming changes to update the authorization time period as well as to modify the legislation so that it reflects certain changes made by the senate help committee during their consideration of the companion bill s nine eleven among one of the most noteworthy changes this amendment directs the secretary of h h s in collaboration with the director of the and i age and other federal agencies to continue to enhance expand and intensify pediatric cancer research another important change made by the amendment is clarification that the secretary of h h s may award grants to childhood cancer professional and direct service organizations for the expansion and widespread implementation of activities and i'll give you some examples first that provide available information on treatment protocols to ensure early access to therapies and clinical trials for pediatric centers another example that would provide available information on the late effects pediatric cancer treatment to ensure access to necessary long term medical and psychological care and another another example that would direct resources to support and referral services such as educational outreach for parents it also ensures that with respect to the national childhood cancer registry or regulations promulgated by this act are in full compliance with informed consent and privacy requirements already contained within existing programs including the health insurance portability and accountability act and again i would encourage all of my colleagues to join me it's bipartisan in supporting the amendment in the nature of the of the substitute so we can move this bill to the full through the subcommittee into the full committee does any member seek recognition to speak on the substitute ok as any member i think we don't have any amendments in the ne to the substitute so we'll just move forward to consideration of the substitute seeing on the question now occurs on agreeing to the poll and substitute all in favor say  all in or say i all opposed say no you guys appear to have it the eyes have it and the bill is forwarded to the full committee and next we have an i guess this is the last one  three one one two and the subcommittee will now consider h r three one one to the clerk will report the title h r three one one to a bill to amend the public health service act to increase the provision of scientifically sound information and support services to patients receiving a positive test diagnosis for down's syndrome or other prenatally diagnosed conditions without objection the because the bill is considered as read in the open for a member of any point the chair recognize original text for purposes of amendment sure recognize themselves for five minutes and support of the amendment this amendment has been worked out again on a bipartisan basis between the majority and the minority it makes a series of technical and conforming changes to update the authorization time period and clarified terminology as well as to modify the legislation so that it reflects certain changes made by the senate health committee there during their consideration of the companion bill  hundred ten among one of the most know where the changes the amendment broadens the scope of the legislation to include both prenatally and postnatal diagnose conditions additionally this amendment gives the secretary of h h s the authority to award grants contracts or cooperative agreements to eligible entities to expand and further develop the national dissemination center for children with disabilities so that the center can more effectively conduct outreach to new and expecting parents and provide them with up to date information concerning those conditions furthermore this amendment identifies entities eligible to receive grants for purposes of this legislation and directs the secretary of h h s to place an emphasis on funding partnerships between health care professional groups and disability advocacy organizations and finally this amendment ensures that information provided by this act shall be culturally and linguistically appropriate courage all of my colleagues to join us in supporting the amendment nature of a substitute again this is is a bipartisan and i think the minority for working with the majority in putting this together as any other member seek recognition to speak on the substitute centers and these other bills with this year deal and and the minority obviously we spend a lot of time on these bills particularly the community health centers but i think that the outcome is good and certainly every one of these bills  important so without objection the staff is authorized to make technical and conforming changes to the bill consistent with the actions taken by the subcommittee on the bills today the chair thanks the members and the subcommittee stands a