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[Senate Hearing 114-680]
[From the U.S. Government Publishing Office]

 
  DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND 
          RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2017

                              ----------                              

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    [Clerk's note.--The subcommittee was unable to hold 
hearings on departmental and nondepartmental witnesses. The 
statements and letters of those submitting written testimony 
are as follows:]

                         DEPARTMENTAL WITNESSES

Prepared Statement of the America's Public Television Stations and the 
                      Public Broadcasting Service
    On behalf of America's 171 public television licensees, we 
appreciate the opportunity to submit testimony for the record on the 
importance of Federal funding for local public television stations and 
PBS. We urge the Subcommittee to support level funding of $445 million 
in 2-year advance funding for the Corporation for Public Broadcasting 
(CPB) in fiscal year 2019, $50 million for the Public Television 
Interconnection System in fiscal year 2017 and $25.7 million for the 
Ready To Learn program at the Department of Education in fiscal year 
2017.
 corporation for public broadcasting: $445 million (fiscal year 2019), 
                         2-year advance funded
    Local stations and PBS are committed to serving the public good in 
education, public safety, civic leadership, and other essential fields. 
Federal funding for CPB makes these services possible and is deserving 
of continued support. The overwhelming majority of Americans agree. In 
a bipartisan Hart Research Associates/American Viewpoint poll, nearly 
70 percent of American voters, including majorities of Republicans, 
Independents, and Democrats, support Federal funding for public 
broadcasting. Additionally, polls show that Americans consider PBS to 
be the second most appropriate expenditure of public funds, behind only 
military defense. Over 70 percent of the Federal funding for CPB goes 
directly to local stations, resulting in a successful public-private 
partnership of locally owned and controlled, trusted, community 
servants.
Education
    Local public television stations are America's largest classroom, 
meeting their communities' lifelong learning needs by providing the 
highest quality educational content and resources on multiple media 
platforms and in-person. Public television's exceptional content is 
available to nearly every household in America and has helped more than 
90 million pre-school age children get ready to learn and succeed in 
school. PBS, in partnership with local public television stations, has 
created PBS LearningMedia, an online portal where more than 1.8 million 
K-12 educators and users and 39,000 homeschoolers access more than 
118,000 standards-based, curriculum-aligned interactive digital 
learning objects created from public television content, as well as 
material from the Library of Congress, National Archives and other 
high-quality sources. Overall, PBS LearningMedia helps teach 40 million 
students every day. Public television stations also operate virtual 
high schools that bring high-quality instruction in specialized fields 
to remote areas.
    Through the American Graduate Initiative, CPB and public media 
stations are working to confront the dropout crisis in America's high 
schools by providing resources and services to lower the drop-out rate 
in their communities. In partnership with others engaged in this work, 
American Graduate has helped raise the national high school graduation 
rate to 81 percent--an all-time high. In addition, by operating the 
most comprehensive non-profit GED programs in the country, public 
television stations have helped hundreds of thousands of individuals 
get their high-school equivalency certificate. Public television 
stations have also made it a top priority to help retrain the American 
workforce, including veterans, by providing digital learning 
opportunities for those looking for training, licensing, and more.
Partners in Public Safety
    Public broadcasting stations throughout the country are leading 
innovators and irreplaceable partners to local public safety officers. 
In partnership with FEMA, the public television interconnection system 
provides the necessary redundant path for the Warning Alert and 
Response Network that enables cell subscribers to receive geo-targeted 
text messages in the event of an emergency--reaching citizens wherever 
they are. This digital infrastructure and public television's spectrum 
also enable stations to provide State and local officials with critical 
community emergency alert, public safety, first responder and homeland 
security services and information during emergencies through a process 
known as datacasting. Datacasting uses broadcast spectrum to send 
encrypted data and video to first responders with no bandwidth 
constraints. In partnership with local public television stations and 
local law enforcement agencies, the U.S. Department of Homeland 
Security recently conducted two pilots in Houston and Chicago 
demonstrating the efficacy of this technology for expanding emergency 
communications capabilities. Stations are increasingly partnering with 
their local emergency responders to customize and utilize public 
television's infrastructure for public safety in a variety of critical 
ways, with many serving as their States' Emergency Alert Service (EAS) 
hub for weather and AMBER alerts.
Providing Civic Leadership
    Public television strengthens the American democracy by providing 
citizens with access to the history, culture and civic affairs of their 
communities, their States and their country. Local public television 
stations often serve as the State-level ``C-SPAN'' by airing State 
government proceedings. Local stations also provide more public affairs 
programming, local history, arts and culture, candidate debates, 
specialized agricultural news, and citizenship information of all kinds 
than anyone else.
Public Broadcasting is a Smart Investment
    All of this public service is made possible by the Federal funding 
to CPB that amounts to about $1.35 per year, per American. This Federal 
investment sustains the public service missions of public television, 
which are distinct from the mission of commercial broadcasting and will 
not be funded by private sources, as the Government Accountability 
Office concluded in a 2007 study commissioned by the Congress. The need 
for Federal investment is particularly acute in small-town and rural 
America, whose lack of population density, shortage of corporate and 
philanthropic involvement, and challenging topography make the 
economics of local television and public service especially 
challenging. As a result, public broadcasters can be the only local 
broadcaster serving rural communities--and only with the help of the 
Federal investment. For all stations, Federal funding is the 
``lifeblood'' of public broadcasting, providing indispensable seed 
money to stations to build additional support from State legislatures, 
foundations, corporations, and ``viewers like you.''
    Thus, for every dollar in Federal funding, local stations raise six 
dollars in non-Federal funding, creating a strong public-private 
partnership and supporting approximately 20,000 jobs across America.
Two-Year Advance Funding
    Two-year advance funding is essential to the mission of public 
broadcasting. This longstanding practice, proposed by President Ford 
and embraced by Congress in 1976, establishes a firewall insulating 
programming decisions from political interference, enables the 
leveraging of funds to ensure a successful public-private partnership, 
and provides stations with the necessary lead time to plan in-depth 
programming and accompanying educational materials--all of which 
contribute to extraordinary levels of public trust. For the thirteenth 
consecutive year, the American people have ranked PBS as one of the 
most trusted national institutions.
    Local stations leverage the 2-year advance funding to raise State, 
local and private funds, ensuring the continuation of this strong 
public-private partnership. These Federal funds act as the seed money 
for fundraising efforts at every station, no matter its size. Advance 
funding also benefits the partnership between States and stations since 
many States operate on 2-year budget cycles. Finally, the 2-year 
advance funding mechanism gives stations and producers, both local and 
national, the critical lead time needed to raise the additional funds 
necessary to sustain effective partnerships with local community 
organizations and engage them around high-quality programs. Producers 
like Ken Burns spend years developing programs like The Civil War, 
Cancer: The Emperor of All Maladies and future programs on the history 
of the Vietnam War and the history of country music. It would be 
impossible to produce this in depth programming and the curriculum-
aligned educational materials that accompanies it without the 2-year 
advance funding.
         public television interconnection system: $50 million
    The public television interconnection system is the infrastructure 
that connects PBS and national, regional and independent producers to 
every local public television station around the country. The 
interconnection system is essential to bringing public television's 
educational, cultural and civic programming to every American 
household, no matter how rural or remote. Without interconnection, 
there is no Nation-wide public media service. The interconnection 
system is also critical for public safety, providing key redundancy for 
the communication of presidential alerts and warnings, and ensuring 
that cellular customers can receive geo-targeted emergency alerts and 
warnings.
    Congress recognized the need for interconnection when it created 
CPB and authorized it to ``assist in the establishment and development 
of one or more interconnection systems'' in the Public Broadcasting Act 
of 1967. As technology has advanced, public television has worked to 
make the interconnection system more efficient and cost-effective. 
Congress has always provided Federal funding for periodic improvements 
of the interconnection system including year-one funds in the fiscal 
year 2016 Omnibus. The previous two rounds of interconnection funding 
were provided by Congress in fiscal 1991-1993 and fiscal year 2004-
2007.
The Next Interconnection System
    Current interconnection satellite leases, support contracts, and 
existing financing expire on September 30, 2016. CPB and the public 
television system are committed to ensuring that the next 
interconnection system efficiently supports our universal service and 
public service commitments, while taking advantage of technological 
advances. PBS operates the interconnection system and is collaborating 
with CPB to design and implement a system that encompasses maximum 
efficiencies and supports emerging applications and expanded station 
collaboration.
    Public television is very appreciative that Congress provided the 
funding necessary for the first year of this multi-year project in 
fiscal year 2016. For fiscal year 2017 $50 million in interconnection 
funding is necessary to continue the essential work that is now 
underway. It is critical that Congress continue to provide 
interconnection funding in fiscal year 2017 to avoid any interruption 
of service to the millions of Americans served by PBS and over 350 
noncommercial educational stations across the country.
        ready to learn: $25.7 million (department of education)
    The Ready To Learn (RTL) competitive grant program, recently 
reauthorized in the Every Student Succeeds Act, uses the power of 
public television's on-air, online, mobile, and on-the-ground 
educational content to build the literacy and STEM skills of children 
between the ages of two and eight, especially those from low-income 
families. Through their RTL grant, CPB and PBS are delivering evidence-
based, innovative, high-quality transmedia content to improve the math 
and literacy skills of high-need children. CPB and PBS, in partnership 
with local stations, have been able to ensure that the kids and 
families that are most in need have access to these groundbreaking and 
proven effective educational resources.
Results
    RTL is rigorously tested and evaluated to assess its impact on 
children's learning and to ensure that the program continues to offer 
children the tools they need to succeed in school. Highlights of recent 
studies show that: use of PBS KIDS content and games by low-income 
parents and their preschool children improves math learning and helps 
prepare children for entry into kindergarten; use of RTL content has 
been associated with a 29 percent improvement in reading ability in 
children grades K-2; and parents who used RTL math resources in the 
home became considerably more involved in supporting their children's 
learning outcomes. In combination, RTL games, activities and videos 
provide early learners with the critical math and literacy skills 
needed to succeed in school.
An Excellent Investment
    In addition to being research-based and teacher tested, RTL also 
provides excellent value for our Federal dollars. In the last 5-year 
grant round, public broadcasting leveraged an additional $50 million in 
non-Federal funding to augment the $73 million investment by the 
Department of Education for content production. RTL exemplifies how the 
public-private partnership that is public broadcasting can change lives 
for the better.
                               conclusion
    Americans across the political spectrum rely on public broadcasting 
on television, on the radio, online, and in the classroom--because we 
provide essential education, public safety, and informed citizenry 
services that are not available anywhere else. And none of this would 
be possible without the Federal investment in public broadcasting. A 
2007 GAO report concluded that CPB's federally appropriated Community 
Service Grants to public television stations are an irreplaceable 
source of revenue for public broadcasting, and a 2012 study conducted 
by an independent third party for CPB at Congress's request came to the 
same conclusion. For all of these reasons we request that Congress 
continue its commitment to the highly successful, hugely popular 
public-private partnership that is public broadcasting by providing 
level funding of $445 million in fiscal year 2019 for the 2-year 
advance of the Corporation for Public Broadcasting, $50 million in 
fiscal year 2017 for the Public Television Interconnection System and 
$25.7 million in fiscal year 2017 for the Ready To Learn Program.
                                 ______
                                 
     Prepared Statement of the Corporation for Public Broadcasting
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the subcommittee, thank you for allowing me to submit this testimony on 
behalf of America's public media service--public television and public 
radio--on-air, online and in the community. The Corporation for Public 
Broadcasting (CPB) requests level funding of $445 million for fiscal 
year 2019, $50 million in fiscal year 2017 for the replacement of the 
public broadcasting interconnection system, and $25.74 million for 
Ready To Learn at the Department of Education.
    Nearly 50 years after passage of the Public Broadcasting Act, this 
uniquely American public-private partnership is keeping its promise--to 
provide high-quality trusted content that educates, inspires, informs 
and enriches. Through the nearly 1,500 locally owned and operated 
public radio and television stations across the country, public media 
reaches nearly 99 percent of the American people--with an overwhelming 
majority of them consuming public media throughout the year.
    Every day more people, businesses, organizations and foundations 
are committing their time and resources to support the work of public 
media. President Ronald Reagan said, ``government should provide the 
spark and the private sector should do the rest.'' The Federal 
appropriation remains the critical investment that ensures your 
constituents have access to public media for free and commercial free. 
America's local public media stations utilize the ``spark'' of the 
Federal investment--approximately 10 to 15 percent of a stations' 
budget--and raise the rest from non-Federal resources.
    Private donations and existing funding sources can and do help 
defray costs for the much-honored programs of public television and 
radio. In fact, non-Federal funding represents five of every six 
dollars invested annually in public broadcasting. However, the Federal 
investment is indispensable to sustaining the operations of public 
broadcasting stations, capitalizing on the benefits of an integrated 
system, and fostering the public service mission they pursue: 
community-based accountability and a universal service to which the 
Public Broadcasting Act aspires. Over the years, congressionally 
mandated studies have concluded that there is no alternative to Federal 
funding when it comes to safeguarding the public media service that 
Americans know and love.
    Our trusted, noncommercial services are especially important to 
those living in rural communities where the local public media station 
is sometimes the only source of broadcast news, information and 
educational programming. For these smaller stations serving rural, 
minority and other underserved communities, the Federal dollars provide 
much more than just a spark, in some cases CPB's investment can 
represent as much as 40 percent of their budget.
    Public media's contribution to education--from early childhood 
through adult learning--is well documented. We are America's largest 
classroom, with proven educational content available to all children, 
including those who cannot afford preschool. Further, parents, 
caregivers and teachers repeatedly value public media content as the 
``most trusted.''
    CPB's work with the Department of Education's Ready To Learn 
program is an excellent example of how public media brings together 
high-quality educational content with on-the-ground work in local 
communities. More than 20 years ago, Congress recognized the reach and 
potential of public media to help disadvantaged children become better 
prepared to enter school. Last year, Congress reaffirmed this belief in 
the Every Student Succeeds Act by reauthorizing Ready To Learn. For the 
next 5 years, public media will continue to provide coordinated and 
connected STEM and literacy learning experiences for children across 
multiple platforms, including TV, Internet, mobile, and in multiple 
settings, including in classrooms, summer and after-school programs, 
and at home.
    While innovation on multiple platforms is important, television is 
still the primary tool to reach low-income and rural families. More 
than 80 studies have proven that Ready To Learn content builds and 
improves early literacy skills for high-need children, ages two to 
eight. Continued funding will allow public media to carry-on this 
critical work.
    Public media is also differentiated from commercial media through 
content that matters and engagement that counts. An example of this is 
CPB's ``American Graduate'' initiative, which puts faces behind the 
statistic of one million young people failing to graduate from high 
school every year. Our stations told the stories, and communities 
throughout the country responded. Over the past 5 years more than 120 
public media stations located in at-risk communities in 49 States have 
worked with nearly 1,600 national and community-based partners to bring 
together diverse stakeholders and community organizations all working 
toward a national graduation rate of 90 percent by 2020. I are pleased 
to report that as a result of our and others combined efforts, in 2015, 
the high school graduation rate rose to 82 percent for the first time 
in our Nation's history. However, much work remains and many stories 
remain untold.
    Public media is utilizing today's technology to provide content of 
value to millions of Americans. CPB strategically focuses its 
investments through the lens of what we refer to as the ``Three D's'' 
--Digital, Diversity and Dialogue. This refers to support for 
innovation over multiple platforms; content that is for, by and about 
Americans of all backgrounds; and services that foster engagement 
between the American people and the public service media organizations 
that serve them.
    Public media tells stories that are worth telling, worth watching 
and worth listening to. The Public Broadcasting Act ensures diversity 
in programming by requiring CPB to fund independent and minority 
producers. CPB fulfills this mission, in part, by funding the 
Independent Television Service, the five Minority Consortia entities in 
television (African American, Latino, Asian American, Native American 
and Pacific Islander), several public radio consortia (Latino Public 
Radio Consortia, African American Public Radio Stations, and Native 
Public Media) and numerous minority public radio stations. Moreover, 
CPB, through its Diversity and Innovation fund, makes direct 
investments in the development of diverse primetime and children's 
broadcast programs as well as innovative digital content.
    What further distinguishes the power of public media is that our 
mission directs us to serve every American--not only on-air or online, 
but face to face in our communities. More than 70 percent of CPB's 
appropriation goes directly to local stations who work closely with 
their communities to best serve local interests and concerns. This 
allows public media to work in partnership with people of diverse 
backgrounds, ensuring that we are listening to and reflecting the 
changing story of America.
    Facing the reality that many communities are losing local news 
coverage because of cutbacks in commercial journalism outlets, CPB is 
helping stations support the production of more local news content. 
Since 2009, CPB has invested more than $27 million to launch 22 local 
and regional newsroom collaborative operations. These partnerships 
connect 105 public media stations in 37 States, providing the basis for 
a vibrant multimedia network of high-quality journalism.
    In the coming years, public media has an opportunity to help fill 
the widening substantive news gap left by weak local newspapers. CPB's 
goal is to support and encourage public media organizations and 
producers to operate as a true news network--one that routinely works 
together to strengthen both the signature national programs and the 
local/regional news, reaching more of the American people more often on 
more platforms with more compelling journalism.
    The work of public media goes well beyond broadcast. Public 
television and radio stations are increasingly effective partners with 
State and local public safety, law enforcement and first responder 
organizations--connecting these agencies with one another, with the 
public, and with vital data-casting capabilities in times of crisis.
    Further, CPB is supporting stations, both financially and by 
defining best practices, so they can create more public-private 
partnerships, bringing more services and benefits to their communities. 
One example of this local public-private partnership is CPB's Veterans 
Coming Home initiative. Stations and their partners are communicating 
veterans' stories through award winning reporting, documentaries, and 
online content; convening local events such as town hall meetings that 
connect veterans with resources; and collaborating with local veterans' 
organizations to identify services available to them.
    Ever since the FCC set aside a block of spectrum exclusively for 
non-commercial educational use in 1953, public media has been 
efficiently utilizing this spectrum as a vehicle to serve families all 
across America. The FCC's upcoming spectrum incentive auction and 
subsequent repacking process present a unique set of challenges for 
public media.
    Unlike commercial broadcast stations, where auction decisions will 
be made at the corporate level, public television stations are locally 
owned and operated, so each station will directly incur the costs of 
the auction and repacking process. Not all of these costs will be 
covered by auction proceeds, nor is it certain that the $1.75 billion 
that Congress has set aside for repacking will be sufficient. Indeed, 
many stations that do not participate in the auction will still have to 
spend time and resources on the mandatory repacking process.
    Finally, it must be understood that CPB will not receive any 
auction proceeds. Further, public broadcasting license holders that 
participate in the auction are not required to invest their proceeds in 
a public media service. The auction brings an air of uncertainty to 
public television service both in terms of future signal coverage and 
financial impact. The continued Federal investment will help safeguard 
this valued service for all Americans.
                            interconnection
    Interconnection is the backbone of the public broadcasting system, 
delivering content every day from public media producers to the locally 
owned and operated public television and radio stations in communities 
throughout the country. Without it, there is no nationwide public media 
service. Congress recognized the need for an interconnection system in 
1967 when it passed the Public Broadcasting Act. It has always funded 
the interconnection system, and has provided a separate appropriation 
for interconnection since fiscal year 1991.
    As we near the expiration of our current interconnection system for 
both television and radio, CPB must plan for the next generation of 
interconnection. Technology and distribution systems have greatly 
evolved since Congress established its practice of funding 
interconnection. Today, an expansive range of technologies, including 
satellite, cloud and terrestrial broadband, is widely available to 
create the most cost effective and efficient means to distribute 
content to public broadcasting stations. We are grateful for Congress's 
$40 million initial investment in the public broadcasting 
interconnection system in fiscal year 2016 and would appreciate your 
continued support for this essential infrastructure.
                               conclusion
    Public media's treasure trove of content and services is available 
to all Americans for about $1.35 per American per year. As a result of 
the Federal investment, public media stations are able to connect to 
people's lives in impactful ways--ensuring every child is ready to 
learn, every person has access to lifelong learning; every veteran can 
connect to resources and support; and every citizen has access to fact-
based local, national and global journalism. We make the arts 
accessible to all Americans and provide emergency alert services for 
first responders. CPB ensures that 95 cents of every dollar it receives 
goes to support local stations and the programs and services they offer 
to their communities; no more than five cents of every dollar goes to 
the administration of funding programs and overhead.
    CPB's fiscal year 2019 request of $445 million and fiscal year 2017 
requests of $50 and $25.74 million for interconnection and Ready To 
Learn, respectively, balance the fiscal reality facing our Nation with 
our statutory mandate to provide a valuable and trusted service to all 
Americans. Today, the challenges we face are more complex than ever and 
require attention to education, innovation, and collaboration.
    Public media has been inspiring and enriching our lives for nearly 
half a century, and Congress' support of our request will allow 
stations to continue providing high-quality trusted content that 
educates, informs, and strengthens our civil society. Mr. Chairman and 
members of the subcommittee, this is only part of the story of 
America's public media system. Public media is truly a national 
treasure. I thank you for allowing me to submit this testimony and 
appreciate your consideration of our request for funding.

    [This statement was submitted by Patricia de Stacy Harrison, 
President and CEO, Corporation for Public Broadcasting.]
                                 ______
                                 
            Prepared Statement of the National Public Radio
    Dear Chairman Blunt, Senator Murray and Members of the 
Subcommittee: Thank you for this opportunity to urge the Subcommittee's 
support for an annual Federal investment of $445 million to public 
broadcasting through the Corporation for Public Broadcasting, (CPB) for 
fiscal year 2019. Public radio joins with our public television 
partners in urging the Subcommittee's support for $50 million in fiscal 
year 2017 for the second year of a multi-year request to upgrade 
interconnection for the public broadcasting system. With your support, 
and these essential funds, every American will continue to have free 
access to the best in public service journalism, music, news, 
educational, entertainment and cultural programming.
    I offer this testimony on behalf of the public radio system, a 
uniquely American public service, non-for-profit media enterprise that 
includes NPR, our more than 950 independently owned local member 
stations, other producers and distributors of public radio programming 
including American Public Media (APM), Public Radio International 
(PRI), the Public Radio Exchange (PRX), and many stations, both large 
and small, rural and urban, that create and distribute content through 
the Public Radio Satellite System (PRSS).
    The annual demonstration of support by Congress to CPB helps to 
sustain and enhance a system that is wholly representative of its users 
in our country. While just a tiny fraction (0.01 percent) of the entire 
Federal budget goes to CPB, you help support one of America's most 
successful community-centric programs. With the money provided by 
Congress, local stations are able to raise $6 for every Federal grant 
dollar they are awarded. This Federal financial investment permits 
local stations to invest more deeply in their own local news and 
cultural programming and participate in CPB-backed regional news 
collaborations with stations across the country. This in turn enables 
our stations to provide the American public with an enduring and daily 
return on investment that is heard, seen, read, and experienced in 
public radio broadcasts, apps, podcasts, and on online.
    With support from CPB's community service grants, each of the 
hundreds of independently operated public radio stations is responsible 
for curating and creating the mix of programs that best addresses the 
needs of their local community. Local stations and their programming 
choices are as diverse as the people who live in the communities they 
serve. Some have all-news formats. Others have all-music formats and 
still other blend news, talk, commentary and music into their program 
offerings. Close to thirty percent of our stations' daily programming 
is locally generated. Every year the Federal Government invests roughly 
$90 million dollars in the operation of America's local public radio 
stations. And these stations provide service to all of America's 
communities.
    Each public radio station operates autonomously, but they are all 
interconnected through a single satellite service that allows Americans 
to receive free and universal access to a wide array of content and 
services from local, national and international reporters and 
producers. The Public Radio Satellite System reaches 95 percent of the 
U.S. population, making a community's local station the single most 
reliable source for public safety information in an emergency or 
natural disaster situation. PRSS fulfills an important mission by 
providing a common, shared platform for secure, reliable, cost-
effective and efficient distribution of all public radio content 
including news, music, cultural, educational and entertainment 
programming to almost 1,600 stations across the country that serve an 
increasingly diverse population. As part of that mission, the PRSS 
provides satellite transmission services to distribute programming that 
reaches under-served audiences and rural areas.
    With the combined strength of public radio's role as a trusted 
media and information resource and the interconnected of the PRSS 
serving as an essential public-safety asset, U.S. consumers are urging 
the mobile phone industry to install and activate FM chips in all 
cellphones and smart phones. During every hurricane, tornado, flood, 
earthquake, blizzard and wildfire, local public radio stations play an 
essential role in conveying information about response efforts, local 
relief supplies, evacuation orders, emergency routs and where to find 
food, shelter and fuel, as well as on-the-ground, and at-the-scene 
reporting to help affected communities understand and respond. Now is 
the time for major cell carriers and manufacturers to activate FM chips 
in their mobile devices.
    Our overarching goal is to ensure that we are serving our audience 
wherever they are, and however they are finding us, with exceptional 
journalism, balancing the needs of our traditional broadcast listeners 
with those whose connection to public radio's work is through our many 
digital platforms. With more than 1,400 journalists in nearly 200 
newsrooms across America, public radio is already an essential part of 
people's lives. The opportunity now is to share expertise between our 
journalists to make our local, regional and national stories even 
better. Collaborative reporting helps local stories spread national and 
give national stories unique local perspective by leveraging the ideas, 
the money and the system that are already in place. For example, the 
CPB supported New England News Collaborative (NENC) will produce 
multimedia coverage focusing on the region's energy usage, climate, 
transportation infrastructure, and its people and immigration issues. 
This robust partnership will produce dynamic reporting projects for on-
air broadcast, digital and web presentations, and a series of public 
Town Hall-style meetings designed to discuss and debate the issues 
facing New England and its residents.
    Public radio's culture of innovation is evident in the system's 
commitment to the news collaborations. The base of public radio's 
efforts to improve news collaboration are strengthened by NPR One, the 
audio app that connects listeners to a stream of public radio news, 
stories and podcasts curated for the listener. A service that is not 
provided anywhere else- making news and information accessible for all 
citizens via mobile device. News of the listener's community is 
seamlessly woven into the listening experience, informing, engaging, 
inspiring and surprising. This creates access for an individual to be 
informed and up to date at all times, whether they have a transistor 
radio available or not.
    Stations continue to adapt their coverage to meet their community's 
needs. In Missouri Chairman Blunt, St. Louis Public Radio is making 
their mission in news to help the people of the region understand this 
moment in history, appreciate their culture, recognize their strengths, 
while meeting challenges and embracing opportunities. The Ferguson 
Project is a locally produced focused effort to illuminate and explain 
the events that have happened and the wide-ranging conversation that is 
going on for the citizens of Missouri. In addition, St. Louis on the 
Air creates a unique local space where guests and listeners can share 
ideas and opinions. Whether exploring issues and challenges confronting 
the region, discussing the latest innovations in science and 
technology, taking a closer look at history or talking with authors, 
artists and musicians, St. Louis on the Air brings the stories of St. 
Louis and the people who live, work and create in the region. Also, We 
live Here explores the issues of race, class and power that led to the 
emotional eruption in the wake of Michael Brown's shooting death in 
Ferguson by providing an in-depth exploration of how systematic racism 
impacts people and the well-being of the region.
    In Central Washington, Northwest Public Radio and Spanish-language 
public radio station KDNA established a bilingual news reporting team. 
The new initiative pairs the talents of the two stations to bridge the 
cultural and linguistic gaps between communities by combining their 
reporting and digital services teams and tackling the issues of their 
respective communities, bilingually. Northwest Public Radio also 
provides a forum for Listener Stories to be shared; how the public 
service is incorporated into their routines, the benefits they gain, 
and the gifts of Public Radio they hope to leave behind to future 
generations. Also, Ask the Governor is a locally run program where 
Governor Jay Inslee takes questions about State Government and hears 
ideas from the community about how Washington can improve. The public 
service show has been opening up dialogue between Washington citizens 
and government since 1993.
    Federal funding for public broadcasting is a small investment that 
pays big dividends. And when it comes to music, public radio plays a 
unique and critically important role. We have created a value 
partnership that connects music and those who devote their lives to it 
from artists, performers and composers to audiences. Our local stations 
play a significant role in music discovery, preservation, education, 
diversification and local music economies. And this role is enabled by 
CPB's community service grants to local public radio stations.
    Nationally, more than 400 public radio stations have full-time 
music formats and an additional 747 play music as part of their 
programming lineups. Local public radio stations air more than 5.6 
million hours of music per year, the majority of which is local 
programming. In addition to prerecorded music, member stations host 
more than 10,000 in-studio and community-based performances.
    With music platforms changing so dramatically in the last 10 years, 
public radio provides a home for genres that are economically 
unsustainable in the commercial market, including classical, jazz, 
folk, opera and traditional regional music such as bluegrass and 
zydeco. In fact, over 90 percent of all broadcast classical music in 
America is available only on public radio, and the same is quickly 
becoming true for jazz. Our stations help support and preserve cultural 
institutions, including local bands, symphony orchestras, philharmonic 
societies, theater groups, and historical venues. Public radio's role 
in music is not possible without a diverse revenue base, including 
CPB's financial support to local stations.
    Mr. Chairman and Senator Murray, NPR and the public radio system 
are committed to being America's public radio where rationale, fact-
based, accurate and civil reporting and conversation are our top 
priorities. We have no political agenda and we do not take sides. 
Public radio plays an important, significant and growing role in news, 
journalism, talk and music/cultural programming across all age groups. 
Our stations are essential to, and part of, the communities they serve.
    Through news, talk, music and cultural programming, public radio 
stations are reaching out to audiences wherever they are with the 
content their audience wants. We're embracing America's changing 
demographics and using digital media and news collaborations to connect 
better, more quickly and in more diverse ways. Today's public radio 
isn't going away, it's going everywhere and we are working every day to 
earn the trust of the 38 million Americans who rely on us for news and 
insights that guide and inform.

    [This statement was submitted by Michael Riksen, Vice President--
Policy & Representation, National Public Radio.]
                                 ______
                                 
          Prepared Statement of the Railroad Retirement Board
    Mr. Chairman and Members of the Committee: We are pleased to 
present the following information to support the Railroad Retirement 
Board's (RRB) fiscal year 2017 budget request of $122,499,000 for our 
retirement, unemployment and other programs.
    The RRB administers comprehensive retirement/survivor and 
unemployment/sickness insurance benefit programs for railroad workers 
and their families under the Railroad Retirement (RRA) and Railroad 
Unemployment Insurance (RUIA) Acts. The RRB also has administrative 
responsibilities under the Social Security Act for certain benefit 
payments and Medicare coverage for railroad workers and special 
economic recovery payments and extended unemployment benefits under a 
variety of public laws.
    During fiscal year 2015, the RRB paid $12.2 billion, net of 
recoveries, in retirement/survivor benefits to about 558,000 
beneficiaries. We also paid $85.1 million in net unemployment/sickness 
insurance benefits to about 25,000 claimants. Temporary extended 
unemployment benefits paid were $8.625 million. In addition, the RRB 
paid benefits on behalf of the Social Security Administration amounting 
to $1.5 billion to about 111,000 beneficiaries.
               proposed funding for agency administration
    The RRB faces major challenges in its mission to pay benefits and 
serve as responsible stewards for our Customer's Trust funds and agency 
resources. Those areas of challenge include agency staffing, 
information technology, and program integrity. The President's proposed 
budget would provide $122,499,000 for agency operations. This level of 
funding includes $6.1 million toward a multi-year plan to re-engineer 
legacy mainframe applications while maintaining 850 full-time 
equivalents (FTEs). Historically, however, the enacted level of funding 
awarded to the RRB, has not been sufficient to implement significant 
improvements and initiatives in our most challenging areas. The 
remainder of this testimony will focus on these areas with a few 
additional topics in conclusion.
                            agency staffing
    The RRB's dedicated and experienced workforce is the foundation for 
our tradition of excellence in customer service and satisfaction. 
Eighty-percent of our administrative expense is for labor. Like many 
Federal agencies, however, the RRB has a number of employees at or near 
retirement age. About 55 percent of our employees have 20 or more years 
of service, and over 40 percent of our current workforce will be 
eligible for retirement by fiscal year 2017. Based on trend analysis of 
our position index, hiring plans, and full-time equivalent (FTE) 
reporting of attritions and accessions from 2010 through 2016, the RRB 
has attrited half of its agency.
    Almost half of our staff has been replaced. The agency has been 
able to utilize the re- employment of retirees under the Civil Service 
and FERS to temporarily rehire under Section 1122(a) of Public Law 111-
84 and assist in areas that have knowledge gaps due to attrition. The 
implementation of Learning Management System (LMS), an Internet-based 
software package that provides comprehensive functionality for training 
administration, documentation, tracking, reporting and delivery of e-
learning education and training programs supports the agency's efforts 
for continued excellence in our workforce. Although 850 is the FTE 
level the RRB can maintain for fiscal year 2017 President's Budget in 
order to leverage funds to support information technology (IT) and 
program integrity initiatives, the agency would be at-risk if such 
strategy was used for fiscal year 2018 and out-years as our attrition 
rate is expected to take a significant downturn from 7 separations/
retirements per month to 4 separations/retirements per month now that 
half of our workforce over 6 years is replaced. At a minimum, the 
agency needs to be able to restore FTE funding to 860 starting with 
fiscal year 2018, and maintain an 885 FTE level in the out-years to 
address our most vital costs, which is sustaining our workforce.
                  information technology improvements
    The President and the Office of Management and Budget (OMB) have 
challenged agencies to create a 21st Century Government. Although we 
are not a CFO Act agency, we are classified as a significant entity for 
Federal Government audit and reporting purposes. The RRB has chosen to 
be progressive in implementing initiatives and improvements. In fiscal 
year 2017, $6.1 million in IT requested funding is targeted toward 
system modernization to re- engineer mainframe applications that build 
on prior year investments. Fiscal year 2016 enacted funding provided no 
such investments. As a result, the agency is taking risk in the current 
year of $2 million in support of the agency's critical need to migrate 
over 14 million lines of common business-oriented language (COBOL) code 
that support more than 4,200 custom programs included in 200 major 
application systems. We awarded a contract in fiscal year 2015 to 
implement the conversion, subject to funds availability. We have taken 
risk in our fiscal year 2016 Operating Plan to leverage funds of $2 
million towards this legacy benefit system modernization contract. We 
took this risk because in addition to mitigating cybersecurity risks of 
operating legacy systems, enhancing data analytics capabilities towards 
stronger program integrity measures, and creating 26 FTE savings that 
can be accrued from change in business processes, a large number of the 
agency's technology employees are at or nearing retirement age. As the 
years go by, the skills required to enhance and maintain legacy benefit 
systems, especially developers with COBOL skills, will be hard to find. 
By re-engineering the applications, we mitigate the inherent risks of 
an aging workforce of which 40 percent can retire today, some taking 
with them the institutional knowledge of over 40 years. Given that 
technology advances rapidly, it is essential that we have the ability 
to modernize business applications.
    Fiscal year 2017 funding of $6.1 million for legacy benefit system 
modernization, if received, will re-engineer critical legacy mainframe 
applications to sustain agency operations and enable a future ready RRB 
workforce equipped with modern tools and technologies to do their jobs 
in the most efficient and effective manner that leads to sustained 
customer satisfaction in the railroad community. The RRB would be able 
to revolutionize the current applications development environment to 
make it flexible to accommodate change and embrace new technologies. 
Each year that enacted funding does not equal the agency's request for 
system modernization, contract work will have to stop as we enter 
fiscal year 2017 and jeopardizes the success of the on-going project.
                           program integrity
    Fiscal year 2017 President's Budget also provides approximately 
$4.3 million in mandatory no-year funding for the RRB's program 
integrity activities. In light of recent fraud events that have 
impacted the agency, the RRB must increase staff disability oversight, 
improve existing program integrity functions, and implement initiatives 
to target groups of annuitants most likely to commit medical and/or 
earnings fraud. The proposed $4.3 million was determined based on a 
review of current operations as well as disability recommendations from 
the Government Accountability Office and the RRB's Office of the 
Inspector General. The RRB takes its program integrity initiatives very 
serious and increased its standards significantly.
    These new standards come at a cost greater than what the agency 
continually absorbs from enacted funds provided. In the current fiscal 
year, the agency has experienced increased costs of at least $2.5 
million in the area of medical examinations, training and staffing. As 
long as we continue to absorb program integrity cost increases in our 
baseline budget without receiving mandatory funding, the RRB risks 
having to halt system modernization efforts and perform fragmented 
staffing efforts of workforce after fiscal year 2017.
    The proposed funding is for staffing costs and contractual costs. 
Augmented staff includes four people dedicated to quality assurance and 
seven people dedicated to program evaluation through such activities as 
oversight of fraud prevention initiatives, special studies, and the 
development and implementation of enhanced procedures critical to 
program integrity. An additional six employees will support enhanced 
emphasis on initial eligibility and continuing entitlement to benefits. 
A Chief Medical Officer will be hired to provide assistance and 
guidance to agency staff in the adjudication of disability claims, work 
with our medical contractors and develop processes to ensure disability 
examiners have updated training. Contractor costs include on-going 
annual fraud training for employees at all levels of the organization 
and confirming medical exams for all initial disability applications.
    The RRB has proven to be a good investment for program integrity 
over the years. Our program integrity efforts save the Trust Fund from 
which railroad benefits are paid an estimated $4.49 for each $1 spent 
on program integrity activities.
                         legislative proposals
    In connection with these workforce planning efforts, the 
President's budget request includes a legislative proposal to enable 
the RRB to utilize various hiring authorities available to other 
Federal agencies. Section 7(b) (9) of the Railroad Retirement Act 
contains language
    requiring that all employees of the RRB, except for one assistant 
for each Board Member, must be hired under the competitive civil 
service. We propose to eliminate this requirement, thereby enabling the 
RRB to use various hiring authorities offered by the Office of 
Personnel Management.
    Our budget request includes two additional legislative proposals. 
The first is to amend the RRA and the RUIA to include a felony charge 
for individuals committing fraud against the agency. The second is to 
amend the Social Security Act to provide access for the RRB to the 
National Directory of New Hires (NDNH). Access to NDNH supports the 
RRB's integrity efforts to prevent improper payments.
                  financial status of the trust funds
    Railroad Retirement Accounts.--The RRB continues to coordinate its 
activities with the National Railroad Retirement Investment Trust 
(Trust), which was established by the Railroad Retirement and 
Survivors' Improvement Act of 2001 (RRSIA) to manage and invest 
railroad retirement assets. Pursuant to the RRSIA, the RRB has 
transferred a total of $21.276 billion to the Trust. All of these 
transfers were made in fiscal years 2002 through 2004. The Trust has 
invested the transferred funds, and the results of these investments 
are reported to the RRB and posted periodically on the RRB's website. 
The net asset value of Trust-managed assets on September 30, 2015, was 
approximately $24.5 billion, a decrease of almost $1.6 billion from the 
previous year. Through February 2016, the Trust had transferred 
approximately $18.3 billion to the Railroad Retirement Board for 
payment of railroad retirement benefits.
    The RRB's latest report required by the Railroad Retirement Act of 
1974 and Railroad Retirement Solvency Act of 1983 was released in 
September 2015. The overall conclusion is, barring a sudden, 
unanticipated, large decrease in railroad employment or substantial 
investment losses, the railroad retirement system will experience no 
cash flow problems during the next 32 years. The report recommended no 
change in the rate of tax imposed on employers and employees. The tax 
adjustment mechanism will automatically increase or decrease tax rates 
in response to changes in fund balance. Only under the most pessimistic 
employment assumption does the tax rate mechanism not avoid cash flow 
problems.
    Railroad Unemployment Insurance Account.--The RRB's latest annual 
report required by Section 7105 of the Technical and Miscellaneous 
Revenue Act of 1988 was issued in June 2015. The report indicated that 
even as maximum daily benefit rates rose approximately 39 percent (from 
$70 to $97) from 2014 to 2025, experience-based contribution rates are 
expected to keep the unemployment insurance system solvent.
    Unemployment levels are the single most significant factor 
affecting the financial status of the railroad unemployment insurance 
system. However, the system's experience-rating provisions, which 
adjust contribution rates for changing benefit levels, and its 
surcharge trigger for maintaining a minimum balance, help to ensure 
financial stability in the event of adverse economic conditions. No 
financing changes were recommended at this time by the report.
    Thank you for your consideration of our budget request. We will be 
happy to provide further information in response to any questions you 
may have.

    [This statement was submitted by Walter A. Barrows, Labor Member 
and Steven J. Anthony, Management Member, Railroad Retirement Board.]
                                 ______
                                 
 Prepared Statement of the Inspector General, Railroad Retirement Board
    Mr. Chairman and Members of the Subcommittee: My name is Martin J. 
Dickman, and I am the Inspector General for the Railroad Retirement 
Board. I would like to thank you, Mr. Chairman, and the members of the 
Subcommittee for your continued support of the Office of Inspector 
General.
                             budget request
    The President's proposed budget for fiscal year 2017 would provide 
$10,499,000 to the Office of Inspector General (OIG) to ensure the 
continuation of the OIG's independent oversight of the Railroad 
Retirement Board (RRB). During fiscal year 2017, the OIG will focus on 
areas affecting program performance; the efficiency and effectiveness 
of agency operations; and areas of potential fraud, waste and abuse.
                         operational components
    The OIG has three operational components: the immediate Office of 
the Inspector General, the Office of Audit (OA), and the Office of 
Investigations (OI). The OIG conducts operations from several 
locations: the RRB's headquarters in Chicago, Illinois; an 
investigative field office in Philadelphia, Pennsylvania; and five 
domicile investigative offices located in Virginia, Texas, California, 
Florida, and New York. These domicile offices provide more effective 
and efficient coordination with other Inspector General offices and 
traditional law enforcement agencies, with which the OIG works joint 
investigations.
                            office of audit
    The mission of the Office of Audit (OA) is to promote economy, 
efficiency, and effectiveness in the administration of RRB programs and 
detect and prevent fraud and abuse in such programs. To accomplish its 
mission, OA conducts financial, performance, and compliance audits and 
evaluations of RRB programs. In addition, OA develops the OIG's 
response to audit-related requirements and requests for information.
    During fiscal year 2017, OA will focus on areas affecting program 
performance; the efficiency and effectiveness of agency operations; and 
areas of potential fraud, waste, and abuse. OA will continue its 
emphasis on long-term systemic problems and solutions, and will address 
major issues that affect the RRB's service to rail beneficiaries and 
their families. OA has identified six broad areas of potential audit 
coverage: Financial Accountability; Railroad Retirement Act and 
Railroad Unemployment Insurance Act Benefit Program Operations; RRB 
Contracts and Contracting Activities; Railroad Medicare Program 
Operations; Security, Privacy, and Information Management; and Improper 
Payments Act of 2010 Oversight.
    OA must also accomplish the following mandated activities with its 
own staff: Audit of the RRB's financial statements pursuant to the 
requirements of the Accountability of Tax Dollars Act of 2002; 
evaluation of information security pursuant to the Federal Information 
Security Management Act (FISMA); audit of the RRB's compliance with the 
Improper Payments Elimination and Recovery Act of 2010; review of IG 
Requirements for Government Charge Card Abuse and Prevention Act of 
2012; assessments required under the Digital Accountability and 
Transparency Act of 2014; and semi-annual reporting in accordance with 
the Inspector General Act of 1978, as amended.
    During fiscal year 2017, OA will complete the audit of the RRB's 
fiscal year 2016 financial statements and begin its audit of the 
agency's fiscal year 2017 financial statements. OA contracts with a 
consulting actuary for technical assistance in auditing the RRB's 
``Statement of Social Insurance'', which became basic financial 
information effective in fiscal year 2006. In addition to performing 
the annual evaluation of information security, OA also conducts audits 
of individual computer application systems which are required to 
support the annual FISMA evaluation. Our work in this area is targeted 
toward the identification and elimination of security deficiencies and 
system vulnerabilities, including controls over sensitive personally 
identifiable information.
    The portion of OA resources dedicated to conducting mandated audits 
continues to increase substantially. In fiscal year 2015, approximately 
50 percent of direct audit time was spent completing mandated audits. 
While mandated work results in important audit findings and increased 
agency oversight, it also limits other audits that can be undertaken 
without an increase in resources.
    OA currently reports on seven major challenges facing the RRB. 
Additional resources will make it possible for OA to provide additional 
oversight to these programs that represent billions in taxpayer 
dollars.
    OA undertakes additional projects with the objective of allocating 
available audit resources to areas in which they will have the greatest 
value. In making that determination, OA utilizes a strategic planning 
process to focus on areas affecting program performance, the efficiency 
and effectiveness of agency operations, and areas of potential waste, 
fraud and abuse. OA also considers staff availability, current trends 
in management, and Congressional and Presidential concerns.
                        office of investigations
    The Office of Investigations (OI) focuses its efforts on 
identifying, investigating, and presenting cases for prosecution, 
throughout the United States, concerning fraud in RRB benefit programs. 
OI conducts investigations relating to the fraudulent receipt of RRB 
disability, unemployment, sickness, and retirement/survivor benefits. 
OI investigates railroad employers and unions when there is an 
indication that they have submitted false reports to the RRB. OI also 
conducts investigations involving fraudulent claims submitted to the 
Railroad Medicare Program. These investigative efforts can result in 
criminal convictions, administrative sanctions, civil penalties, and 
the recovery of program benefit funds.

              OI INVESTIGATIVE RESULTS FOR FISCAL YEAR 2015
------------------------------------------------------------------------
                      Indictments/                         Recoveries/
 Civil Judgments      Informations       Convictions       Receivables
------------------------------------------------------------------------
             27                 49                 43   \1\ $203,692,184
------------------------------------------------------------------------
\1\ This total amount of financial accomplishments reflect fraud amounts
  related to programs administered exclusively by the RRB and fraud
  amounts from other Federal Programs such as Medicare or Social
  Security, which were included in the disposition resulting from the
  investigation.

    OI anticipates an ongoing caseload of about 350 investigations in 
fiscal year 2017. During fiscal year 2015, OI opened 186 new cases and 
closed 212. At present, OI has cases open in 48 States, the District of 
Columbia, and Canada with estimated fraud losses of over $596 million. 
Disability and Medicare fraud cases represent the largest portion of 
OI's total caseload. These cases involve more complicated schemes and 
often result in the recovery of substantial amounts for the RRB's trust 
funds. They also require considerable resources such as travel by 
special agents to conduct surveillance, numerous witness interviews, 
and more sophisticated investigative techniques. Additionally, these 
fraud investigations are extremely document-intensive and require 
forensic financial analysis.
    Of particular significance is an ongoing disability fraud 
investigation related to a large number of individuals in New York. To 
date, this investigation has resulted in 33 individuals pleading guilty 
or being convicted in Federal court. All individuals prosecuted in 
connection with this case have been sentenced. This investigation is 
continuing, and there is the potential for more charges in this case. 
OI agents will likely have to spend a considerable amount of time 
traveling to New York for continuing investigations. Based on this 
investigation, the OI has initiated several other large scale 
disability investigations that could result in significant charges 
being filed.
    The OI continues to work joint cases with other Offices of 
Inspector General and Federal law enforcement agencies that have 
responsibility for healthcare fraud matters. Medicare fraud 
investigations currently represent approximately 18 percent of OI's 
total caseload and more than $378 million in fraud losses. OI's 
collaborative joint investigative efforts ensure that RRB beneficiaries 
are protected from sham medical practitioners, and that the Railroad 
Medicare program's interests are safeguarded from fraudulent schemes.
    During fiscal year 2017, OI will continue to coordinate its efforts 
with agency program managers to address vulnerabilities in benefit 
programs that allow fraudulent activity to occur and will recommend 
changes to ensure program integrity. OI plans to continue proactive 
projects to identify fraud matters that are not detected through the 
agency's program policing mechanisms.
    Findings will be conveyed to agency management through OIG systemic 
implication reports to alert officials of operational weaknesses that 
may result in fraud against RRB programs. OI will also continue to work 
with RRB program managers to ensure appropriate and timely referral of 
all fraud matters to the OIG.
                               conclusion
    In fiscal year 2017, the OIG will continue to focus its resources 
on the review and improvement of RRB operations and will conduct 
activities to ensure the integrity of the agency's trust funds. This 
office will continue to work with agency officials to ensure the agency 
is providing quality service to railroad workers and their families. 
The OIG will also aggressively pursue all individuals who engage in 
activities to fraudulently receive RRB funds. The OIG will continue to 
keep the Subcommittee and other members of Congress informed of any 
agency operational problems or deficiencies.

    [This statement was submitted by Martin J. Dickman, Inspector 
General, Railroad Retirement Board.]

                       NONDEPARTMENTAL WITNESSES

         Prepared Statement of the Academy of General Dentistry
    Dear Chairman Blunt and Ranking Member Murray: On behalf of the 
Academy of General Dentistry (AGD) and its 39,000 national membership, 
I am writing to respectfully request the inclusion of the following 
report language in the Labor-HHS appropriations bill for fiscal year 
2017. Our requests focus on the critical issue of oral health literacy 
and the importance of maintaining a well-trained and robust oral health 
workforce.
    Oral disease left untreated can result in pain, disfigurement, loss 
of school and work days, nutritional deficiencies, expensive emergency 
department use for preventable dental conditions, and even death. 
Despite these grim outcomes, studies show that regardless of insurance 
status and income, many individuals forgo preventive and needed dental 
services because the relationship between good oral health and overall 
health is not well understood.
    The AGD feels strongly that the importance of prevention in the 
form of oral health literacy is often overlooked--especially by the 
Federal agencies--much to the detriment of our Nation's oral health 
needs. Our goal with the enclosed language is to push agencies that 
play an important role, like HRSA, to step up on this issue and make 
oral health literacy a top public health priority.
    Therefore, we recommend that you consider the following language to 
be included in the Committee Report at the appropriate point with 
respect to either Training in Oral Health Care and/or Rural Health:
      The Committee encourages HRSA to work with the States to develop 
        and facilitate public education programs that promote 
        preventive oral health treatments and habits via increased oral 
        health literacy in rural and underserved areas. The Committee 
        believes that prevention-centered programs represent a cost 
        effective way to address oral health access. The Committee also 
        encourages the Office of Rural Health Policy to support these 
        programs. Further, the Committee encourages HRSA to include 
        innovative public education programs as eligible for funding as 
        part of the State Oral Health Workforce Improvement Program.
    We also ask that the Committee continue its investment in our 
Nation's oral health by fully funding HRSA's Title VII Primary Care 
Dental Training Cluster and Related Oral Health Programs, and to again 
include a $10 million set-aside for general dentistry residencies and a 
$10 million set-aside for pediatric dentistry residencies within the 
funds provided. Title VII grantees play a key role in diversifying the 
dental workforce and providing outreach and services to underserved and 
vulnerable populations, resulting in better oral health for many 
Americans.
    Relatedly, we ask that the Committee request $875,000 for section 
748 authority for the Dental Faculty Loan Repayment Program and include 
language directing HRSA to issue a new grant cycle for fiscal year 2017 
from the funding provided. Please see below for our suggested language 
pertaining to these Title VII requests:
            Title VII--Dental Workforce
      Sec. 748. Within the funds provided, the Committee intends no 
        less than $10,000,000 for General Dentistry Programs and no 
        less than $10,000,000 for Pediatric Dentistry programs. The 
        Committee provides $875,000 for section 748 authority for the 
        Dental Faculty Loan Repayment Program. The Health Resources and 
        Services Administration (HRSA) is directed to publish a new 
        funding opportunity and then award grants in fiscal year 2017 
        from the funding provided.
    The AGD thanks you and the Committee for your consideration and 
encourages you to contact Daniel J. Buksa, JD, Associate Executive 
Director, Public Affairs, by email at daniel.buksa@agd.org should you 
have any questions concerning our report language requests.
    Thank you again for your ongoing support of and commitment to 
improving oral health for all Americans.
    Sincerely.

    [This statement was submitted by W. Mark Donald, DMD, MAGD, 
President, Academy of General Dentistry.]
                                 ______
                                 
      Prepared Statement of the Academy of Nutrition and Dietetics
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    The Academy of Nutrition and Dietetics (the ``Academy'') is part of 
a nationwide coalition, the Food is Medicine Coalition, of over 80 food 
and nutrition services providers, affiliates and their supporters 
across the country that provide food and nutrition services to people 
living with HIV/AIDS (PWH) and other chronic illnesses. The Academy, 
with 76,000 members throughout the Nation, is the world's largest 
organization of food and nutrition professionals, committed to 
improving the Nation's health through healthy and safe food choices. 
Collectively, the Food is Medicine Coalition is committed to increasing 
awareness of the essential role that food and nutrition services (FNS) 
play in successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
                         better health outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/
conclusion.cfm?conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW,Weiser SD, McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510--1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
                         lower healthcare costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
                     improved patient satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438;Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, 
Bangsberg DR. Food insecurity is associated with incomplete HIV RNA 
suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
                               conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Respectfully submitted.

    [This statement was submitted by Mary Pat Raimondi, MS, RD, Vice 
President, Strategic Policy and Partnerships, Academy of Nutrition and 
Dietetics.]
                                 ______
                                 
      Prepared Statement of the Ad Hoc Group for Medical Research
    The Ad Hoc Group for Medical Research is a coalition of patient and 
voluntary health groups, medical and scientific societies, academic and 
research organizations, and industry. We appreciate the opportunity to 
submit this statement in support of strengthening the Federal 
investment in biomedical, behavioral, social, and population-based 
research conducted and supported by the National Institutes of Health 
(NIH).
    The Ad Hoc Group is deeply grateful to the Subcommittee for its 
long-standing and bipartisan leadership in support of NIH, as 
demonstrated most recently by the $2 billion increase provided in the 
fiscal year 2016 omnibus spending bill. We believe that science and 
innovation are essential if we are to continue to meet current and 
emerging health challenges, improve our Nation's health, and sustain 
our leadership in medical research.
    If this Nation is to continue to accelerate the development of 
life-changing cures, pioneering treatments, and innovative prevention 
strategies, it is essential to sustain predictable increases in the NIH 
budget.
    The Ad Hoc Group recommends that Congress appropriates at least 
$34.5 billion through the Labor-HHS-Education spending bill for fiscal 
year 2017. This $2.4 billion increase represents 5 percent real growth 
above the projected rate of biomedical inflation, and will help ensure 
that NIH-funded research can continue to improve our Nation's health 
and enhance our competitiveness in today's global information and 
innovation-based economy.
    We share the bipartisan enthusiasm in Congress for the potential 
that NIH-supported research holds in improving the health and well-
being of all Americans. We look forward to working with appropriators 
to secure an increase of 5 percent real growth in fiscal year 2017 for 
NIH as the next step to ensuring stability in the Nation's research 
capacity over the long term. We also stand ready to work with 
authorizers on unique mechanisms to take full advantage of the 
exceptional scientific opportunities now available and to meet current 
and emerging health challenges.
NIH: A Public-Private Partnership to Save Lives and Provide Hope
    The partnership between NIH and America's scientists, medical 
schools, teaching hospitals, universities, and research institutions is 
a unique and highly-productive relationship, leveraging the full 
strength of our Nation's research enterprise to foster discovery, 
improve our understanding of the underlying cause of disease, and 
translate this knowledge into the next generation of diagnostics, 
therapeutics, and other clinical innovations. Nearly 84 percent of the 
NIH's budget is competitively awarded through more than 55,000 research 
and training grants to more than 300,000 researchers at over 2,500 
universities and research institutions located in every State.
    The Federal Government has an essential and irreplaceable role in 
supporting medical research. No other public, corporate or charitable 
entity is willing or able to provide the broad and sustained funding 
for the cutting edge basic research necessary to yield new innovations 
and technologies of the future.
    NIH has supported biomedical research to enhance health, lengthen 
life, and reduce illness and disability for more than 100 years. The 
following are a few of the many examples of how NIH research has 
contributed to improvements in the Nation's health.
  --The death rate for all cancers combined has been declining since 
        the early 1990s for adults and since the 1970s for children. 
        Overall cancer death rates have dropped by about 1.5 percent 
        per year, or nearly 15 percent in total from 2003--2012. 
        Research in cancer immunotherapy has led to the development of 
        several new methods of treating cancer by restoring or 
        enhancing the immune system's ability to fight the disease. As 
        researchers develop new approaches to overcoming tumor 
        avoidance of immune destruction and new methods for identifying 
        antigens on tumor cells that can be targeted most effectively, 
        immunotherapy is becoming an integral part of precision 
        medicine.
  --Deaths from heart disease fell 67.5 percent from 1969 to 2013, 
        through research advances supported in large part by NIH. The 
        Framingham Heart Study and other NIH-supported research have 
        identified risk factors for heart disease, such as cholesterol, 
        smoking, and high blood pressure. This work has led to new 
        strategies for preventing heart disease.
  --Since 1950, the stroke mortality rate has decreased by 79 percent, 
        due in part to NIH-funded research on treatments and 
        prevention.
  --Despite the increasing prevalence of diabetes in the U.S., from 
        1969 to 2013 the death rate for adults with diabetes declined 
        by 16.5 percent. Between 1990 and 2010, the rates of major 
        diabetes complications dropped dramatically, particularly for 
        heart attacks, which declined by 68 percent, and stroke, which 
        declined by 53 percent. These improvements are due largely to 
        clinical trials supported by NIH. NIH's Diabetes Prevention 
        Program has shown that lifestyle changes, such as diet and 
        physical activity, can lower the risk of developing type 2 
        diabetes by 58 percent in adults at high risk for the disease.
  --Thanks to an unprecedented collaborative effort between NIH and 
        industry, today treatments can suppress HIV to undetectable 
        levels, and a 20-year-old HIV-positive adult living in the 
        United States who receives these treatments is expected to live 
        into his or her early 70s, nearly as long as someone without 
        HIV. Since the mid-1990s, HIV testing and prevention strategies 
        based on NIH research have resulted in a more than 90 percent 
        decrease in the number of children perinatally infected with 
        HIV in the United States.
  --In 1960, 26 of every 1,000 babies born in the United States died 
        before their first birthday. By 2013, that rate had fallen to 
        under 6 per 1,000 babies, thanks in large part to NIH research 
        on reducing preterm births, neonatal mortality, and other 
        complications.
  --The haemophilus influenza type B (Hib) vaccine has reduced the 
        cases of Hib, once the leading cause of bacterial meningitis in 
        children, by more than 99 percent.
  --NIH-supported researchers partnered with a pharmaceutical company 
        to produce a naloxone nasal spray, the first easy-to-use, non-
        injectable version of a life-saving treatment for opioid or 
        heroin overdoses. NIH-supported researchers collaborated with 
        the pharmaceutical industry to develop the drug buprenorphine, 
        the first drug for opioid addiction that could be prescribed in 
        a doctor's office instead of requiring daily visits to a 
        clinic.
  --As a result of NIH efforts, nearly all infants born in U.S. 
        hospitals in 2010 were screened for hearing loss, allowing them 
        to get hearing aids or cochlear implants during their 
        developmental years when they will be most helpful. Studies 
        have shown that screening and implantation before the age of 18 
        months allows more than 80 percent of children with hearing 
        loss to join mainstream classes with their normal-hearing 
        peers.
  --Deep brain stimulation is used to help relieve symptoms of 
        Parkinson's disease and Obsessive Compulsive Disorder, thanks 
        in part to NIH-funded research, and is currently being tested 
        in other neuropsychiatric conditions, such as treatment-
        resistant depression and dementia.
  --In the mid-1970s, burns that covered even 25 percent of the body 
        were almost always fatal. Today, people with burns covering 90 
        percent of their bodies can survive. NIH-funded research on 
        wound cleaning, skin replacement, infection control, and other 
        topics has greatly improved the chances of surviving 
        catastrophic burns and traumatic injuries.
    For patients and their families, NIH is the ``National Institutes 
of Hope.''
    NIH is the world's premier supporter of merit-reviewed, 
investigator-initiated basic research. This fundamental understanding 
of how disease works and insight into the cellular, molecular, and 
genetic processes underlying life itself, including the impact of 
social environment on these processes, underpin our ability to conquer 
devastating illnesses. The application of the results of basic research 
to the detection, diagnosis, treatment, and prevention of disease is 
the ultimate goal of medical research. Ensuring a steady pipeline of 
basic research discoveries while also supporting the translational 
efforts necessary to bring the promise of this knowledge to fruition 
requires a sustained investment in NIH.
Sustaining Scientific Momentum Requires Sustained Funding
    Despite the increase in fiscal year 2016, over the past decade, NIH 
has lost more than 22 percent of its budget after inflation, 
significantly impacting the Nation's ability to sustain the scientific 
momentum that has contributed so greatly to our Nation's health and our 
economic vitality. The leadership and staff at NIH and its Institutes 
and Centers has engaged patient groups, scientific societies, and 
research institutions to identify emerging research opportunities and 
urgent health needs, and has worked resolutely to prioritize precious 
Federal dollars to those areas demonstrating the greatest promise. 
Sustained predictable increases in NIH funding are needed if we are to 
continue to take full advantage of these opportunities to accelerate 
the development of pioneering treatments and innovative prevention 
strategies.
    One long-lasting potential impact of the past decade is on the next 
generation of scientists, who have seen training funds slashed and the 
possibility of sustaining a career in research diminished. The 
continued success of the biomedical research enterprise relies heavily 
on the imagination and dedication of a diverse and talented scientific 
workforce. Of particular concern is the challenge of maintaining a 
cadre of clinician-scientists to facilitate translation of basic 
research to human medicine. NIH supports many innovative training 
programs and funding mechanisms that foster scientific creativity and 
exploration. Additional funding is needed if we are to strengthen our 
Nation's research capacity, ensure a biomedical research workforce that 
reflects the racial and gender diversity of our citizenry, and inspire 
a passion for science in current and future generations of researchers.
NIH is Critical to U.S. Competitiveness
    Our country still has the most robust medical research capacity in 
the world, but that capacity simply cannot weather repeated blows such 
as persistent below-inflation funding levels and sequestration cuts, 
which jeopardize our competitive edge in an increasingly innovation-
based global marketplace.
    Other countries have recognized the critical role that biomedical 
science plays in innovation and economic growth and have significantly 
increased their investment in biomedical science. This shift in funding 
is creating an innovation deficit in the U.S. and raises the concern 
that talented medical researchers from all over the world, who once 
flocked to the U.S. for training and stayed to contribute to our 
innovation-driven economy, are now returning to better opportunities in 
their home countries. We cannot afford to lose that intellectual 
capacity, much less the jobs and industries fueled by medical research. 
The U.S. has been the global leader in medical research because of 
Congress's bipartisan recognition of NIH's critical role. To continue 
our dominance, we must reaffirm this commitment to provide NIH the 
funds needed to maintain our competitive edge.
NIH: An Answer to Challenging Times
    The research supported by NIH drives not only medical progress but 
also local and national economic activity, creating skilled, high-
paying jobs and fostering new products and industries. According to a 
report released by United for Medical Research, a coalition of 
scientific advocates, institutions and industries, in fiscal year 2011, 
NIH-funded research supported an estimated 432,000 jobs all across the 
United States and generated more than $62 billion in new economic 
activity.
    The Ad Hoc Group's members recognize the tremendous challenges 
facing our Nation's economy and acknowledge the difficult decisions 
that must be made to restore our country's fiscal health. Nevertheless, 
we believe strongly that NIH is an essential part of the solution to 
the Nation's economic restoration. Strengthening our commitment to 
medical research, through robust funding of the NIH, is a critical 
element in ensuring the health and well-being of the American people 
and our economy.
    Therefore, the Ad Hoc Group for Medical Research recommends that 
NIH receive at least $34.5 billion in fiscal year 2017 as the next step 
toward a multi-year increase in our Nation's investment in medical 
research.
                                 ______
                                 
      Prepared Statement of the Adult Congenital Heart Association
    On behalf of the Adult Congenital Heart Association (ACHA), I am 
pleased to submit testimony in support of funding for the National 
Institutes of Health (NIH) and the Centers for Disease Control and 
Prevention's (CDC) National Center on Birth Defects and Developmental 
Disabilities (NCBDDD). We urge you to include $34.5 billion for NIH and 
$10 million for congenital heart disease at NCBDDD in the Labor-Health 
and Human Services-Education appropriations bill for fiscal year 2017.
    Founded in 1998 by a group of adult congenital heart defect 
survivors and their families, the ACHA and its Board of Directors 
continues to consist primarily of those living with heart defects. ACHA 
is dedicated to promoting excellence in adult congenital heart disease 
(ACHD). Our mission is to improve and extend the lives of the millions 
born with heart defects through education, advocacy and the promotion 
of research.
    The success of childhood cardiac intervention has created a new and 
growing patient population of those living with CHDs into adulthood. 
Thanks to the increase in survival, of the over 2 million people alive 
today with CHD, more than half are adults, increasing at an estimated 
rate of 5 percent each year. Few congenital heart survivors are aware 
of their high risk of additional problems as they age, facing high 
rates of neuro-cognitive deficits, heart failure, rhythm disorders, 
stroke, and sudden cardiac death. Many survivors require multiple 
operations throughout their lifetime. Fifty percent of all congenital 
heart survivors have complex problems for which lifelong care from an 
adult congenital heart specialist, who has training is more specialized 
than a general cardiologist, is required. Yet less than 10 percent of 
adult congenital heart patients receive this cardiac care. Delays in 
care can result in premature death and disability. In adults, this 
often occurs during prime wage-earning years.
                     national institutes of health
    The National Heart Lung and Blood Institute (NHLBI) is the research 
home for congenital heart disease. The research undertaken there is one 
of the primary reasons children born with CHDs are living into 
adulthood. We believe that the one critical challenge for adults with 
CHD is the matter of continued expert care across the lifespan. 
Continued research into better quality of care for those with CHDs--
whether it be better surgical techniques or a better understanding of 
what those with CHDs face as they age--is a critical area for NHLBI to 
address.
    To advance research on CHDs, NHLBI should prioritize the following 
research areas:
  --Advancing Translational Research: Ensuring that basic science is 
        translated into clinical practice is essential. While there 
        have been great strides in ensuring that babies born with CHD 
        are identified and repaired, we know that there are lifelong 
        implications for those with CHDs that require continued follow-
        up and treatment. As the proportion of adults with CHD grows 
        larger than the pediatric population, NHLBI must look at this 
        area as an opportunity for advancing translational research. It 
        is an area of great need.
  --Development of Workforce and Resources: No where do we see a 
        greater need than in the area of workforce, specifically for 
        experts in CHD. We are working with others to ensure that those 
        with CHDs have access to the best care, but the continued need 
        for additional partners remains. Ensuring that researchers and 
        clinicians have the training and resources available to address 
        areas of need is essential. Focusing on ensuring access to 
        science and care will certainly further the needs of this 
        important population as well as the broader heart health 
        community.
    national center on birth defects and developmental disabilities
    Despite its prevalence and significance, there are gaps in research 
and standards of care for CHD patients. Previous Congressional support 
for the congenital heart disease activities at the NCBDDD has yielded 
an increased understanding of the public health burden of this 
condition, but additional resources are required to continue and expand 
these efforts. Continued Federal investment is necessary to provide 
rigorous epidemiological and longitudinal public health surveillance 
and research on infants, children, adolescents, and adults to better 
understand congenital heart disease across the lifespan, improve 
outcomes, and reduce costs.
    Increasing congenital heart disease funding at the CDC to $10.0 
million in fiscal year 2017 would allow for improved awareness of CHDs 
and understanding of prevalence, healthcare utilization, and short and 
long-term physical and psychosocial outcomes, achieved by building upon 
the pilot congenital heart adolescent and adult surveillance program, 
incorporating public health research, developing a longitudinal cohort, 
and completing a survivorship study. This funding would allow NCBDDD to 
develop a report on adult congenital heart disease surveillance 
efforts, including an estimated number of individuals in the U.S. 
living with a CHD, epidemiology of CHDs across the life span, age-
specific prevalence and factors associated with those patients ``lost 
to care'' who may have dropped out of appropriate specialty care. 
Having this information is critical to meeting the needs of adults with 
CHDs.
                                 ______
                                 
       Prepared Statement of the Agriculture Workforce Coalition
                         Statement on Behalf of
         American Farm Bureau Federation  AmericanHort
                 Florida Fruit & Vegetable Association
               National Council of Agricultural Employers
     National Council of Farmer Cooperatives  U.S. Apple 
                              Association
    United Fresh Produce Association  USA Farmers  
                            Western Growers
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee, thank you for your continued leadership and support for 
U.S. agriculture. The above signed steering committee members of the 
Agriculture Workforce Coalition appreciate this opportunity to submit 
our views regarding the fiscal year 2017 Labor, Health and Human 
Services, and Education, and Related Agencies appropriations bill, and 
respectfully requests this statement be made part of the official 
hearing record.
    The labor situation in agriculture has been a concern for many 
years, but is moving towards a breaking point. Today, large segments of 
American agriculture face a critical lack of workers, a shortage that 
makes our farms and ranches less competitive with food from abroad and 
that threatens the abundant, safe and affordable domestic food supply 
American consumers enjoy today.
    Repeated evidence over the past decades has shown that there are 
some jobs in agriculture that Americans simply do not want to do. 
Although many of these jobs offer wages competitive with similar, non-
agricultural occupations, they are physically demanding, conducted 
outdoors in all seasons and weather, and are often seasonal or 
transitory. It is for this reason that farmers have grown to rely on 
foreign workers to perform this work.
    The overarching challenge to workforce stability in agriculture is 
the widely acknowledged lack of authorized work status by a large 
number of agricultural workers despite the prevalence of documentation 
presented by workers to the contrary. The only option for farmers and 
ranchers to legally find the workers they need is the H-2A temporary 
work visa program, a program that has not worked for many agricultural 
employers.
    The H-2A program's basic framework is overly restrictive and 
difficult to maneuver. Furthermore, the H-2A program is only accessible 
for producers with seasonal needs; excluding the year-round needs of 
many producers such as dairy, livestock, mushrooms, and other crops. In 
recent years the program has become even more bureaucratic, burdensome 
and costly to use. But, each year, more and more farms have to turn to 
the H-2A program for legal foreign labor to meet their workforce needs.
    The demand on the program is increasing as producers have nowhere 
else to turn; yet the administrative weight of the program cannot keep 
up. H-2A employment has doubled in the past 4 years and will double 
again in the next 2 years or less. Even at current levels, capacity and 
infrastructure issues at the Departments of State, Homeland Security 
and Labor are leading to greater processing delays than ever before. 
This means bureaucratic red tape and delays in the program result in 
workers showing up at the farm well after the date they were needed to 
be there, and millions of dollars in agricultural production is lost in 
the interim.
    To improve the function of the H-2A program, we seek the following 
as part of the fiscal year 2017 Labor, Health and Human Services, and 
Education, and Related Agencies appropriations bill:
Farm Labor Survey Wage Categories
        Agency: Department of Labor
        Program: Farm Labor Survey
        Justification: Allows for more detailed data collection and 
        normalizes the data with Occupational Employment Statistics 
        categories used by the Department of Labor.
        Language Type: Bill
        Proposal: No such sums shall be provided for the determination 
        pursuant to 20 CFR 655.120 unless the Secretary determines the 
        weighted average annual rate for field workers separately from 
        livestock workers and equipment operators and provides a rate 
        for field workers and a separate rate for livestock workers and 
        equipment operators.
Advertising
        Agency: DOL Employment and Training Administration
        Program: H-2A Program
        Justification: The H-2A program's basic framework is overly 
        restrictive and difficult to maneuver. The traditional 
        newspaper advertising requirement is another example of sheer 
        inefficiencies. In this modern day farmers should not be 
        required to place costly job postings in newspapers, but rather 
        use the already existing DOL State Workforce Agency's online 
        tools.
        Language Type: Bill
        Proposal: No such sums shall be used to implement or enforce 20 
        CFR 655.121, as long as the employer is using the Department of 
        Labor State Workforce Agency's online system for advertising 
        methods.
Staggered Entry
        Agency: Department of Labor--Office of Foreign Labor 
        Certification
        Program: H-2A Program
        Justification: This modification was recommended by the 
        Government Accounting Office in a September 2012 report, which 
        stated that to reduce the burden on agricultural employers and 
        improve customer service, the Secretary of Labor should permit 
        the use of a single application with staggered dates-of-need 
        for employers who need workers to arrive at different points of 
        a harvest season.
        Language Type: Bill
        Proposal: No such funds may be used to implement 20 CFR 655 
        unless provisions are made to allow for staggered entry dates 
        for workers defined in 8 USC 1101(a)(15)(H)(ii)(A). (NOTE: 
        Staggered entry for seafood was included under H-2B in the 
        fiscal year 2016 omnibus: Division H, Title 1, Sec. 111, page 
        358)
Limitations on NFJP
        Agency: Department of Labor
        Program: Migrant and Seasonal Farmworker Programs under Section 
        167 of the Workforce Innovation and Opportunity Act
                Account: 016-0174-0-1-504-0011
                POTUS Budget: Page 787
        Justification: At a time of increased labor shortages in the 
        agricultural sector, the Federal Government should not continue 
        spending money to exacerbate this problem, but should instead 
        be directing these funds in a manner that will enhance skills 
        needed for agricultural work.
        Language Type: Bill
        Proposal: No such funds may be used for training purposes under 
        Section 167 of the Workforce Innovation and Opportunity Act 
        unless the training is dedicated to skills improvement for 
        workforce development in all aspects of agricultural 
        operations.
Corresponding Employment
        Agency: Department of Labor Office of Foreign Labor 
        Certification
        Program: H-2A Program
        Justification: From 1987 until 2010, DOL interpreted the term 
        corresponding employment to mean that a U.S. worker who 
        performed all the duties in the occupation defined in the job 
        order was in corresponding employment with H-2A workers and had 
        to be provided the same wages and benefits as the H-2A worker. 
        In 2010, DOL changed the wording of the regulation to state 
        that any U.S. worker who performed any activity in the job 
        order was in corresponding employment. The adverse consequence 
        is that an H-2A worker may perform highly skilled work most of 
        the time but occasionally performs very basic unskilled work. 
        If the H-2A worker performs any unskilled work, then the 2010 
        rule sweeps the entire U.S. workforce incapable of performing 
        the skilled work defined in the job order into corresponding 
        employment, forcing the employer to pay unskilled workers the 
        same as highly skilled workers.
        Language Type: Bill
        Proposal: No such funds shall be used to implement the 
        definition of corresponding employment (20 CFR 655.103) unless 
        it is implemented consistent with the final 1987 regulation (29 
        CFR Sec. 501.0, 52 Fed.Reg. page 20524) to read that ``the 
        employment of workers who are not H-2A workers by an employer 
        who has an approved H-2A application for Temporary Employment 
        Certification in the occupation described in the job order 
        performed by H-2A workers and for the time period set forth in 
        the approved job order.''
Commuter Housing
    For operations along the southern border, workers commute daily 
from their homes in Mexico. Required housing that is provided to these 
workers goes unused and is therefore an unnecessary cost imposed on 
employers.
        Agency: DHS U.S. Citizenship & Immigration Services and DOL 
        Wage and Hour Division
        Program: H-2A Program
        Proposal: 8 USC 1188(c)(4) is amended as follows: the housing 
        requirement for H-2A workers is waived when the job site is 
        within 50 miles of the border and the worker's place of 
        residence is within normal commuting distance.
    We remain steadfast in our pursuit of broader immigration reform 
that meets both the short- and long-term workforce requirements of all 
of agriculture--both those producers with seasonal labor needs, and 
those with year-round needs. Yet we recognize such reforms may not come 
to fruition in the near term.
    Left with no other alternative, we seek your support for the 
inclusion of these modest adjustments as you prepare fiscal year 2017 
appropriations legislation.
    Thank you again, and members of the Subcommittee, for the 
opportunity to share our views.

    [This statement was submitted by Lisa Van Doren, Vice President & 
Chief of Staff, Government Affairs, National Council of Farmer 
Cooperatives.]
                                 ______
                                 
 Prepared Statement of the AIDS Alliance for Women, Infants, Children, 
                            Youth & Families
    Dear Chairman Blunt and Members of the Subcommittee: AIDS Alliance 
for Women, Infants, Children, Youth & Families was founded in 1994 to 
help respond to the unique concerns of HIV-positive and at-risk women, 
infants, children, youth, and families. AIDS Alliance conducts policy 
research, education, and advocacy on a broad range of HIV/AIDS 
prevention, care, and research issues. We are pleased to offer written 
testimony for the record in opposition of the fiscal year 2017 budget 
proposal consolidating Ryan White Part D funding into Part C and in 
support of maintaining Part D of the Ryan White Program as part of the 
fiscal year 2017 Labor, Health and Human Services, Education, and 
Related Agencies appropriations measure. This testimony also has the 
support of the Elizabeth Glaser Pediatric AIDS Foundation.
Ryan White Part D Funding Request
    Sufficient funding of Ryan White Part D, the program funded solely 
to provide family-centered primary medical care and support services 
for women, infants, children, and youth with HIV/AIDS has successfully 
identified, linked, and retained these vulnerable populations in much 
needed care and treatment, resulting in optimum health outcomes. We 
thank the Subcommittee for its continuous support of Ryan White Part D 
Programs, providing $75,008,000 million to the program in fiscal year 
2016, restoring dedicated funding eliminated in the President's fiscal 
year 2016 budget proposal. While the AIDS Alliance for Women, Infants, 
Children, Youth & Families understands that these are difficult 
economic times, we are requesting the Subcommittee to maintain its 
commitment to the Ryan White Part D program and again restore its 
dedicated funding eliminated in the President's fiscal year 2017 budget 
proposal and increase Ryan White Part D funding by $9.9 million in 
fiscal year 2017.
Ryan White Part D Background and History
    Over concerns with the increase in the number of pediatric AIDS 
cases, Congress first acted to address pediatric cases in 1987 by 
providing $5 million for the Pediatric AIDS Demonstration Projects in 
the fiscal year 1988 budget. Those demonstration projects became part 
of the Ryan White CARE Act of 1990 and today are known as Ryan White 
Part D and have served approximately 200,000 women, infants, children, 
youth and family members. Since the program's inception in 1988, Part D 
programs have been and continue to be the entry point into medical care 
for women and youth. The family-centered primary medical and supportive 
services provided by Part D are uniquely tailored to address the needs 
of women, including HIV positive pregnant women, HIV exposed infants, 
children and youth. Part D programs are the only perinatal clinical 
service available to serve HIV-positive pregnant women and HIV exposed 
infants, when payments for such services are unavailable from other 
sources. Ryan White Part D programs have been extremely effective in 
bringing the most vulnerable populations into and retained in care and 
is the lifeline for women, infants, children and youth living with HIV/
AIDS. The Part D programs continue to be instrumental in preventing 
mother-to-child transmission of HIV and for ensuring that women, 
including HIV- positive pregnant women, HIV exposed infants, children 
and youth have access to quality HIV care. The program is built on a 
foundation of combining medical care and essential support services 
that are coordinated, comprehensive, and culturally and linguistically 
competent. This model of care addresses the healthcare needs of the 
most vulnerable populations living with HIV/AIDS in order to achieve 
optimal health outcomes.
    In 2012, Part D provided funding to 114 community-based 
organizations, academic medical centers and hospitals, federally 
qualified health centers, and health departments in 39 States and 
Puerto Rico. These federally, directly-funded grantees provide HIV 
primary care, specialty and subspecialty care, oral health services, 
treatment adherence monitoring and education services pertaining to 
opportunities to participate in HIV/AIDS- related clinical research. 
These grantees also provide support services which include case 
management (medical, non-medical, and family-centered); referrals for 
inpatient hospital services; treatment for substance use, and mental 
health services. Part D grantees receive assistance from other parts of 
the Ryan White Program that help support HIV testing and linkage to 
care services; provide access to medication; additional medical care, 
such as dental services; and key support services, such as case 
management and transportation, which all are essential components of 
the highly effective Ryan White HIV care model. This model has 
continuously provided comprehensive quality healthcare delivery systems 
that have been responsive to women, infants, children, youth and 
families for two decades.
A Response to Women, Infants, Children, and Youth
    The Ryan White Program has been enormously successful in meeting 
its mission to provide life-extending care and services. Yet, even 
though we have made significant progress in decreasing HIV-related 
morbidity and mortality, much work remains to be done. While accounting 
for less than 5 percent of Ryan White direct care dollars (minus ADAP 
and Part F), Ryan White Part D programs have been extremely effective 
in bringing our most vulnerable populations into care and developing 
medical care and support services especially designed to reach women, 
children, youth, and families. Part D funded programs played a leading 
role in reducing mother-to-child transmission of HIV-from more than 
2,000 newborn infections annually more than a decade ago to an 
estimated 174 in 2014 through aggressive efforts to reach out to 
pregnant women. Appropriate funding is critical to maintain and improve 
upon this success, as there are still approximately 8,500 HIV-positive 
women giving birth every year in the United States that need 
counseling, services and support to prevent pediatric HIV infections. 
According to the CDC, youth aged 13-24 accounted for more than 1 in 5 
new HIV diagnoses in the U.S. in 2014. Most new HIV infections in youth 
(about 55 percent) occur in young Black gay and bisexual males. Of the 
new HIV infections among youth, 80 percent are among young women of 
color. Ryan White Part D programs are the entry point into medical care 
for many of these HIV positive youth and lead the Nation's effort in 
recruiting and retaining HIV positive youth to comprehensive medical 
care and support services. According to the Health Resources and 
Services Administration, more than 37 percent of women receiving 
medical care in Ryan White Programs do so through Part D. Additionally, 
Part D provides medical and supportive services to a large number of 
women over 50 who are heading into their senior years as HIV survivors 
which is a testament to the high standard of care provided to Ryan 
White Part D programs. Support and care through the Ryan White Part D 
program was and continues to be funding of last resort for the most 
vulnerable women and children, who often have fallen through the cracks 
of other public health safety nets. Full implementation of the 
Affordable Care Act (ACA), along with continuation of the Ryan White 
Program will dramatically improve health access and outcomes for many 
more women, infants, children, and youth living with HIV disease.
Proposed Consolidation
    The medical and supportive services provided by Ryan White Part D 
are unique and are not currently being provided by other parts of the 
Ryan White Program, including Ryan White Part C. These services are 
uniquely tailored to address the needs of women, including HIV positive 
pregnant women, HIV exposed infants, children and youth living with 
HIV/AIDS. The proposed consolidation of Part D funding into Part C in 
the Federal budget would eliminate a strong safety net for our most 
vulnerable populations and weaken the systems of care Part D programs 
have created and invested in for more than 25 years. Furthermore, the 
loss of Part D funds in some community areas would profoundly impact 
access to comprehensive HIV care and treatment for women, infants, 
children and youth. Many of the population served by Part D will be 
lost or never enter into care thus increasing the existing gaps in the 
HIV Care Continuum. Moreover, major program changes that are this 
controversial should be left to Congress and should not be done through 
the appropriations process.
Conclusion
    While we recognize the need to reduce administrative burdens 
associated with the overall operational aspects of Ryan White programs 
, the elimination of dedicated funding for Ryan White Part D in fiscal 
year 2017 and the proposed Part C/D consolidation would undoubtedly 
destabilize existing models of care created to address the unique needs 
of women, infants, children, and youth living with HIV/AIDS and 
jeopardizes the success of retaining these most vulnerable populations 
in life-saving HIV/AIDS care and treatment ensuring achieved and 
maintained viral load suppression. If we believe that one day we will 
realize an ``AIDS-free generation,'' then surly we know how essential 
it is to maintain the Ryan White Program and all of its Parts.
    AIDS Alliance for Women, Infants, Children, Youth & Families urges 
the Committee to again reject the President's fiscal year 2017 budget 
proposal to eliminate dedicated funding for Ryan White Part D and move 
the funding to Part C, and respectfully request that the Committee 
include language in the appropriations bill attesting to such. Without 
the Ryan White Part D program, many of these medically-underserved 
women, infants, children and youth would not receive the vital primary 
care and support services provided to them for the last two decades.
    On behalf to the women, infants, children, and youth living with 
HIV/AIDS and the Ryan White Part D funded programs across the country 
that serve them we sincerely thank you for all that you do to ensure 
that these populations receive the much needed primary care, treatment 
and supportive services needed to sustains their lives.

    [This statement was submitted by Dr. Ivy Turnbull, Deputy Executive 
Director, AIDS Alliance for Women, Infants, Children, Youth & 
Families.]
                                 ______
                                 
                Prepared Statement of The AIDS Institute
    Dear Chairman Blunt and Members of the Subcommittee: The AIDS 
Institute, a national public policy, research, advocacy, and education 
organization, is pleased to offer comments in support of critical 
domestic HIV/AIDS and hepatitis programs as part of the fiscal year 
2017 Labor, Health and Human Services, Education, and Related Agencies 
appropriation measure. We thank you for supporting these programs over 
the years, and hope you will do your best to adequately fund them in 
the future in order to provide for and protect the health of many 
Americans.
                     cdc viral hepatitis prevention
    Before detailing our HIV/AIDS requests, we would like to highlight 
the critical importance of increasing funding for viral hepatitis at 
the Centers for Disease Control and Prevention (CDC). The CDC estimates 
that between 2010 and 2013, the U.S. saw an increase in new hepatitis 
infections of more than 150 percent. With 55,000 new infections every 
year, and nearly 5.3 million people living with hepatitis B (HBV) or 
hepatitis C (HCV) in the U.S., increased investments in hepatitis are 
needed now more than ever before. Similar to the factors that resulted 
in the 2015 HIV and HCV outbreak in Scott County, Indiana, new 
hepatitis infections are largely driven by increases in the use of 
heroin and other opiates. Additionally, HBV and HCV are the leading 
causes of liver cancer, which is now one of the most lethal and fastest 
growing cancers in the United States. The CDC estimates that deaths 
attributed to HCV now surpass the number of deaths associated with all 
59 other notifiable infectious disease combined.
    We are thankful for the small increase the CDC's Division of Viral 
Hepatitis (DVH) received in fiscal year 2016, but it is nowhere near 
the estimated $170 million needed for DVH to reduce new hepatitis 
infections in the U.S. We have the tools to prevent this growing 
epidemic and to eliminate hepatitis in the U.S., but only with 
increased funding for DVH to provide the level of testing, education, 
and surveillance needed.
                                hiv/aids
    HIV/AIDS remains one of the world's worst health pandemics. A 
record 1.2 million people in the U.S. are living with HIV, and there 
are still 50,000 new infections each year. Persons of minority races 
and ethnicities are disproportionately affected. The rate of new 
infections in the African American community is eight times that of 
whites. HIV/AIDS disproportionately affects low income people; nearly 
90 percent of Ryan White Program clients have a household income of 
less than 250 percent of the Federal Poverty Level.
    The U.S. Government has played a leading role in fighting HIV/AIDS, 
both here and abroad. The vast majority of the discretionary programs 
supporting domestic HIV/AIDS efforts are funded through this 
Subcommittee. We are keenly aware of current budget constraints and 
competing interests for limited dollars, but programs that prevent and 
treat HIV are inherently in the Federal interest as they protect the 
public health against a highly infectious virus. If left unaddressed, 
it will certainly lead to increased infections, more deaths, and higher 
health costs.
    With the advent of antiretroviral medicines, HIV has turned from a 
near certain death sentence to a treatable chronic disease if people 
have access to consistent and affordable healthcare and medications. 
Through prevention, care and treatment, and research we now have the 
ability to actually end AIDS. HIV treatment not only saves the lives of 
people with HIV, but also reduces HIV transmission by more than 96 
percent. Therefore, HIV treatment is also HIV prevention. In order to 
realize these benefits, people with HIV must be diagnosed through 
testing, and linked to and retained in care and treatment.
    Diagnosing, treating, and achieving viral suppression for all 
individuals living with HIV are key elements to achieving the goals of 
the updated National HIV/AIDS Strategy, and to one day reaching an 
AIDS-free generation.
                    the ryan white hiv/aids program
    The Ryan White HIV/AIDS Program, acting at the payer of last 
resort, provides medications, medical care, and essential coverage 
completion services to approximately 512,000 low-income, uninsured, and 
underinsured individuals with HIV/AIDS in the U.S. With people living 
longer and continued new diagnoses, the demands on the program continue 
to grow and many needs remain unmet. According to the CDC, only 39 
percent of people living with HIV in the U.S. are retained in HIV care, 
36 percent have been prescribed antiretroviral treatment, and 30 
percent are virally suppressed. We have a long way to go before we can 
realize the dream of an AIDS-free generation. With continued funding we 
can improve these numbers and health outcomes.
    The AIDS Drug Assistance Program (ADAP), one component of the Ryan 
White Program, provides States with funds to pay for medications for 
over 262,000 people. While ADAPs continue to provide medications to 
Ryan White clients to keep them healthy, an increased amount of ADAP 
funding is being used to help low-income enrollees afford insurance 
premiums, deductibles, and high cost-sharing related to the cost of 
their HIV medications. We urge you to ensure that ADAP and the rest of 
the Ryan White Program receive adequate funding to keep up with the 
growing demand. With this increased demand for medications comes a 
corresponding increase in medical care and support services provided by 
all other parts of the program.
    With the Affordable Care Act (ACA), there are expanded 
opportunities for healthcare coverage for some Ryan White clients. 
While the ACA will result in some cost shifting for medications and 
primary care, it will never be a substitute for the Ryan White Program. 
Nearly three-quarters of all Ryan White Program clients today have some 
sort of insurance coverage; over half have coverage through Medicaid 
and Medicare. However, public and private insurance programs do not 
always provide the comprehensive array of services required to meet the 
needs of individuals living with HIV/AIDS. Services critical to 
managing HIV include case management; mental health and substance use 
services; adult dental services; and transportation, legal, and 
nutritional support services. Because not all States are choosing to 
expand Medicaid, benefits differ from State to State, and for many 
individuals living with HIV/AIDS, the Ryan White Program is the only 
source of care and treatment. This approach of coordinated, 
comprehensive, and culturally competent care leads to better health 
outcomes. In fact, over 81 percent of those in the Ryan White Program 
are virally suppressed, an increase of over 17 percent since 2010. 
Therefore, the Ryan White Program must continue and be adequately 
funded.
    The AIDS Institute urges the Committee to reject the President's 
budget proposal to eliminate dedicated funding for Part D of the Ryan 
White Program and transfer it to Part C. Part D serves women, infants, 
children, and youth with HIV/AIDS and is a well-established system of 
care that has worked since 1988 in nearly eliminating mother-to-child 
transmission and providing medical care and family-centered support 
that helps ensure these vulnerable populations remain in care and 
adherent to their medications. While changes to the Ryan White Program 
might be needed in the future, it should not be done through the 
appropriations process and must include community input.
    Additionally, we support the President's request to increase by $9 
million the Part F Special Projects of National Significance in order 
to increase HCV testing, and care and treatment for people living with 
HIV who are co-infected with HCV. About one in four people living with 
HIV is co-infected with HCV.
                           cdc hiv prevention
    We have made significant progress in the fight against HIV/AIDS in 
the United States over the last 30 years. Due to past investments, we 
have averted thousands of new infections and lowered new infection 
rates among heterosexuals, people who inject drugs, and African 
Americans. However, some communities continue to experience increases 
in new infections, including gay, bisexual, and other men who have sex 
with men (MSM), particularly young black and Latino MSM. In fact, MSM 
accounted for 70 percent of all new HIV infections in 2014, and black 
MSM have experienced a 22 percent increase in infections since 2005. 
Averting all 50,000 new infections each year would result in 
approximately $20 billion in lifetime treatment costs.
    With more people living with HIV than ever before, there are 
greater chances of HIV transmission. The CDC and its grantees have been 
doing their best with limited resources to keep the number of 
infections stable, but that is not good enough. It is focusing 
resources on those populations and communities most impacted by HIV and 
investing in those programs that will prevent the most number of 
infections. With over 156,000 people living with HIV in the U.S. who 
are unaware of their infection, the CDC is also focused on increased 
HIV testing programs. Testing people early allows them to be diagnosed 
and referred to care and treatment earlier, which is critical to 
bettering individual health outcomes and preventing new infections. We 
are also in support of the Administration's proposal that would allow 
health departments to spend a limited portion of their prevention 
funding on pre-exposure prophylaxis (PrEP) and related services. PrEP 
has been proven to reduce the chances of HIV infection by up to 92 
percent in people, and are particularly effective for those who are at 
high risk.
    The CDC estimates that one in four new HIV infections are among 
young people between the age of 13 and 24; most of whom are young gay 
men. We must do a better job of educating the youth, including gay 
youth, about HIV. Increasing funding to the HIV Division of Adolescent 
and School Health (DASH) would help build schools' capacity to 
implement quality sexual health education, support student access to 
healthcare, and enable safe and supportive environments.
                       syringe services programs
    In the fiscal year 2016 omnibus appropriations bill, Congress 
revised the restrictions on the use of Federal funds for syringe 
service programs (SSPs). Federal funding can now be used for SSPs in 
jurisdictions that are experiencing or are at risk for significant 
increases in HIV or hepatitis infections due to injection drug use. 
Federal funding cannot support the purchase of actual syringes. We urge 
the Subcommittee to maintain the current appropriations language that 
allows access to syringe services in those jurisdictions that meet the 
criteria.
         hiv/aids research at the national institutes of health
    While we have made great strides, there is still a long way to go 
for AIDS research. NIH (National Institutes of Health) has supported 
innovative basic science for better drug therapies, behavioral and 
biomedical prevention interventions, and has saved the lives of 
millions around the world. However, continued research is necessary to 
learn more about the disease and to develop new treatments and 
prevention tools. NIH has proved the efficacy of pre-exposure 
prophylaxis (PrEP), the effectiveness of treatment as prevention, and 
the first partially effective AIDS vaccine. We look forward to an 
eventual cure. AIDS research has also contributed to the development of 
effective treatments for other diseases, including cancer and 
Alzheimer's disease.
 hiv research network at the agency for healthcare research and quality
    We ask the Subcommittee to restore funding to the HIV Research 
Network (HIVRN) at the Agency for Healthcare Research and Quality 
(AHRQ). This $1.6 million program funds clinical research that measures 
the quality and cost-effectiveness of HIV/AIDS care in the U.S. 
Additionally, HRSA relies on this data for monitoring the status of 
clients served by the Ryan White Program. We urge the Subcommittee to 
restore AHRQ funding for the HIVRN.
                        minority aids initiative
    As racial and ethnic minorities in the U.S. are disproportionately 
impacted by HIV/AIDS, it is critical that this Subcommittee continue to 
support the Minority AIDS Initiative (MAI). The resources for MAI 
supplement, rather than replace, other Federal funding for HIV/AIDS, 
and encourage capacity building, innovation, collaboration, and 
integration of best practices to fully address the needs of some of the 
most vulnerable populations for HIV infection.
    Again, we thank you for your continued support of these programs. 
We have made great progress, but we are still far from achieving zero 
new HIV infections, an AIDS-free generation, and eradicating viral 
hepatitis. We now have the tools, but we need continued leadership and 
the necessary resources to realize our goals. Thank you.

    [This statement was submitted by Carl Schmid, Deputy Executive 
Director, The AIDS Institute.]
                                 ______
                                 
         Prepared Statement of the Alliance for Aging Research
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee, for 30 years the nonprofit Alliance for Aging Research, 
has advocated for policies that will accelerate the pace of scientific 
discoveries and their application to improve the universal experience 
of aging and health. We support increased Federal funding of aging 
research by the National Institutes of Health (NIH), through the 
National Institute on Aging (NIA) and other NIH institutes and centers. 
The Alliance for Aging Research appreciates the opportunity to submit 
testimony highlighting the important role the NIH plays in facilitating 
medical research activities related to aging and the need for sustained 
Federal investment to advance scientific discoveries to keep aging 
Americans healthier longer. When considering the rapid aging of America 
and the resources the Federal Government devotes to Medicare and other 
healthcare services for age-related diseases, we find it prudent to 
increase appropriated spending on aging research. Considering the 
unique funding challenges facing the NIA, and the range of promising 
scientific opportunities in the field of aging research, the Alliance 
for Aging Research recommends an additional $500 million in the fiscal 
year 2017 NIH budget to support biomedical, behavioral, and social 
sciences aging research efforts at the NIH and a minimum increase of 
$400 million in Alzheimer's disease and related dementias research. To 
ensure that overall research progress at the NIH continues, the 
Alliance for Aging Research endorses the Ad Hoc Group for Medical 
Research recommendation that the NIH be funded at $34.5 billion in 
fiscal year 2017. We further urge the committee to include report 
language requesting that the U.S. Secretary of Health and Human 
Services establish an Interagency Geroscience Research Coordination 
Committee (IGRCC) comprised of representatives from the NIH, FDA and 
other designated agencies to identify and direct grants for new 
geroscience research; and, to provide $1 million to administer the 
activities of the IGRCC and $5 million in grant-making authority to 
advance aging research priorities.
    The NIA leads the national scientific effort to understand the 
nature of aging and to extend the healthy, active years of life. 
Congress established the NIA in 1974 with the mission of conducting and 
supporting genetic, biological, clinical, behavioral, social, and 
economic researched related to the aging process, diseases and 
conditions associated with aging, and needs of older Americans; 
developing research and clinician-scientists for research and aging; 
and disseminate information about aging and advances in research with 
the scientific community, healthcare providers, and the public. These 
following projects highlight some of the important work directed by the 
NIA:
  --The Biology of Aging Program is a trans-NIH initiative, 
        coordinating with the Nathan Shock Centers of Excellence, to 
        support translational research at the individual and community 
        level. Under this umbrella, the Interventions Testing Program 
        seeks to identify compounds that extend median and/or maximal 
        life span in both mammal and non-mammalian organisms.
  --The Behavioral and Social Research Program conducts longitudinal 
        studies focusing on trends in late-life disability and on the 
        influences of behavioral, psychological, and social factors in 
        mid-life on age-related variations in health and well-being. 
        Major programs include initiatives to stimulate research on 
        mid-life adults informing efforts to optimize health and well-
        being, prevent illness and disability in later years, and 
        potentially reverse the negative impact of early life adversity 
        on later life health.
  --The Geriatrics and Clinical Gerontology Program is studying how 
        early life factors influence health and diseases as people age. 
        The program also plans and administers clinical trials for age-
        related conditions and is conducting an on-going initiative to 
        identify behavioral interventions with a high potential impact 
        to improve health outcomes for individuals with three or more 
        chronic conditions.
  --The Neuroscience Program seeks to expand knowledge on the aging 
        nervous system to allow improvement in the quality of life of 
        older people. The program supports a national network of 
        Alzheimer's disease centers to translate research advances into 
        improved diagnosis and care of Alzheimer's disease patients.
  --The Accelerating Medicines Partnership (AMP) is a collaboration 
        between the NIH and 10 pharmaceutical company partners to 
        identify and characterize biomarkers and targets of 
        intervention for Alzheimer's disease, type 2 diabetes, and 
        autoimmune disorders, rheumatoid arthritis, and systemic lupus 
        erythematosus.
  --The Healthy Aging in Neighborhood of Diversity across the Life Span 
        (HANDLS) is a 20-year project within the NIA Intramural 
        Research Program to examine the influences of race and 
        socioeconomic status on the development of age-related health 
        disparities in Baltimore.
  --The NIA has partnered with Patient-Centered Outcomes Research 
        Institute (PCORI) on an intervention study testing individually 
        tailored strategies for falls prevention in older adults.
    The NIA's mission becomes ever more urgent as the American 
population ages. Older Americans now make up the fastest growing 
segment of the population. According to the U.S. Census Bureau, the 
number of Americans aged 65 and older is expected to double between 
2010 and 2050 to 88.5 million; the number of Americans aged 85 and 
older is expected to triple in the same time period. The impact this 
will have on the U.S. healthcare system is profound. As the American 
population ages, the number of Americans living with chronic diseases 
skyrockets.
    The influx of Americans living with the chronic diseases of aging 
threatens to overwhelm the U.S. healthcare system. According to the 
Centers for Medicare & Medicaid Services, in 2011 approximately 23 
percent of beneficiaries had four to five chronic diseases associated 
with aging. This increase of people living with multiple chronic 
disease is a large contributing factor to the Congressional Budget 
Office projecting total spending on healthcare to increase by 25 
percent of the U.S. GDP by 2025. Streamlining delivery and eliminating 
unneeded care will not sufficiently contain the costs of caring for the 
chronic diseases of geriatric populations. To effectively solve this 
problem, we must increase Federal resources to understand the biology 
of aging. Research to better understanding the aging process and its 
underlying relationship to chronic disease could help Americans live 
longer and more productive lives while greatly alleviating much of the 
burden to the healthcare system. Scientists studying aging are in 
general agreement that there is a strong likelihood the pace of aging 
can be slowed. Closing the gap between the promises of basic research 
into aging and the clinical application of this research will require 
considerable focus and investment.
    An increase in funding for aging research is urgently needed to 
enable scientists to capitalize on the field's recent exciting 
discoveries. The Alliance for Aging Research, has led the Healthspan 
Campaign--an awareness campaign to educate the public and policymakers 
about the need to focus and adequately fund basic research into the 
underlying processes of aging--that if targeted can extend a person's 
healthy years of life. In addition to increased resources, we believe 
that the field could benefit from the creation of a trans-agency 
coordinating committee that could improve the quality and pace of 
research that advances the understanding of aging, its impact on age-
related diseases, and the development of interventions to extend human 
healthspan. Throughout the first half of 2012 the Alliance and its 
Healthspan Campaign partners met with the leadership of the NIA, the 
National Institute of Neurological Diseases and Stroke (NINDS), the 
National Institute of Arthritis Musculoskeletal and Skin Diseases 
(NIAMS), the National Institute of Diabetes Digestive and Kidney 
Diseases (NIDDK), the National Heart Lung and Blood Institute (NHLBI), 
and the National Cancer Institute (NCI). These meetings led to the 
establishment of the Trans-NIH GeroScience Interest Group (GSIG), a 
group seeking to discover common risks and mechanisms behind age-
related diseases and conditions. Twenty-one of the 27 institutes and 
centers at the NIH are now working on the GSIG. The regular meetings, 
quarterly seminars, and the recommendations from the ``Advances in 
Geroscience: Impact on Healthspan and Chronic Disease Summit'' have 
identified multiple opportunities for collaboration. Funding these 
research opportunities can reduce the burden of a ``Silver Tsunami'' of 
age-associated chronic diseases. We urge the committee to include 
report language requesting that the U.S. Secretary of Health and Human 
Services establish an Interagency Geroscience Research Coordination 
Committee (IGRCC) comprised of representatives from the NIH, FDA and 
other designated agencies to identify and direct grants for new 
geroscience research; and, to provide $1 million to administer the 
activities of the IGRCC and $5 million in grant-making authority to 
advance aging research priorities.
    NIA leads the Federal effort on researching Alzheimer's disease, 
receiving roughly 70 percent of NIH Alzheimer's disease research 
funding. As many as five million Americans aged 65 years and older are 
living with Alzheimer's disease, with 13.2 million anticipated by 2050. 
The national cost of caring for individuals with Alzheimer's disease is 
estimated at $100 billion annually. To address the problem, the NIA has 
a comprehensive research agenda to understand the disease, spanning 
from basic neuroscience through translational research and clinical 
applications. The NIA supports treatment trials that aim to slow the 
disease or alleviate its symptoms, such as last year's discovery that 
the anti-depressant citalopram may be a safer and more effective 
treatments for disruptive agitation in Alzheimer's disease than 
currently used treatments.
    The exponential increase in computer processing power has 
strengthened the NIA's efforts to study Alzheimer's disease. These new 
technologies allow researchers to generate and analyze enormous data 
sets with the aim of identifying risk and protective genes for 
Alzheimer's disease. This has led to the Alzheimer's disease Sequencing 
Project (ADSP), a collaborative effort between the NIA and the National 
Human Genome Research Institute working to identify genomic variants 
contributing to the development and protecting against the development 
of Alzheimer's disease. The NIA is also using the Accelerating 
Medicines Partnership (AMP) to incorporate an expanded set of 
biomarkers into three ongoing trials designed to delay or prevent 
Alzheimer's disease and determine their usefulness in tracking disease 
progression and treatment responsiveness. These trials will be ongoing 
from 2017 to 2020. AMP also supports large-scale systems biology 
analyses using data from 2,500 brains at different stages of 
Alzheimer's disease to build predictive models of the disease. All of 
the data from this initiative is shared with the public.
    However, despite the NIH's exciting work on Alzheimer's disease, 
the current level of funding the NIH receives is insufficient to meet 
the National Plan to Address Alzheimer's disease's goal of developing 
effective treatment modalities to treat or cure Alzheimer's disease by 
2025. To meet this goal, we support an increase of at least $ 400 
million for Alzheimer's disease and related dementia research. This 
would put the NIH-wide dementia research budget at $1.34 billion in 
fiscal year 2017. Furthermore, the NIA's current budget does not 
reflect the tremendous responsibility it has to meet the health 
research needs of America's aging population. When adjusting for 
inflation, the NIA's budget has decreased more than 20 percent since 
2003. An increase of $500 million will allow the NIH to capitalize on 
the potential transformational gains in aging research. Few, if any, 
investments have a greater potential return on investment for public 
health. The Alliance for Aging Research recommends that overall NIH 
funding be increased to $34.5 billion in fiscal year 2017. We also 
support a minimum $500 million increase over fiscal year 2016 enacted 
levels for aging research across the NIH that will accelerate progress 
toward preventing, treating, and slowing the progression, or even 
possibly curing conditions related to aging. We would also be remiss 
not to acknowledge the Subcommittee's significant increase for the NIH 
and Alzheimer's disease and related dementia research in fiscal year 
2016. We truly appreciate your prioritization of the critical work 
conducted at the NIH and ask for your ongoing support.
    Mr. Chairman, thank you for the opportunity to present testimony 
and elucidate on the challenges posed by the aging population. Our 
organization will gladly provide additional information and answer 
questions upon request.

    [This statement was submitted by Cynthia Bens, Vice President 
Public, Alliance for Aging Research.]
                                 ______
                                 
 Prepared Statement of the Alliance of Information and Referral Systems
    Chairman Blunt, Ranking Member Murray: On behalf of the Alliance of 
Information and Referral Systems (AIRS), we thank you for the 
opportunity to offer testimony in support of the Department of Health 
and Human Services' proposed increase of $10 million for the Older 
Americans Act Title III(B) Home and Community-Based Supportive Services 
program within the Administration for Community Living, as well as 
testimony against the Department of Health and Human Services' proposed 
cuts to the Low-Income Home Energy Assistance Program and Community 
Services Block Grant program within the Administration for Children and 
Families.
    AIRS, with more than 1,000 members from across the United States 
and Canada, is the organization which brings people and services 
together. More specifically, we are the lead national agency which 
developed the professional standards that are a part of thousands of 
quality Information and Referral (I&R) programs operated under the 
Older Americans Act. AIRS members answer more than 28 million calls per 
year for help about community, social and health services.
 older americans act title iii(b) home and community-based supportive 
                                services
    I&R services provided under Title III(B) of the Older Americans Act 
are critical to providing older adults in need with assistance in every 
community in this Nation. I&R organizations have databases of programs 
and services and disseminate information through a variety of channels 
to individuals and communities. Older adults in need of critical 
services such as food, shelter, work and job training, and mental 
health support often do not know where to turn for support. I&R 
services provide answers.
    Title III(B) also provides important supportive services such as 
home healthcare, transportation, and adult day care, programs to which 
AIRS members refer older adults. These programs are all in need of 
increased funding. The Administration has proposed an increase of $10 
million for Title III(B) for fiscal year 2017. Title III(B) has been 
level-funded for years and has not had funding restored from 
sequestration cuts in fiscal year 2013. This increase would not fully 
restore funding, but it would help immensely to serve the growing need 
for these programs as our population ages.
               low-income home energy assistance program
    AIRS is very concerned about the Administration's proposed cut to 
the Low-Income Home Energy Assistance Program (LIHEAP). This 12 percent 
cut would reduce funding for LIHEAP by $390 million.
    One AIRS member stated that in her county's elderly services 
program, two-thirds of her clients either have low enough incomes or 
have enough medical expenses to qualify for LIHEAP. When they receive 
shut-off notices, they call her I&R service for assistance; the I&R 
service refers the clients to one of a few possible resources for help. 
However, those resources do not have enough funding, so these older 
adults go without heating for days. In the winter, their pipes may 
break due to lack of heat, and it can take several days to start 
repairs. Meanwhile, these vulnerable adults have no heat or water.
    This is only one local example; these issues happen nationally. 
Another AIRS member said that during the 4th quarter of 2015, 40 
percent of the requests his agency received for heating or electric 
assistance were recorded as an unmet request, primarily because there 
were insufficient resources to assist households to pay arrearages. 
During the 3rd quarter, the unmet need requests neared 80 percent. 
Reducing funding for this important program would be a huge mistake and 
could harm many vulnerable populations, including frail older adults.
                     community services block grant
    AIRS is also very concerned about the Administration's proposed cut 
to the Community Services Block Grant (CSBG). This cut would reduce 
funding for CSBG by $41 million.
    Many I&R providers refer callers to the services provided under the 
CSBG, such as employment, education, housing assistance, nutrition, 
energy, emergency services, health, and substance abuse. These programs 
serve people of all ages. Reducing funding for this program would mean 
that many important services could be cut.
    We thank you for your past and future support, and hope to continue 
to work with you through the appropriations process.

    [This statement was submitted by Robert McKown, President, Board of 
Directors and Charlene Hipes, Chief Operating Officer, Alliance of 
Information and Referral Systems.]
                                 ______
                                 
              Prepared Statement of the Alpha-1 Foundation
    On behalf of the Alpha-1 Foundation, I am pleased to submit 
testimony in support of funding for the National Institutes of Health 
(NIH). We urge you to include $34.5 billion for NIH in the Labor-Health 
and Human Services-Education appropriations bill for fiscal year 2017.
    The Alpha-1 Foundation is committed to finding a cure for Alpha-1 
Antitrypsin Deficiency (Alpha-1) and to improving the lives of people 
affected by Alpha-1 worldwide. This condition is inherited and may 
result in serious lung disease, like COPD, and/or liver disease. Like 
many other inherited conditions, those with Alpha-1 must have two 
defective genes to cause disease. In the case of Alpha-1 this results 
in lower than normal levels of protective protein in the blood and 
lungs.
    Prioritizing research related to Alpha-1, specifically, Alpha-1 
associated Chronic Obstructive Pulmonary Disease (COPD) at the National 
Heart Lung and Blood Institute (NHLBI) in fiscal year 2017 is essential 
to tackling the broader issue of not just rare diseases, but also 
public health issues related to COPD. In fiscal year 2016, the NHLBI 
convened an interagency meeting on Federal COPD planning. Unfortunately 
we have yet to see any peer-reviewed publications following this 
meeting. I hope that you will include language in the accompanying 
report that urges NHLBI to move forward on efforts to address the 
rising burden of COPD in the U.S.
    Specifically, we know that Alpha 1 Antitrypsin Deficiency (Alpha 1) 
is a major genetic risk factor for developing COPD. Therefore we at the 
Alpha-1 Foundation believe that a treatment algorithm for Alpha-1 
related disease along with a coordinated public-private collaborative 
approach will not only increase the knowledge that can improve the 
diagnosis of Alpha 1, but make for a more clear understanding of COPD. 
We urge you to encourage the NHLBI to convene a group of expert 
stakeholders and other Federal agencies to take the first steps in 
developing such a treatment algorithm.
    In short, we are committed to ensuring that Alphas have a community 
of support, places to go for answers, and in furthering research for 
therapies and ultimately, cures. Prioritizing research at the NHLBI, 
specifically ensuring that this treatment algorithm related to Alpha-1 
associated COPD is created, will go a long way in furthering these 
goals.
                                 ______
                                 
      Prepared Statement of the Alzheimer's Foundation of America
    As President and CEO of the Alzheimer's Foundation of America 
(AFA), a national nonprofit organization that unites more than 2,400 
member organizations nationwide with the goal of providing optimal care 
and services to individuals confronting dementia, and to their 
caregivers and families I, Charles J. Fuschillo, Jr., urges the Senate 
Appropriations Committee to commit:
  --An additional $1 billion for Alzheimer's disease research at the 
        National Institutes of Health (NIH); and
  --An additional $40 million to fund caregiver supports and services 
        provided by programs administered by the Administration for 
        Community Living (ACL)
National Institutes of Health (NIH):
    AFA wants to commend the Committee for approving an historic 
increase in funding for Alzheimer's disease research at the National 
Institutes of Health (NIH) in fiscal year 2016. The $350 million in 
additional resources will help ensure promising research gets funded 
and that we move ever closer to the goal of finding a cure or disease-
modifying treatment by 2025 as articulated in the National Plan to 
Address Alzheimer's Disease.
    AFA hopes Congressional appropriators will continue to build upon 
this progress and make combatting Alzheimer's disease a national 
priority. To this end, AFA urges the Committee to provide an additional 
$1 billion for Alzheimer's disease in fiscal year 2017. Leading 
Alzheimer's disease scientists have called for $2 billion in annual 
research funding to keep us on track to achieve the 2025 goal. With 
just eight short years until the deadline, we can no longer wait. We 
need to ensure there is proper investment in promising research today 
that will get us to a cure tomorrow. An increase of $1 billion in 
fiscal year 2017 would put research funding close to that $2 billion 
dollar target.
    AFA also urges the Committee to include $34.5 billion in total 
funding for NIH, as recommended by the Ad Hoc Group for Medical 
Research. Even if funding remains flat, NIH's actual budget will still 
be effectively cut as spending will not be able to keep pace with 
biomedical inflation.
Administration on Community Living (ACL) Programs:
    AFA would like to highlight the following programs within the ACL 
that are critical to individuals living with dementia and their 
caregivers. As incidences of Alzheimer's disease increase, the 
importance of these programs to family caregivers is vital in meeting 
the challenges of caring for a loved one living with dementia.
  --National Family Caregiver Support Program (NFCSP): NFCSP provides 
        grants to States and territories, based on their share of the 
        population aged 70 and over, to fund a range of supportive 
        services that assist family and informal caregivers in caring 
        for their loved ones at home for as long as possible, thus 
        providing a more person-friendly and cost-effective approach 
        than institutional care. Last year's appropriation of $150.5 
        million cannot possibly keep up with the need for care as our 
        population ages. AFA urges that $161 million be appropriated in 
        fiscal year 2017 to support this important program.
  --Lifespan Respite Care Program (LRCP): AFA urges the Committee to 
        commit $9 million, a $4 million increase to LRCP in fiscal year 
        2017. LRCP provides competitive grants to State agencies 
        working with Aging and Disability Resource Centers and non-
        profit State respite coalitions and organizations to make 
        quality respite care available and accessible to family 
        caregivers regardless of age or disability.
  --The Alzheimer's Disease Supportive Services Program (ADSSP) 
        provides competitive grants to States to expand dementia-
        capable home and community-based long-term services and 
        supports. It was funded at $4.8 million in fiscal year 2016. 
        AFA is calling for an increase of $2.5 million to bring the 
        ADSSP up to $7.3 million in fiscal year 2017.
  --Alzheimer's Disease Initiative (ADI): AFA supports a budget request 
        of $16.5 million--a $6 million increase for this program--in 
        fiscal year 2017 that provides grants for services such as 
        supporting caregivers in the community, improving healthcare 
        provider training, and raising public awareness. Research shows 
        that education, counseling and other support for family 
        caregivers can delay institutionalization of loved ones and 
        improve a caregiver's own physical and mental well-being--thus 
        reducing costs to families and government. In addition, AFA 
        supports an appropriation of $6.7 million, a $2.5 million 
        increase, for the Alzheimer's Disease Communications Campaign.
    AFA thanks the Committee for the opportunity to present its 
recommendations and looks forward to working with you through the 
appropriations process. Please contact me or Eric Sokol, AFA's vice 
president of public policy, at esokol@alzfdn.org if you have any 
questions or require further information.

                                 ______
                                 
          Prepared Statement of the America Forward Coalition
    Dear Chairman Blunt and Ranking Member Murray: As you prepare the 
fiscal year 2017 Appropriations bill, the America Forward Coalition 
urges you to include funding for the programs identified below that 
spur innovation, reward results, and catalyze cross-sector partnerships 
to propel America forward.
    The America Forward Coalition is a network of more than 70 social 
innovation organizations that champion innovative, effective, and 
efficient solutions to our country's most pressing social problems. Our 
Coalition members are achieving measurable outcomes in more than 14,500 
communities nationwide, touching the lives of 8 million Americans each 
year, and driving progress in education, workforce development, early 
learning, poverty alleviation, public health, pay for success, social 
innovation, national service, and criminal justice reform. Since 2007, 
America Forward's community of innovators has played a leading role in 
driving the national dialogue on social innovation and advocating for 
lasting policy change.
    We are eager to work with you to advance the policies outlined in 
this letter and urge you to include and prioritize the following 
programs in the Labor, Health and Human Services, Education and Related 
Agencies Appropriations bill for fiscal year 2017.
Corporation for National and Community Service
  --$1.47 billion for the Corporation for National and Community 
        Service to support high-impact, cost-effective service 
        opportunities in communities that continue to fuel the 
        expansion of innovative programs in a variety of fields.
  --$70 million for the Social Innovation Fund to test promising new 
        approaches to major social challenges and to expand evidence-
        based programs that demonstrate measureable outcomes. This 
        includes the allowable use of up to 20 percent of funds for Pay 
        for Success projects.
    The America Forward Coalition respectfully requests that the above 
programs be included at the identified levels in your fiscal year 2017 
Appropriations bill. We recognize the many difficult choices the 
Committee faces and thank you for the Committee's ongoing support for 
social innovation policies. We look forward to working with you to 
advance these important issues in the months ahead.
    Sincerely,
    Members of the America Forward Coalition
                       america forward coalition
Acelero Learning/Shine Early Learning

Alternative Staffing Alliance

America's Promise Alliance

ANet

AppleTree Institute for Education Innovation

AVANCE, Inc.

Bard Early Colleges

BELL

Beyond 12

Blue Engine

Bottom Line

BUILD

Child Mind Institute

Citizen Schools

City Year, Inc.

College Advising Corps

College Forward

College Possible

College Summit

Compass Working Capital

Connecticut Center for Social Innovation, Inc.

Corporation for Supportive Housing (CSH)

Enterprise Community Partners

Eye to Eye

Family Independence Initiative (FII)

First Place for Youth

Generation Citizen

Genesys Works

Global Citizen Year

GreenLight Fund

iMentor

Institute for Child Success

Invest in Outcomes

Jumpstart for Young Children, Inc.

KIPP

LIFT

LISC

Match Education

National Center for Learning Disabilities (NCLD)

New Classrooms Innovation Partners

New Leaders

New Sector Alliance

New Teacher Center

Opportunity Nation

Peace First

Peer Health Exchange

Public Allies

Reading Partners

REDF

Roca

Root Cause

Save the Children

Say Yes to Education

ServiceNation

Single Stop

Social Enterprise Alliance

Social Finance US

Teach For America

The Children's Aid Society

The Corps Network

The Mission Continues

Third Sector Capital Partners, Inc.

Turnaround for Children

Twin Cities RISE!

uAspire

Waterford Institute

Year Up

YouthBuild USA

Youth Villages, Inc.

10,000 Degrees

                      
                                 ______
                                 
          Prepared Statement of the America Forward Coalition
    Dear Chairman Blunt and Ranking Member Murray: As you prepare the 
fiscal year 2017 Appropriations bill, the America Forward Coalition 
urges you to include funding for the programs identified below that 
spur innovation, reward results, and catalyze cross-sector partnerships 
to propel America forward.
    The America Forward Coalition is a network of more than 70 social 
innovation organizations that champion innovative, effective, and 
efficient solutions to our country's most pressing social problems. Our 
Coalition members are achieving measurable outcomes in more than 14,500 
communities nationwide, touching the lives of 8 million Americans each 
year, and driving progress in education, workforce development, early 
learning, poverty alleviation, public health, pay for success, social 
innovation, national service, and criminal justice reform. Since 2007, 
America Forward's community of innovators has played a leading role in 
driving the national dialogue on social innovation and advocating for 
lasting policy change.
    We are eager to work with you to advance the policies outlined in 
this letter and urge you to include and prioritize the following 
programs in the Labor, Health and Human Services, Education and Related 
Agencies Appropriations bill for fiscal year 2017.
Department of Education
  --$1.16 billion for 21st Century Community Learning Centers, which is 
        the same amount provided in fiscal year 2016, to support 
        effective extended learning and enrichment opportunities that 
        are connected to content covered during the school day through 
        effective community-school partnerships.
  --$350 million for the Charter Schools Program to support high-
        quality charter schools that break the mold of the status quo 
        and create new solutions to meet critical needs.
  --$180 million for the Education, Innovation, and Research (EIR) to 
        increase the number of high-quality applications to build 
        evidence of effectiveness and to demonstrate the feasibility of 
        scaling effective interventions, including support for ARPA-ED, 
        to spur the development of educational technology necessary to 
        personalize learning.
  --$100 million for First in the World to encourage innovation in 
        higher education necessary to tackle and improve college 
        completion rates, increase the productivity of higher 
        education, build evidence of what works, and scale up proven 
        strategies.
  --$9.6 billion for Head Start to increase the number of children 
        attending Head Start for a full school day and a full school 
        year.
  --$15 million for the InformED initiative at the Institute of 
        Education Sciences to support efforts that will collect, 
        analyze, and release data and evaluation studies, for internal 
        users and the public, to answer pressing education questions.
  --$13.6 billion for IDEA to serve students with disabilities.
  --$350 million for Preschool Development Grants to support 
        significant national investments necessary to ensure that all 
        young people have access to a high quality education and the 
        opportunity to succeed.
  --$30 million for the School Leader Recruitment and Support Program 
        to seed models of promising principal preparation programs, 
        scale preparation programs with results, and support effective 
        professional development for school leaders in the field. $100 
        million for the Supporting Effective Educator Development 
        (SEED) Grant Program to recruit and develop teachers, 
        principals, or other school leaders.
  --$190 million for the Striving Readers Comprehensive Literacy Grant 
        program to advance literacy skills for students from birth 
        through grade 12.
  --$1.6 billion for Student Support and Academic Enrichment Grants to 
        support locally designed efforts to provide students with well-
        rounded educational experiences, safe and healthy learning 
        environments, and personalized instruction, including through 
        the effective use of technology.
General Provision--Department of Education
  --Continued authority for Performance Partnership Pilots to award up 
        to 10 new pilots that allow States, tribes and localities to 
        blend certain discretionary funding in order to improve 
        education, employment and other key outcomes for vulnerable 
        youth.
    The America Forward Coalition respectfully requests that the above 
programs be included at the identified levels in your fiscal year 2017 
Appropriations bill. We recognize the many difficult choices the 
Committee faces and thank you for the Committee's ongoing support for 
social innovation policies. We look forward to working with you to 
advance these important issues in the months ahead.
    Sincerely,
    Members of the America Forward Coalition
                       america forward coalition
Acelero Learning/Shine Early Learning

Alternative Staffing Alliance

America's Promise Alliance

ANet

AppleTree Institute for Education Innovation

AVANCE, Inc.

Bard Early Colleges

BELL

Beyond 12

Blue Engine

Bottom Line

BUILD

Child Mind Institute

Citizen Schools

City Year, Inc.

College Advising Corps

College Forward

College Possible

College Summit

Compass Working Capital

Connecticut Center for Social Innovation, Inc.

Corporation for Supportive Housing (CSH)

Enterprise Community Partners

Eye to Eye

Family Independence Initiative (FII)

First Place for Youth

Generation Citizen

Genesys Works

Global Citizen Year

GreenLight Fund

iMentor

Institute for Child Success

Invest in Outcomes

Jumpstart for Young Children, Inc.

KIPP

LIFT

LISC

Match Education

National Center for Learning Disabilities (NCLD)

New Classrooms Innovation Partners

New Leaders

New Sector Alliance

New Teacher Center

Opportunity Nation

Peace First

Peer Health Exchange

Public Allies

Reading Partners

REDF

Roca

Root Cause

Save the Children

Say Yes to Education

ServiceNation

Single Stop

Social Enterprise Alliance

Social Finance US

Teach For America

The Children's Aid Society

The Corps Network

The Mission Continues

Third Sector Capital Partners, Inc.

Turnaround for Children

Twin Cities RISE!

uAspire

Waterford Institute

Year Up

YouthBuild USA

Youth Villages, Inc.

10,000 Degrees

                      
                                 ______
                                 
          Prepared Statement of the America Forward Coalition
    Dear Chairman Blunt and Ranking Member Murray: As you prepare the 
fiscal year 2017 Appropriations bill, the America Forward Coalition 
urges you to include funding for the programs identified below that 
spur innovation, reward results, and catalyze cross-sector partnerships 
to propel America forward.
    The America Forward Coalition is a network of more than 70 social 
innovation organizations that champion innovative, effective, and 
efficient solutions to our country's most pressing social problems. Our 
Coalition members are achieving measurable outcomes in more than 14,500 
communities nationwide, touching the lives of 8 million Americans each 
year, and driving progress in education, workforce development, early 
learning, poverty alleviation, public health, pay for success, social 
innovation, national service, and criminal justice reform. Since 2007, 
America Forward's community of innovators has played a leading role in 
driving the national dialogue on social innovation and advocating for 
lasting policy change.
    We are eager to work with you to advance the policies outlined in 
this letter and urge you to include and prioritize the following 
programs in the Labor, Health and Human Services, Education and Related 
Agencies Appropriations bill for fiscal year 2017.
Department of Labor
  --$1.33 billion for major formula funds under the Workforce 
        Innovation and Opportunity Act (WIOA), including the adult, 
        youth, and dislocated worker funding streams and $3.2 million 
        for WIOA technical assistance to provide resources to support 
        State implementation of WIOA.
  --$500 million for the creation of a Workforce Data Science and 
        Innovation Fund to address the quality of workforce related 
        data in order to improve training programs and consumer choice.
  --$2 billion for an Apprenticeship Training Fund to be funded over 5 
        years in an effort to double the number of registered 
        apprenticeships by helping more employers provide high-quality 
        on-the-job training through apprenticeship and to support 
        States and localities with resources to assist employers in 
        creating and expanding apprenticeships.
  --$102.5 million for YouthBuild grants that are used to engage low-
        income 16-24 year olds in a comprehensive full-time education, 
        job training, and community service program in which students 
        earn their GED or HSD while learning job skills by building 
        affordable green housing under skilled supervision, or through 
        providing health or technology services in their communities.
General Provision--Department of Labor
  --Continued authority for Performance Partnership Pilots to award up 
        to 10 new pilots that allow States, tribes and localities to 
        blend certain discretionary funding in order to improve 
        education, employment and other key outcomes for vulnerable 
        youth.
    The America Forward Coalition respectfully requests that the above 
programs be included at the identified levels in your fiscal year 2017 
Appropriations bill. We recognize the many difficult choices the 
Committee faces and thank you for the Committee's ongoing support for 
social innovation policies. We look forward to working with you to 
advance these important issues in the months ahead.
    Sincerely,
    Members of the America Forward Coalition
                       america forward coalition
Acelero Learning/Shine Early Learning

Alternative Staffing Alliance

America's Promise Alliance

ANet

AppleTree Institute for Education Innovation

AVANCE, Inc.

Bard Early Colleges

BELL

Beyond 12

Blue Engine

Bottom Line

BUILD

Child Mind Institute

Citizen Schools

City Year, Inc.

College Advising Corps

College Forward

College Possible

College Summit

Compass Working Capital

Connecticut Center for Social Innovation, Inc.

Corporation for Supportive Housing (CSH)

Enterprise Community Partners

Eye to Eye

Family Independence Initiative (FII)

First Place for Youth

Generation Citizen

Genesys Works

Global Citizen Year

GreenLight Fund

iMentor

Institute for Child Success

Invest in Outcomes

Jumpstart for Young Children, Inc.

KIPP

LIFT

LISC

Match Education

National Center for Learning Disabilities (NCLD)

New Classrooms Innovation Partners

New Leaders

New Sector Alliance

New Teacher Center

Opportunity Nation

Peace First

Peer Health Exchange

Public Allies

Reading Partners

REDF

Roca

Root Cause

Save the Children

Say Yes to Education

ServiceNation

Single Stop

Social Enterprise Alliance

Social Finance US

Teach For America

The Children's Aid Society

The Corps Network

The Mission Continues

Third Sector Capital Partners, Inc.

Turnaround for Children

Twin Cities RISE!

uAspire

Waterford Institute

Year Up

YouthBuild USA

Youth Villages, Inc.

10,000 Degrees

                      
                                 ______
                                 
    Prepared Statement of the American Academy of Family Physicians
    The American Academy of Family Physicians (AAFP), which represents 
120,900 family physicians and medical students across the country, 
submits this written statement for the record to urge the House 
Appropriations Committee to invest appropriately in our Nation's 
primary care physician workforce in fiscal year 2017.
    In order to ensure high-quality, cost-effective healthcare for 
patients of all ages, the AAFP recommends that the Committee restore 
the discretionary budget authority for the Health Resources and 
Services Administration (HRSA) to the fiscal year 2010 level of $7.48 
billion and provide $364 million in budget authority for the Agency for 
Healthcare Research and Quality (AHRQ).
    Within those agency budgets, we specifically highlight the need to 
provide the following appropriations for programs which are 
particularly important to family physicians and their patients:
  --$59 million for Health Professions Primary Care Training and 
        Enhancement authorized under Title VII, Section 747 of the 
        Public Health Service Act ;
  --An additional $70 million for the National Health Service Corps for 
        a total program level of $380 million at least $20 million of 
        which should be discretionary funding; and
  --$364 million for the AHRQ to support research vital to primary care 
        practice.
HRSA--Title VII Primary Care Training & Enhancement
    The Primary Care Training & Enhancement (PCTE) program administered 
by the Health Resources and Services Administration (HRSA) and 
authorized by Title VII, Sec. 747 of the Public Health Service Act of 
1963 is important to support the education and training of family 
physicians. The PCTE strengthens medical education for physicians to 
improve the quantity, quality, distribution, and diversity of the 
primary care workforce. Without additional funding, there will be no 
new grant competitions for four more years. For that reason, we urge 
the Committee to increase the appropriation by $20 million from the 
fiscal year 2016 level to $59 million in fiscal year 2017.
    An Annals of Family Medicine [http://www.annfammed.org/content/13/
2/107.full] study projects that the rising number of primary care 
office visits for the expanding, aging, and increasingly insured 
population will require an additional 33,000 practicing primary care 
physicians by 2035. Another study in the same journal [http://
www.annfammed.org/content/10/2/163] noted meeting the increased demand 
for primary care physicians would require a major investment in 
training. The article explicitly called for the expansion of Title VII, 
Section 747 to improve access to primary care. But we already face 
family physician shortages. A National Association of Community Health 
Centers report found that more than two-thirds of centers are actively 
recruiting for at least one family physician. [http://www.nachc.com/
client/NACHC_Workforce_Report_2016.pdf].
    The Federal Advisory Committee on Training in Primary Care Medicine 
and Dentistry noted in a report released early in 2015 [http://
www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/Reports/
eleventhreport.pdf] that the funds ``available through Title VII, Part 
C, sections 747 and 748 have decreased significantly over the past 10 
years, and are currently inadequate to support the system changes.'' 
The advisory committee recommended restoring funding to inflation-
adjusted fiscal year 2003 levels plus an additional $25 million per 
year over the next 5 years beginning in fiscal year 2017 to permit 
annual competitive grant cycles for primary care training grants.
    For decades, these grants to medical schools and residency programs 
have helped increase the number of physicians who select primary care 
specialties and who go on to work in underserved areas. A 2014 study of 
the effect of a PCTE grant addressing faculty development needs found 
that targeted Federal funding can bring about changes that contribute 
to an up-to-date, responsive primary care workforce. [http://
www.jgme.org/doi/full/10.4300/JGME-D-14-00329.1].
National Health Service Corps
    Since in 1972, the National Health Service Corps (NHSC), also 
administered by HRSA, has offered financial assistance to recruit and 
retain healthcare providers to meet the workforce needs of communities 
across the Nation designated as health professional shortage areas. The 
AAFP is committed to supporting the objectives of the NHSC in assisting 
communities in need of additional primary care physicians, and we 
support the Administration's budget request for the NHSC of $20 million 
in discretionary appropriations for fiscal year 2017.
    The Government Accountability Office (GAO-01-1042T) described the 
NHSC as ``one safety-net program that directly places primary care 
physicians and other health professionals in these medically needy 
areas.'' As the only medical society devoted solely to primary care, 
the AAFP recognizes the importance of the NHSC to the reducing 
geographic disparities in healthcare access.
    Not only does the NHSC program of placing physicians and medical 
professionals in health professional shortage areas to meet the needs 
of patients in rural and medically underserved areas, it also provides 
scholarships as incentives for medical students to enter primary care 
and to provide healthcare to underserved Americans. By addressing 
medical school debt burdens, NHSC scholarships ensure wider access to 
medical education opportunities by providing financial support for 
tuition and other education expenses, and a monthly living stipend for 
medical students committed to providing primary care in underserved 
communities of greatest need.
    More than 40,000 providers have served in the NHSC since its 
inception. In fiscal year 2015, the National Health Service Corps 
(NHSC) had a field strength of 9,683 primary care and other clinicians. 
However, the need for primary care continues to exceed the available 
investment. The AAFP recommends that the Congress provide at least the 
program level of $380 million for the NHSC in fiscal year 2017.
Agency for Healthcare Research and Quality--Primary Care Research?
    The Agency for Healthcare Research and Quality (AHRQ) is the sole 
Federal agency charged with producing research to support clinical 
decisionmaking, reduce costs, advance patient safety, decrease medical 
errors and improve healthcare quality and access. AHRQ provides the 
critical evidence reviews needed to answer questions on the common 
acute, chronic, and co-morbid conditions that family physicians 
encounter in their practices on a daily basis.
    Without AHRQ research, too little is known about appropriate care 
for real patients in primary care practices. More attention and 
research need to be directed to patients with more than one mental or 
physical health condition. In 2000, for example, an estimated 60 
million Americans had multiple chronic conditions. By 2020, that 
population is expected to grow to an estimated 81 million. Care for 
people with chronic conditions is expected to consume 80 percent of the 
resources of publicly funded health insurance programs by 2020. 
Treatment of patients with multiple chronic conditions already accounts 
for 51 percent of total health expenditures.
    Unfortunately, fiscal year 2016 cuts harmed AHRQ's efforts to 
research the care of those with multiple chronic conditions. The 
agency's research initiative aimed at optimizing care for patients with 
multiple chronic conditions halted this year due to lack of funds. 
Restoring AHRQ's funding to fiscal year 2015 levels will support 
research to provide primary care physicians the tools they need for 
evidence-based practice.
    The AAFP urges the Committee provide no less than $364 million in 
appropriated funds for AHRQ to support research vital to primary care.
                                 ______
                                 
           Prepared Statement of the American Academy of PAs
    On behalf of more than 108,500 nationally-certified PAs (physician 
assistants), the American Academy of PAs (AAPA) is pleased to submit 
comments on the fiscal year 2017 appropriations for the Departments of 
Labor, Health and Human Services, and Education and related agencies. 
AAPA respectfully requests the Subcommittee to approve funding of $280 
million for the Title VII health professions education program 
administered by the Health Resources and Services Administration (HRSA) 
and provide $12 million of the funding allocated to the Primary Care 
Training and Enhancement program (PCTE) for PA education programs. 
Additionally, AAPA supports continued funding for the National Health 
Service Corps (NHSC), community health centers (CHCs), and activities 
within the Substance Abuse and Mental Health Services Administration 
(SAMHSA) which use PAs to increase access to treatment for mental 
illnesses and substance use disorders.
PA Education and Practice
    PAs receive a broad education over approximately 27 months which 
consists of two parts. The didactic phase includes coursework in 
anatomy, physiology, biochemistry, pharmacology, physical diagnosis, 
behavioral sciences, and medical ethics. This is followed by the 
clinical phase, which includes rotations in medical and surgical 
disciplines such as family medicine, internal medicine, general 
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and 
psychiatry. Due to these demanding rotation requirements, PA students 
will have completed at least 2,000 hours of supervised clinical 
practice in various settings and locations by graduation.
    There are currently 210 accredited PA educational programs in the 
U.S., all of which are located within schools of medicine or health 
sciences, universities, teaching hospitals, and the Armed Services. The 
majority of these programs award a master's degree. PAs must pass the 
Physician Assistant National Certifying Examination and be licensed by 
a State in order to practice. The PA profession is the only medical 
profession that requires a practitioner to periodically take and pass a 
high-stakes comprehensive exam to remain certified, which PAs must do 
every 10 years. To maintain their certification, PAs must also complete 
100 hours of continuing medical education (CME) every 2 years.
    PAs practice and prescribe medication in all 50 States, the 
District of Columbia, and all U.S. territories with the exception of 
Puerto Rico. They manage the full scope of patient care, often handling 
patients with multiple comorbidities. In their normal course of work, 
PAs conduct physical exams, order and interpret tests, diagnose and 
treat illnesses, assist in surgery, and counsel on preventative 
healthcare. The rigorous education and clinical training of PAs enables 
them to be fully qualified and equipped to care for patients in every 
medical and surgical specialty and setting.
PAs and Title VII Funding
    Title VII of the Public Health Service (PHS) Act is the only 
continuing Federal funding available to PA educational programs. As a 
result, AAPA supports increased funding for Title VII, particularly for 
PA education grants funded through PCTE. These grants have proven 
successful in training new PAs; for instance, the Physician Assistant 
Training in Primary Care program supported the education of 4,390 PA 
students in the 2014-2015 school year (up from 4,071 in 2013-2014). Of 
those students, 29 percent were minorities and/or from disadvantaged 
backgrounds, and 13 percent were from rural areas. Fifty-eight percent 
of the institutions which were awarded grants through this program were 
focused on primary care, and the majority of them were in rural or 
medically underserved areas.
    Likewise, the Expansion of Physician Assistant Training (EPAT) 
program under PCTE assisted 429 students during the 2014-2015 school 
year (equal to 2013-2014), with 48 percent of these students receiving 
training in a medically-underserved area. EPAT funds support PA 
students in covering the cost of tuition, fees, and training and 
fellowships for up to 2 years. 130 students supported by these grants 
graduated in 2015--of these, 36 percent intended to practice in a 
medically underserved area, 22 percent wished to practice in a rural 
community, and 73 percent planned to work in primary care. These 
statistics clearly show that both programs have lived up to their 
intended purposes: encouraging students from under-represented groups 
to attend PA school and increasing PA practice in rural and medically 
underserved areas.
    Title VII has been instrumental in allowing increased numbers of PA 
students to pursue their education. However, this funding has also 
helped PA programs expand opportunities for clinical rotations in rural 
and medically underserved areas. This expansion benefits PA students, 
but just as important, it benefits local residents who would otherwise 
have limited access to healthcare providers. It is common for new PAs 
to remain in the area in which they completed their education, and a 
review of PA graduates from 1990-2009 showed that PAs who graduated 
from programs supported by Title VII were 47 percent more likely to 
work in rural health clinics than graduates of other programs. 
Continued funding for PA educational programs under Title VII is a win-
win scenario for underserved communities and the Nation's healthcare 
workforce.
PAs in Primary Care
    Currently, 30 percent of practicing PAs work in primary care 
settings, and PAs are one of three primary care providers along with 
physicians and nurse practitioners (NPs) who may participate in NHSC. 
There are now more than 9,200 clinicians participating in NHSC's loan 
repayment and scholarship programs--12 percent of which are PAs. In 
light of the demand for providers in the rural and medically 
underserved areas which are covered by NHSC, as well as the ongoing 
primary care provider shortage, continued funding is needed to ensure 
this important program can reach patients who lack access to care and 
help grow the next generation of healthcare providers in places where 
they are needed most.
    PAs also provide medical care in community health centers (CHCs), 
and in some cases, serve as CHC medical directors. CHCs offer cost-
effective healthcare throughout the country and serve as medical homes 
for millions of patients who live in medically underserved areas. CHCs 
provide a wide variety of healthcare services through team-based care, 
providing high quality care to CHC patients and significantly reducing 
their medical expenses by focusing on primary care services. AAPA 
supports continued funding for both NHSC and CHCs.
PAs in Mental Health and Addiction Medicine
    PAs typically work on the ``front lines'' of healthcare and they 
often treat patients who are experiencing mental illnesses or 
addiction, even when they do not specialize in these areas. AAPA is 
pleased HRSA acknowledged the role of PAs in the mental healthcare and 
addiction medicine spaces in its fiscal year 2017 budget request by 
including them in the definition of ``behavioral health workforce.'' We 
support efforts in the budget request to further integrate primary care 
and behavioral healthcare by encouraging the use of screenings, 
referrals, and warm handoffs to specialists in the same facility or via 
telemedicine services, all of which have been shown to improve patient 
outcomes and mitigate gaps in coverage caused by too few providers.
    Additionally, we are pleased both Congress and the Administration 
are focused on addressing the shortage of treatment options for 
individuals who are struggling with opioid addiction. AAPA supports 
funding for programs intended to allow additional healthcare 
providers--including PAs--to prescribe buprenorphine as a part of 
medication-assisted treatment (MAT). The Administration has proposed in 
its budget a demonstration program to gauge the feasibility of making 
this change, even though the majority of these providers, including 
PAs, can already prescribe this drug for pain management purposes. 
Instead, we believe it is necessary for Congress to pass a statutory 
fix to the Drug Addiction Treatment Act of 2000 (DATA 2000) which would 
remove the Federal ban on PAs prescribing buprenorphine for MAT. A 
demonstration project is an unnecessary step that only slows down 
bringing in more providers to assist with this crisis.
                                summary
    AAPA recognizes the fiscal challenges facing the country, and we 
understand tough choices must be made in allocating scarce Federal 
dollars to our Nation's varied priorities. Yet, HRSA has estimated 
there could be a shortage of more than 20,000 physicians by 2020. The 
PA profession continues to experience record growth--the profession 
grew 36.4 percent between 2009 and 2014--with historically high numbers 
of PAs currently practicing in the U.S. We believe better utilization 
of PAs--particularly in rural and medically underserved areas--is an 
important way to mitigate these projections and ensure all Americans 
have access to high quality healthcare. As such, AAPA urges continued 
Federal support for programs which support PAs and PA students.
    We appreciate the opportunity to present our views during the 
fiscal year 2017 appropriations process, and we welcome the opportunity 
to serve as a resource to the Subcommittee. If you have any questions, 
please do not hesitate to have your staff contact Sandy Harding, AAPA 
Senior Director of Federal Advocacy, at sharding@aapa.org.
                                 ______
                                 
        Prepared Statement of the American Academy of Pediatrics
    The American Academy of Pediatrics (AAP), a non-profit professional 
organization of 64,000 primary care pediatricians, pediatric medical 
subspecialists, and pediatric surgical specialists dedicated to the 
health, safety, and well-being of infants, children, adolescents, and 
young adults, appreciates the opportunity to submit this statement for 
the record in support of strong Federal investments in children's 
health in fiscal year 2017 and beyond. AAP urges all Members of 
Congress to put children first when considering short and long-term 
Federal spending decisions.
    As pediatricians, we not only diagnose and treat our patients, we 
also promote preventive interventions to improve overall health. 
Likewise, as policymakers, you have an integral role in ensuring the 
health of future generations through adequate and sustained funding of 
vital Federal programs. As such, we urge you to pass strong policies 
that invest in children in the earliest days of life. We implore you to 
take meaningful strides to address chronic poverty and its impacts on 
the health and well-being of American families.
    AAP supports robust funding of the Department of Health and Human 
Services (HHS) and its individual agencies which all combine to support 
important programs that ensure the health and safety of children. 
Federal funding through these agencies supports critical programs that 
address pressing public health challenges including: efforts to prevent 
infant mortality and birth defects; healthy child development; 
antimicrobial resistance and infectious diseases; emergency medical 
services for children; mental health and substance abuse prevention; 
tobacco prevention and cessation; unintentional injury and violence 
prevention; child maltreatment prevention; childhood obesity; 
environmental and chemical exposures; poison control; teen pregnancy 
prevention and family planning; health promotion in schools; and 
medical research and innovation. In addition, we would like to 
highlight our support for investments in the following crucial child 
health programs:
National Center for Birth Defects and Developmental Disabilities (CDC)
    The National Center for Birth Defects and Developmental 
Disabilities (NCBDDD) is a center within CDC that seeks to promote the 
health of babies, children, and adults and enhance the potential for 
full, productive living. According to the CDC, birth defects affect 1 
in 33 babies and are a leading cause of infant death in the United 
States. The center has done tremendous work in the way of identifying 
the causes of birth defects and developmental disabilities, helping 
children to develop and reach their full potential, and promoting 
health and well-being among people of all ages with disabilities. The 
center also conducts important research on fetal alcohol syndrome, 
infant health, autism, congenital heart defects, and other conditions 
like Tourette Syndrome, Fragile X, Spina Bifida and Hemophilia. NCBDDD 
has proven to be an asset to children and their families and supports 
extramural research in every State.
              fiscal year 2017 request: $135.610 million;
                fiscal year 2016 level: $135.610 million
Emergency Medical Services for Children (HRSA)
    Established by Congress in 1984 and last reauthorized in 2015, the 
Emergency Medical Services for Children (EMSC) Program is the only 
Federal program that focuses specifically on improving the pediatric 
components of the emergency medical services (EMS) system. EMSC aims to 
ensure that state of the art emergency medical care for the ill and 
injured child or adolescent pediatric services are well integrated into 
an EMS system backed by optimal resources; and the entire spectrum of 
emergency services is provided to children and adolescents no matter 
where they live, attend school, or travel. Gaps in providing quality 
care to children in emergencies continue to persist throughout the 
country. The EMSC program helps to address these gaps by promoting the 
quality of care provided in the pre-hospital and hospital setting, 
reducing pediatric mortalities due to serious injury, and supporting 
rigorous multi-site clinical trials through the Pediatric Emergency 
Care Applied Research Network (PECARN).
               fiscal year 2017 request: $21.213 million;
                fiscal year 2016 level: $20.162 million
National Vaccine Injury Compensation Program (HRSA)
    The National Vaccine Injury Compensation Program (NVICP) was 
established in 1988 to ensure an adequate supply of vaccines, stabilize 
vaccine costs, and establish and maintain an accessible and efficient 
forum for individuals found to be injured by certain vaccines. NVICP is 
an alternative to the traditional tort system for resolving vaccine 
injury claims and provides compensation to individuals found to have 
been injured by certain vaccines. Over the past 5 years, NVICP has seen 
a 71.6 percent rise in the number of petitions filed, due in large part 
to the flu vaccine. In fact, more than 60 percent of all petitions 
filed are now adult claims for alleged injuries from the flu vaccine. 
Though the number of petitions has risen, the number of staff has not. 
This additional funding can be used to hire more staff in order to 
expedite the processing of claims, thereby reducing the administrative 
backlog.
                fiscal year 2017 request: $9.2 million;
                  fiscal year 2016 level: $7.5 million
Lead Poisoning Prevention Program (CDC)
    There is no safe level of lead exposure, and lead damage can be 
permanent and irreversible, leading to increased likelihood for 
behavior problems, attention deficit and reading disabilities, and 
failure to graduate high school, in addition to experiencing a host of 
other impairments to their developing cardiovascular, immune, and 
endocrine systems. Today, over 500,000 children are exposed to 
unacceptably high levels of lead, and prevention efforts are critical 
to protect children from its harmful effects. The crisis in Flint, MI 
is a tragic inflection point in the ongoing issue of vulnerable 
communities facing lead exposure as one of many forms of adversity, 
with lifelong health effects. Prevention efforts like those at CDC are 
critical to addressing this problem.
                 fiscal year 2017 request: $35 million;
                  fiscal year 2016 level: $17 million
Global Immunizations (CDC)
    The U.S. Government has played a leading role in expanding access 
to immunizations around the world. Since 1988, a coordinated global 
immunization campaign has reduced the number of polio cases by more 
than 99 percent, saving more than 13 million children from paralysis 
and bringing the disease close to eradication. Investments in polio 
have also trained health workers and strengthened the surveillance 
systems, laboratory networks and biocontainment capabilities that 
helped to arrest the spread of Ebola in countries such as Nigeria and 
Uganda. Global mortality attributed to measles, one of the top five 
diseases killing children, declined by 79 percent between 2000 and 2014 
thanks to expanded immunization, saving an estimated 17.1 million 
lives. Despite this progress, the world is failing to meet most of its 
immunization goals, due in large part to weak healthcare systems and 
challenges presented by migration, rapid urbanization, conflict and 
natural disasters. The U.S. Government has a timely opportunity to 
foster interagency coordination for efficiency and impact and 
reprioritize global immunization targets, as outlined in the Global 
Vaccine Action Plan, through its updates of the U.S. National Vaccine 
Plan and the Centers for Disease Control and Prevention's (CDC's) 
Global Immunization Strategic Framework. The CDC should also maintain 
its support for country-level polio transition plans that are led by 
national governments and involve a broad range of stakeholders, which 
will be critical to ensuring continued benefits from past investments 
in the their routine immunization systems.
                fiscal year 2017 request: $224 million;
                  fiscal year 2016 level: $219 million
Title X Family Planning Program (Office of Population Affairs)
    Title X remains the sole source of dedicated Federal funding for 
family planning services for underserved populations. In fact, 91 
percent of clients had incomes at or below 250 percent of the Federal 
poverty level. Through Title X health centers, nearly five million 
women and men access life-saving healthcare such as birth control, 
cancer screenings, and testing for sexually transmitted infections. In 
addition, Title X family planning centers help to avert an estimated 
one million unintended pregnancies.
                fiscal year 2017 request: $327 million;
                  fiscal year 2016 level: $286 million
Children's Hospital Graduate Medical Education (HRSA)
    The Children's Hospital Graduate Medicaid Education (CHGME) program 
is an essential investment in our children's healthcare--in promoting 
prevention and primary care, expanding healthcare for vulnerable and 
underserved children, and ensuring access to care for all children. 
Continued funding is essential to maintaining the gains that have been 
achieved under CHGME in strengthening the pediatric workforce pipeline. 
While much has been achieved, much remains to be done, as serious 
shortages in many pediatric specialties persist. Since Congress created 
the program in 1999 to address the gap in Federal support for pediatric 
training, CHGME has increased the number of pediatric providers, 
addressed critical shortages in pediatric specialty care and improved 
children's access to care. Today, nearly half (49 percent) of all 
pediatric residents are trained by CHGME recipient hospitals. Overall, 
51 percent of pediatric specialists are trained at CHGME hospitals, and 
in many specialties, such as pediatric surgery or critical care 
medicine, over 65 percent of physicians are trained at these children's 
hospitals.
                fiscal year 2017 request: $300 million;
                  fiscal year 2016 level: $295 million
Gun Violence Prevention (CDC)
    Gun violence is a serious public health issue, and the dearth of 
research on how best to prevent related morbidity and mortality makes 
it difficult to implement a public health approach to addressing this 
public health problem. The AAP supports funding to research how gun 
violence affects children, and believes that more research into this 
matter will allow for pediatricians and others who care for children to 
better understand how to protect children from these injuries and 
deaths.
                 fiscal year 2017 request: $10 million;
                      fiscal year 2016 level: n/a
Ryan White HIV/AIDS Program Part D (HRSA)
    Part D of the Ryan White Program provides family-centered, primary 
medical care to women, infants, children, and youth living with HIV/
AIDS throughout the U.S. when payments for such services are 
unavailable from other sources. Part D improves access to primary HIV 
medical care through coordinated, comprehensive, culturally, and 
linguistically competent services. More than 90,000 women, infants, 
children, youth and family members access Ryan White Part D funded 
program services each year. In 2014, Part D provided funding to 114 
community-based organizations, safety net and university hospitals and 
health departments in 39 States and Puerto Rico. We oppose the 
President's budget proposal to consolidate funds from Parts C and D of 
the Ryan White Program. Ryan White Part D is the lifeline for women, 
infants, children, and youth living with HIV/AIDS, and has proved 
instrumental in preventing mother-to-child transmission of HIV.
                fiscal year 2017 request: $75.08 million
                (and no consolidation of parts c and d);
                 fiscal year 2016 level: $75.08 million
    On behalf of the 75 million American children and their families 
that we serve and treat, the Nation's pediatricians hope that Congress 
will respond to mounting evidence that child health has life-long 
impacts and prioritize children while determining fiscal year 2017 
Federal spending levels. Federal support for children's health programs 
will yield high returns for the American economy. Investing in children 
is not only the right thing to do for the long-term physical, mental, 
and emotional health of the population, but is imperative for the 
Nation's long-term fiscal health as well.
    We fully recognize the Nation's fiscal challenges and respect that 
difficult budgetary decisions must be made; however, we do not support 
funding decisions made at the expense of the health and welfare of 
children and families. Rather, focusing on the long-term needs of 
children and adolescents will ensure that the United States can compete 
in the modern, highly-educated global marketplace. Strong and sustained 
financial investments in children's healthcare, research, and 
prevention programs will help keep our children healthy and pay 
extraordinary dividends for years to come.
    There are many ways Congress can help meet children's needs and 
protect their health and wellbeing. Adequate funding for children's 
health programs is one of them. The American Academy of Pediatrics 
looks forward to working with Members of Congress to prioritize the 
health of our Nation's children in fiscal year 2017 and beyond. If we 
may be of further assistance please contact the AAP Department of 
Federal Affairs at pjohnson@aap.org. Thank you for your consideration.

    [This statement was submitted by Benard P. Dreyer, MD, FAAP, 
President, American Academy of Pediatrics.]
                                 ______
                                 
         Prepared Statement of the American Alliance of Museums
    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, thank you for allowing me to submit this testimony on 
behalf of our members and the Nation's larger museum community. My name 
is Laura L. Lott and I serve as President and CEO of the American 
Alliance of Museums. I respectfully request that the Subcommittee make 
a renewed investment in museums in fiscal year 2017. I urge you to 
fully fund the Office of Museum Services (OMS) at the Institute of 
Museum and Library Services (IMLS) at its authorized level of $38.6 
million.
    Before explaining this request, I want to express gratitude for the 
increase of roughly $1.2 million for OMS that was enacted last year by 
the Subcommittee in the Consolidated Appropriations Act, Public Law 
114-113. Your support for museums will help them make a bigger impact 
in communities nationwide. I know that the Subcommittee once again 
faces a very limited 302(b) allocation, and must make difficult 
decisions. In this context, however, I would posit that this extremely 
small program is a vital investment in protecting our Nation's cultural 
treasures, educating students and lifelong learners, and bolstering 
local economies around the country.
    The Alliance is proud to represent the full range of our Nation's 
museums--including aquariums, art museums, botanic gardens, children's 
museums, culturally specific museums, historic sites, history museums, 
maritime museums, military museums, natural history museums, 
planetariums, presidential libraries, science and technology centers, 
and zoos, among others--along with the professional staff and 
volunteers who work for and with museums.
    Museums are economic engines and job creators: We are proud to 
report that U.S. museums employ 400,000 people and directly contribute 
$21 billion to their local economies.
    This Subcommittee may be especially interested in the ways museums 
are providing educational programming and the results of this 
investment:
  --Museums spend more than $2 billion each year on education 
        activities; the typical museum devotes three-quarters of its 
        education budget to K-12 students, and museums receive 
        approximately 55 million visits each year from students in 
        school groups.
  --Children who visited a museum during kindergarten had higher 
        achievement scores in reading, mathematics and science in third 
        grade than children who did not. This benefit is also seen in 
        the subgroup of children who are most at risk for deficits and 
        delays in achievement.
  --According to a recent study by researchers at the University of 
        Arkansas, students who attended a field trip to an art museum 
        experienced an increase in critical thinking skills, historical 
        empathy and tolerance. For students from rural or high-poverty 
        regions, the increase was even more significant.
  --Museums help teach the State and local curriculum, adapting their 
        programs in math, science, art, literacy, language arts, 
        history, civics and government, economics and financial 
        literacy, geography and social studies.
  --Many museums are tailoring programs to serve homeschooling 
        families.
    IMLS is the primary Federal agency that supports the museum field, 
and OMS awards grants in every State to help museums digitize, enhance 
and preserve their collections; provide teacher training; and create 
innovative, cross-cultural and multi-disciplinary programs and exhibits 
for schools and the public.
    In late 2010, legislation to reauthorize IMLS for 5 years was 
enacted (by voice vote in the House and by unanimous consent in the 
Senate). The bipartisan reauthorization included several provisions 
proposed by the museum field, including enhanced support for 
conservation and preservation, emergency preparedness and response and 
statewide capacity building. The reauthorization also specifically 
supports efforts at the State level to leverage museum resources, 
including statewide needs assessments and the development of State 
plans to improve and maximize museum services throughout the State. 
That bill (Public Law 111-340) authorized $38.6 million for the IMLS 
Office of Museum Services to meet the growing demand for museum 
programs and services. The fiscal year 2016 appropriation of $31.3 
million still falls well below its recent high of $35.2 million in 
fiscal year 2010.
    While the funding increase proposed by the president's budget is 
extremely small, it reflects some priority areas in which museums could 
make a greater impact with more Federal investment, such as STEM 
education, national digital infrastructure, and early childhood-family 
learning. The budget also sets out key strategic focuses on training 
for collections care, deepening museums' role as community-centered 
organizations, and serving veterans and military families.
    We applaud the 33 Senators who wrote to you in support of fiscal 
year 2017 OMS funding, including Subcommittee members Durbin, Reed, 
Shaheen, Schatz, and Baldwin, as well as Committee members Leahy, 
Feinstein, Tester, Coons, and Murphy.
    Here are a few examples, just from 2015, of how IMLS Office of 
Museum Services funding is used:
    Early Childhood STEM Engagement and Resources--The Magic House 
(Saint Louis, MO) was awarded $150,000 to research, develop, fabricate, 
and assess a new early childhood STEM exhibit for children ages two 
through six. The 1,500-square-foot learning environment will engage 
children in self-directed activities that align with State educational 
standards for science and math. The museum will also create a new 
guided field trip program, a professional development workshop for 
educators in early childhood STEM education, and tools and resources 
for parents and caregivers.
    Collections Access and Coordination--Tennessee Aquarium 
(Chattanooga, TN) was awarded $112,078 to partner with Tennessee 
Technological University to develop the Freshwater Information Network, 
an interactive portal that combines museum records, recent survey data, 
and photo archives to provide biologists and resource managers with a 
platform for connecting and sharing the best scientific information on 
aquatic animals. This will enhance the conservation value of museum 
data by better connecting it to researchers, students, resource 
managers, conservation organizations, and others.
    Place-based Education--Port Townsend Marine Science Center (Port 
Townsend, WA) was awarded $148,346 to expand an existing initiative 
that integrates local resources with area schools in a place-based 
educational system. By orienting education around the community's 
maritime heritage, the Maritime Discovery Schools initiative is a 
comprehensive framework that increases student engagement. Through this 
grant, the museum will be able to bring in nationally recognized 
education leaders for both teacher professional development and student 
programs.
    Community Anchors--Baltimore Museum of Art (Baltimore, MD) was 
awarded $150,000 to create an exhibition and related programming that 
will use art to examine housing issues in the community. The project 
will include a traveling exhibit that will reach at least twenty-four 
neighborhoods throughout Baltimore, as well as hands-on, interactive 
workshops for Baltimore entities working to address homelessness, 
affordable housing, vacant properties, and other home-related issues. 
These organizations will gain knowledge, skills, and resources that 
enable them to integrate art-based activities into their service 
portfolio.
    It should be noted that each time a museum grant is awarded, 
additional local and private funds are also leveraged. In addition to 
the dollar-for-dollar match required of museums, grants often spur 
additional giving by private foundations and individual donors. Two-
thirds of Museums for America grantees report that their grant 
positioned the museum to receive additional private funding.
    IMLS grants to museums are highly competitive and decided through a 
rigorous, peer-review process. Even the most ardent deficit hawks ought 
to view the IMLS grant-making process as a model for the Nation. Due to 
the large number of grant applications and the limited funds available, 
many highly-rated grant proposals go unfunded each year. In 2015:
  --Only 39 percent of Museums for America project proposals were 
        funded;
  --Only 30 percent of National Leadership Grants for Museums project 
        proposals were funded;
  --Only 15 percent of Sparks! Ignition Grants for Museums project 
        proposals were funded;
  --Only 66 percent of Native American/Hawaiian Museum Services project 
        proposals were funded; and
  --Only 37 percent of African American History and Culture project 
        proposals were funded.
    Again, I know the subcommittee faces difficult decisions and am 
grateful for your previous support. If I can provide any additional 
information about the essential role of the museums in your community, 
I would be delighted to do so. Thank you once again for the opportunity 
to submit this testimony today.

    [This statement was submitted by Laura L. Lott, President and CEO, 
American Alliance of Museums.]
                                 ______
                                 
   Prepared Statement of the American Association for Cancer Research
    The American Association for Cancer Research (AACR) is the world's 
first and largest scientific organization focused on every aspect of 
high-quality, innovative cancer research. The mission of the AACR and 
its more than 35,000 members is to prevent and cure cancer through 
research, education, communication, and collaboration. The AACR calls 
on Congress to provide at least $34.5 billion for the National 
Institutes of Health (NIH) in fiscal year 2017 (a 7.7 percent 
increase), and to provide a $680 million increase above fiscal year 
2016 levels for the National Cancer Institute (NCI) to initiate the 
National Cancer ``Moonshot'' Initiative.
    Keeping the NIH and NCI on a path of sustained, robust, and 
predictable funding growth is the only way we will seize the 
unparalleled scientific opportunities in cancer research that lie 
before us, and the only way we will overcome the challenges we face in 
conquering this complex disease.
    We thank the United States Congress for its longstanding, 
bipartisan support for the NIH and for its commitment to funding cancer 
research. We especially thank Senate Appropriations Subcommittee on 
Labor, Health and Human Services (HHS), Education Chairman Roy Blunt 
and Ranking Member Patty Murray for their unwavering support for the 
NIH. We are grateful for the $2 billion increase appropriated to the 
NIH in the fiscal year 2016 omnibus spending bill, the most significant 
boost in a decade for the agency. Through Congress making medical 
research a national priority, Federal funding for this lifesaving work 
has turned a corner and is once again headed in the right direction.
A Unique Moment for Cancer: Supporting the National Cancer ``Moonshot'' 
        Initiative
    We live in an extraordinary time of scientific opportunity in the 
field of cancer research. The AACR looks forward to continuing to work 
with Congress to accelerate progress against the more than 200 diseases 
we call cancer in the next 5 to 10 years. To that end, the AACR 
strongly supports the National Cancer ``Moonshot'' Initiative. Now is 
the time for a major, new initiative cancer science that both supports 
and builds upon the strong, basic science foundation that has been 
established, and translates the exciting scientific discoveries into 
improved therapies for cancer patients. Nowhere is this more evident 
than in genomics, immuno-oncology and precision medicine, an area in 
which cancer research has been leading the way for more than a decade. 
A strong commitment to the NIH and the NCI is required to move this 
Initiative forward, in addition to continued support for existing NIH 
programs such as the Precision Medicine Initiative, which has an 
important oncology component.
Investments in Cancer Research are Saving and Improving Lives
    Significant progress has been made against cancer because of the 
decades of Federal investment in medical research and the dedicated 
work of researchers, physician-scientists, and patient advocates 
throughout the biomedical research ecosystem. Federal support has 
cultivated new and improved approaches to the prevention, detection, 
diagnosis, and treatment of cancer, and investments in basic research 
have enabled scientists to capitalize on the understanding of what 
causes and drives cancer. As is detailed in the AACR Cancer Progress 
Report 2015, support from the NIH and the NCI for basic, translational, 
and clinical research has led to decreases in the incidence of many 
cancers, cures for a number of these diseases, and higher quality and 
longer lives for many individuals whose cancers cannot yet be prevented 
or cured.
    Consider the progress made in just the last 18 months. Cancer 
patients now have access to:
  --21 new anticancer therapeutics;
  --13 new uses for previously approved cancer drugs;
  --1 new use for an imaging agent;
  --1 new cancer screening test; and,
  --1 new cancer prevention vaccine.
    One of the most exciting breakthroughs in the past 5 years in 
cancer research has been the ability to harness the power of a 
patient's own immune system to fight cancer, leading to the development 
of immunotherapies. The concept of immunotherapy as a means to target 
cancer cells is not new, but we now have achieved the ability to 
effectively translate decades of knowledge about the immune system into 
revolutionary advances in patient care. In 2015 alone, the FDA approved 
five cancer immunotherapies, including the first immunotherapies for 
lung cancer and for children with cancer.
    Perhaps most illustrative of our progress is the fact there are now 
an estimated 14.5 million cancer survivors living today in the United 
States, and this number is expected to grow to 18 million by the year 
2020. These remarkable achievements would never have been possible 
without a national commitment to funding cancer research, screening, 
and treatment programs at the NCI, NIH, and other agencies. We can 
continue to make significant advances, but only if we redouble our 
efforts to ensure the Federal resources are there to continue, and 
increase, the pace of progress.
    In addition to improving health and saving lives, cancer research 
and biomedical science also serves as one of our country's primary 
paths to innovation, global competitiveness, and economic growth. 
According to United for Medical Research, NIH funding directly and 
indirectly supported more than 402,000 jobs in 2012 alone, and 
generated more than $57.8 billion in new economic activity.
    Lastly, conquering cancer is important to the American public. In a 
poll of eligible voters commissioned by the AACR last year, more than 
80 percent of respondents recognized that progress was being made 
against cancer, but the progress was not happening quickly enough. The 
same poll showed that a majority of Americans (3 out of 4 individuals 
polled) support increasing Federal funding for medical research.
Cancer Remains a Significant Public Health Challenge
    Even in the face of the promise and progress highlighted above, 
cancer remains a formidable opponent, and the 2015 AACR poll found that 
it remains the disease Americans fear most. An estimated 1.7 million 
Americans will be diagnosed with cancer this year, and 1 in every 3 
women and 1 in every 2 men will likely develop cancer in their 
lifetimes. It is also projected that more than 595,000 people will die 
this year in the U.S. from cancers. There also are a number of cancers, 
including pancreatic, liver and lung cancers, for which the mortality 
rate remains extraordinarily high and 5-year survival rates are 
typically less than 50 percent. Further, racial and ethnic minorities, 
as well as low-income, rural and elderly populations, continue to 
suffer disproportionately in cancer incidence, prevalence, and 
mortality.
    Because of the steady increase in cancer incidence rates, which is 
due in part to our aging and growing minority populations, continuing 
and strengthening our Nation's commitment to cancer research and 
biomedical science is more critical now than ever. Increasing the 
Federal investment in cancer research and biomedical science will play 
a vital role in addressing the current challenges in cancer, while at 
the same time curbing the overall annual costs of this devastating 
disease --the economic cost of which exceeded $263 billion in 2010 and 
is expected to continue to rise as the number of cancer deaths 
increases.
Progress Against Cancer Requires a Sustained Commitment to Funding
    Our Nation's ability to realize the exciting future that awaits us 
in cancer research depends on a continued, strong commitment by 
Congress to provide sustained, robust, and predictable funding 
increases for the NIH and the NCI. We have reached an inflection point, 
where discoveries are being made at an ever-accelerating pace. These 
discoveries are saving lives and bringing enormous hope for cancer 
patients, even those with advanced disease.
    We must seize the opportunity to continue to invest in our Nation's 
medical research ecosystem by providing at least $34.5 billion for the 
NIH in fiscal year 2017. We also must make, as Vice President Biden 
said in October 2015, an ``absolute national commitment to end cancer 
as we know it today'' by funding the National Cancer Moonshot 
Initiative with the requested $680 million for the NCI.
    Fulfilling these requests will ensure we can continue to transform 
cancer care, spur innovation and economic growth, maintain our position 
as the global leader in science and medical research, and most 
importantly, bring hope to cancer patients and their loved ones 
everywhere. The AACR looks forward to working with you to ensure that 
researchers have the resources they need to continue to deliver hope to 
those who are confronting this dreaded disease.

    [This statement was submitted by Margaret Foti, PhD, MD (hc), Chief 
Executive Officer, American Association for Cancer Research.]
                                 ______
                                 
Prepared Statement of the American Association for Dental Research and 
 the Friends of National Institute of Dental and Craniofacial Research
    On behalf of the American Association for Dental Research (AADR) 
and the Friends of National Institute of Dental and Craniofacial 
Research (FNIDCR), I am pleased to submit testimony describing our 
fiscal year 2017 requests, which include at least $34.5 billion for the 
National Institutes of Health (NIH) and $452 million for the National 
Institute of Dental and Craniofacial Research (NIDCR). We are extremely 
grateful that last year Congress provided the most significant 
increases for NIH and NIDCR in over a decade.
    In the fiscal year 2017 Labor, Health and Human Services and 
Education Appropriations bill, we strongly urge Congress to build on 
this momentum and continue to provide predictable and sustainable 
funding for NIH and NIDCR this year and beyond. Increasing funding for 
NIDCR by an approximate 9 percent would allow for 6 percent real growth 
in this Institute. This increased investment will improve the oral 
health of the Nation, reduce societal costs of dental care and enhance 
the scientific evidence base for the dental profession. Specifically, 
increased funding would enable NIDCR to expand its portfolio of work on 
immunotherapies for oral cancer; research on cleft lip and cleft 
palate; and address oral health disparities among the aging population.
    NIDCR is the largest institution in the world dedicated exclusively 
to research to improve dental, oral and craniofacial health. The health 
of the mouth and surrounding craniofacial (skull and face) structures 
is central to a person's overall health and well-being. Left untreated, 
oral diseases and poor oral conditions make it difficult to eat, drink, 
swallow, smile, communicate and maintain proper nutrition. Scientists 
also have discovered important linkages between periodontal (gum) 
disease and heart disease, stroke, diabetes and pancreatic cancer.
    Investments in NIDCR funded research during the past half century 
have led to improvements in oral health for millions of Americans 
through its impact on areas such as community water fluoridation; the 
implementation of dental sealants to reduce cavities in children; and 
emerging opportunities to assess the efficacy of a human papilloma 
virus (HPV) vaccine for oral and pharyngeal cancers.
    As a result of these investments, today over 200 million Americans 
are benefiting from community water fluoridation. The percent of 
children from 1960-2000 in the U.S. without any dental decay in their 
permanent teeth has almost tripled from about 25 percent to 70 percent. 
Absent advances in oral health research in the fight against dental 
caries (tooth decay) and periodontal diseases there would be an 
additional 18.6 million Americans aged 45 or older who have lost all of 
their natural teeth. Perhaps most striking is that since the 1950s the 
total Federal investment in NIH-funded oral health research has saved 
the American public at least $3 for every $1 invested.
    Despite these improvements, however, treating oral health 
conditions remains extremely costly--with the Nation spending $113.5 
billion on dental services in 2014. While tooth decay and gum disease 
are the most prevalent threats to oral health, complete tooth loss, 
oral cancer and craniofacial congenital anomalies, such as cleft lip 
and palate, impose massive health and economic burdens on Americans. 
Below for your reference are additional examples of the important 
research supported by NIDCR to address some of these topic areas:
  --Point of Care Diagnostics: Salivary diagnostics are devices that 
        draw and analyze saliva to test for conditions and infections 
        such as HIV, human papillomavirus (HPV), substance abuse, 
        caries, periodontitis and oral cancer. As a result of research 
        supported by NIDCR over the last decade, diagnostics are also 
        showing great promise in screening for systemic diseases such 
        as diabetes, heart disease, lung cancer, ovarian cancer and 
        pancreatic cancer.
  --E-Cigarettes: According to the CDC the use of electronic cigarettes 
        has tripled among middle and high school students in 1 year. 
        Currently, there is no scientific evidence to support the 
        safety of e-cigarettes, and initial studies indicate that a 
        variety of chemicals and metal particles are produced during 
        the vaporization of nicotine and additives by these devices. To 
        help address this research gap and inform policymakers, NIDCR 
        has recently provided funding to support several new studies to 
        determine the biological and physiological effects of e-
        cigarette aerosol mixtures. This research will also include the 
        development of new tools and clinically-relevant model systems 
        to assess their effects on oral and periodontal tissues.
  --Precision Medicine: Precision medicine is an approach for disease 
        prevention and treatment that takes into account people's 
        individual variations in genes, environment and lifestyle. 
        NIDCR supports a diverse precision medicine research portfolio 
        related to diseases and conditions of the dental, oral and 
        craniofacial region including research on cancer, craniofacial 
        developmental disorders and salivary diagnostics. Further, 
        NIDCR is a leader in conducting research within networks 
        composed of individual and group dental practices where most 
        personalized oral healthcare in the U.S. is provided.
  --Oral Microbiome: NIDCR funds a community resource providing 
        comprehensive information on over 700 different microbial 
        species present in the oral cavity. To reduce and eliminate 
        oral health disparities, research on the oral microbiome in 
        children will help identify those at increased risk of 
        developing early childhood caries (tooth decay).
  --Enhanced Tissue Regeneration: NIDCR-funded scientists have 
        developed effective techniques to reduce inflammation and 
        enable the use of stem cells to form new bone and cartilage for 
        oral, dental and craniofacial purposes. The isolation and 
        enrichment of stem cells is also being explored, which would 
        further enhance the cells' ability to regrow bone and cartilage 
        at the sites where it is most needed. NIDCR recently funded a 
        tissue engineering consortium employing multidisciplinary teams 
        to translate basic research into innovative tools and 
        strategies to regenerate damaged and diseased tissues.
  --HPV-Related Oral Cancer: Scientists predict that oral cancer will 
        be the most common HPV-related cancer by 2020. In fact, HPV is 
        now causing more oral cancers than smoking. But simply 
        identifying the presence of HPV in a mouth swab or a blood draw 
        does not definitively indicate the presence of cancer. More 
        research is needed to facilitate the early detection of HPV-
        related oral cancer, as well as enhancing prevention and 
        treatment approaches.
  --Cleft Lip and/or Cleft Palate: Craniofacial anomalies such as cleft 
        lip and/or cleft palate are among the most common birth 
        defects. Both genetic and environmental factors contribute to 
        oral clefts. Studies supported by NIDCR are providing important 
        new leads about the role genetic factors and gene-environment 
        interactions play in the development of these conditions.
  --Evidenced-Based Practice: NIDCR supports a National Dental Practice 
        Based Research Network (NDPBRN) that is headquartered at the 
        University of Alabama at Birmingham School of Dentistry. A 
        dental practice-based research network is an investigative 
        union of practicing dentists and their staffs working in 
        concert with academic scientists. The network provides 
        practitioners with an opportunity to propose or participate in 
        research studies that address critical issues that affect oral 
        healthcare. These studies help to expand the profession's 
        evidence base and further refine the delivery of quality oral 
        healthcare.
  --Oral Health Disparities: NIDCR supports a broad portfolio of 
        research strategies to reduce and eliminate oral health 
        disparities. The Institute recently funded a new consortium 
        that will combine health promotion and disease prevention, 
        community-based participation and multilevel interventions to 
        take decisive action to reduce oral health disparities in 
        vulnerable children. Some of the innovative strategies include 
        the use of interactive parent text-messaging, social networks 
        and financial incentives.
  --Generating Smiles: Tremendous advances in the development of new 
        tooth-colored materials are restoring and replacing tooth 
        structure lost to dental disease. These discoveries are 
        providing the opportunity for millions of Americans to again 
        smile with comfort and confidence, greatly affecting their 
        emotional well-being, as well as their ability to chew and 
        speak.
    From a patient perspective, the research at NIDCR has impacted 
millions of patients with a wide range of conditions that impede 
quality of life, are physically debilitating, and create a major 
financial and social burden. Many complex systemic diseases, ranging 
from TMJ to autoimmune disorders, such as Behcet's, and to ectodermal 
dysplasias, have a major oral component. Through research into the 
basic science that is clearly needed to better understand these 
diseases; through the discovery of biomarkers for better diagnosis and 
clinical care; and by the development of new and improved tools for 
management and treatment, NIDCR has provided hope for these patients 
and their families that their lives will one day be improved 
substantially.
    An example of an area in which NIDCR is making huge gains is in the 
understanding of Sjogren's syndrome, a systemic autoimmune disease that 
affects about four million Americans. In addition to affecting the 
entire body and causing symptoms of extensive dryness, serious 
complications can include profound fatigue, chronic pain, major organ 
involvement, neuropathies and lymphomas. No therapies have been 
approved for the systemic complications of Sjogren's, but this is 
changing because NIDCR recently funded a major international registry 
for Sjogren's that is currently providing researchers with critical 
data and biospecimens that are being and will continue to be used by 
many researchers to expand our knowledge. The registry also is an 
example of how initial NIDCR funding can lead to a major ripple effect 
in increased research across the country, because new information 
increases interest in a disease, facilitates fertilization of ideas 
across diseases and provides a basis upon which researchers in many 
specialty areas can build. Clinical practice guidelines are currently 
being developed for many of these conditions for the first time and are 
pointing out the vast gaps in our knowledge about the lack of treatment 
for specific symptoms, which treatments are most effective, the order 
in which available treatments should be initiated and identifying which 
patients will benefit most from a specific treatment. NIDCR is leading 
the cause by proposing funding that would address the important 
questions raised and the gaps in knowledge. Only with sufficient 
funding can we build on the incredible advances being made in science 
and medicine and find answers for the problems affecting millions of 
desperate patients.
    We recognize the fiscal realities and that the overall amount of 
funding for non-defense discretionary programs is essentially level 
with the previous year, providing little opportunity for growth. 
However, the Nation's investment in overall discretionary spending is 
still inadequate to meet the most pressing needs of our country, and we 
encourage Congress to work together to develop a long-term solution to 
our debt and deficit that does not rely on cuts to these critical non-
defense discretionary spending initiatives like oral health.
    Congress has been asked to provide mandatory funding to NIH to help 
get it through this period of austerity. It is vitally important that 
no matter how NIH receives additional funding, that Congress honor the 
long-standing tradition of allocating resources equitably across the 
entire biomedical research enterprise at NIH including all of the 
Institutes and Centers. For it is important to note that a discovery in 
one area of research may benefit another. Maintaining flexibility, 
honoring the scientific peer-review process and supporting all research 
is critical to our endeavor to bring much needed cures to tens of 
millions of Americans.
    In addition to the NIH, our members care deeply about the Title VII 
Health Resources and Services Administration (HRSA) programs training 
the dental health workforce, the Centers for Disease Control and 
Prevention (CDC) Division of Oral Health's public health prevention 
efforts, data from the National Center for Health Statistics (NCHS) and 
the Agency for Healthcare Research & Quality (AHRQ). Please support our 
funding recommendations for these agencies depicted in the chart below.

----------------------------------------------------------------------------------------------------------------
                                                                                Fiscal Year
                          Agency                          ------------------------------------------------------
                                                              2012       2014       2016     2017 PBR  2017 AADR
----------------------------------------------------------------------------------------------------------------
NIH......................................................     $30.7b     $29.9b     $32.3b     $33.1b     $34.5b
NIDCR....................................................      $410m      $398m      $413m      $413m      $452m
NIMHD....................................................      $268m      $271m      $281m      $281m      $302m
AHRQ.....................................................      $405m      $371m      $334m      $364m      $364m
CDC, Oral Health.........................................       $15m       $16m       $18m       $18m       $19m
CDC, NCHS................................................      $154m      $155m      $160m      $160m      $170m
HRSA, Title VII Oral Health..............................       $32m       $32m     $35.8m     $35.8m     $35.8m
----------------------------------------------------------------------------------------------------------------

    Thank you for the opportunity to submit this testimony. We stand 
ready to answer any questions you may have.

    [This Statement was submitted by Jack Ferracane, President, 
American Association for Dental Research and the Friends of National 
Institute of Dental and Craniofacial Research.]
                                 ______
                                 
 Prepared Statement of the American Association of Colleges of Nursing
    As the national voice for baccalaureate and graduate nursing 
education, the American Association of Colleges of Nursing (AACN) 
represents over 780 schools of nursing that educate over 457,000 
students and employ more than 18,000 faculty members. Collectively, 
these institutions prepare our Nation's Registered Nurses (RNs), 
Advanced Practice Registered Nurses (APRNs), nurse faculty members, and 
nurse scientists.
    AACN respectfully requests that the subcommittee invests in 
America's health by providing $244 million for HRSA's Nursing Workforce 
Development programs (authorized under Title VIII of the Public Health 
Service Act [42 U.S.C. 296 et seq.]), at least $34.5 billion for the 
National Institutes of Health (of which, $157 million is provided for 
the National Institute of Nursing Research (NINR)),\*\ and to provide a 
discretionary appropriation for the National Health Service Corps 
(NHSC) in fiscal year 2017. These programmatic requests will ensure 
that our Nation's nurses are prepared to care for the growing number of 
patients requiring a complex range of healthcare services.
    \*\ The Ad Hoc Group for Medical Research, of which AACN is a 
member, requests at least $34.5 billion for NIH in fiscal year 2017, 
and the request level of $157 million for NINR denotes the same 
percentage increase for NIH applied to NINR.
The Role of Nurses in our Healthcare System
    As integral members of the healthcare team, and as the largest 
sector of the workforce with over three million licensed providers,\1\ 
nurses collaborate with other professions and disciplines to improve 
the quality of America's healthcare system and ensure employment of 
timely and effective services. Nurses serve in a multitude of settings, 
including hospitals, long-term care facilities, community centers, 
local and State health departments, schools, workplaces, and patient 
homes. RNs and APRNs treat and educate patients across the entire life 
span and ensure individuals follow through with care plans for optimal 
health outcomes.
---------------------------------------------------------------------------
    \1\ National Council of State Boards of Nursing. (2016). Active RN 
Licenses: A profile of nursing licensure in the U.S. as of January 23, 
2016. Retrieved from: https://www.ncsbn.org/6161.htm.
---------------------------------------------------------------------------
    It is imperative that individuals seeking to enter the nursing 
profession have the financial support to pursue advanced education. 
Federal investments are essential to ensure that a robust workforce of 
RNs and APRNs are available to provide the care that Americans need now 
and in the years to come. Moreover, the nursing pipeline will need to 
supply highly-educated nurses to respond to innovative, team-based 
delivery models that promote safe, efficient, patient-centered care.
Title VIII Programs are Improving Healthcare Today and in the Future
    For over 50 years, the Nursing Workforce Development programs have 
helped build the supply and distribution of qualified nurses to meet 
our Nation's healthcare needs. The programs strengthen nursing 
education at all levels, from entry preparation through graduate study, 
and provide support to educate nurses who practice in rural and 
medically underserved communities. Title VIII programs are essential to 
ensuring that the demand for nursing care is met by supporting future 
practicing nurses and the faculty who educate them. Moreover, the goals 
of these programs align with the Institute of Medicine's report, Future 
of Nursing: Leading Change, Advancing Health, which calls for nurses to 
``achieve higher levels of education and training through an improved 
education system that promotes seamless academic progression.'' \2\
---------------------------------------------------------------------------
    \2\ Institute of Medicine. (2010). Future of Nursing: Leading 
Change, Advancing Health Report Recommendations. Retrieved from: http:/
/www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-
Advancing-Health/Recommendations.aspx.
---------------------------------------------------------------------------
    Title VIII programs address specific aspects of the nursing 
workforce and patient populations experiencing high need, such as 
primary care, diversity in the workforce, and the aging population. The 
demand for APRNs (which include nurse practitioners (NPs), certified 
registered nurse anesthetists (CRNAs), certified nurse-midwives (CNMs), 
and clinical nurse specialists), necessitates a greater number of 
nurses with advanced degrees. According to the U.S. Bureau of Labor 
Statistics, the projected employment of NPs, CRNAs, and CNMs is 
expected to grow 31 percent between 2012-2022.\3\ APRNs are a real 
solution to the challenge of employing high-quality providers in 
primary care and underserved communities. Title VIII programs, such as 
the Advanced Education Nursing Traineeship (AENT) and Nurse Anesthetist 
Traineeship (NAT) provide nurses with exposure to populations in need 
of their care and offer potential future employment opportunities. In 
academic year 2014-2015, AENT supported 3,008 students, of which 72 
percent were trained in primary care settings.\4\ In the same academic 
year, NAT supported 3,229 students, of which 64 percent were trained in 
medically underserved areas.\4\
---------------------------------------------------------------------------
    \3\ U.S. Bureau of Labor Statistics. (2014). Occupational Outlook 
Handbook. Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners. 
Retrieved from: http://www.bls.gov/ooh/healthcare/nurse-anesthetists-
nurse-midwives-and-nurse-practitioners.htm.
    \4\ U.S. Department of Health and Human Services. (2016). Health 
Resources and Services Administration fiscal year 2016 Justification of 
Estimates for Appropriations Committees. Retrieved from: http://
hrsa.gov/about/budget/budgetjustification2017.pdf.
---------------------------------------------------------------------------
    Ensuring a diverse nursing pipeline that reflects an increasing 
diverse population is a national priority. The Title VIII Workforce 
Diversity Grants program specifically targets groups under-represented 
in nursing by awarding grants and contract opportunities. In academic 
year 2014-2015, the program supported 13,225 students and aspiring 
students and partnered with over 900 clinical training sites.\4\
    According to the U.S. Census Bureau, as of July 2013, 44.7 million 
people (14.1 percent of the Nation's population) are over the age of 
65, and by 2060, one in four U.S. residents will be 65 years of age or 
older.\5\ The IOM identified that in order to adequately meet the 
demands of our aging population, our healthcare system must address the 
severe shortage of geriatric specialists and providers with geriatric 
skills and the increased demand for chronic care management skills.\2\ 
The Title VIII Comprehensive Geriatric Education program directly 
addresses those target areas identified by the IOM. In academic year 
2014-2015, the program supported 22,743 nurses and health professionals 
who provide direct care to our Nation's elderly patients.\4\ In 
addition, these programs help prepare faculty members and provide 
continuing education those pursing advanced degrees in geriatric 
nursing.\4\
---------------------------------------------------------------------------
    \5\ United States Census Bureau. (2015). Older Americans Month: May 
2015. Retrieved from: http://www.census.gov/content/dam/Census/
newsroom/facts-for-features/2015/cb15-ff09_older_
american_month.pdf.
---------------------------------------------------------------------------
    AACN urges the subcommittee to preserve and support increased 
funding for all six of the Nursing Workforce Development programs 
including; Advance Education Nursing; Nursing Workforce Diversity; 
Nurse Education, Practice, Quality, and Retention; NURSE CORPS Loan 
Repayment and Scholarship Programs; Nurse Faculty Loan Program; and the 
Comprehensive Geriatric Education. These programs are vital investments 
to support the supply and distribution of qualified nurses to meet our 
Nation's healthcare needs.
  aacn respectfully requests $244 million for the title viii nursing 
          workforce development programs in fiscal year 2017.
National Institute of Nursing Research: Care Across the Lifespan
    As one of the 27 Institutes and Centers at the National Institutes 
of Health (NIH), NINR develops knowledge to build the scientific 
foundation for clinical practice, prevent disease and disability, 
manage and eliminate symptoms caused by illness, and enhance end-of-
life and palliative care.\6\ Broadly speaking, these priorities focus 
on reducing disease and promoting health and wellness across the entire 
lifespan. Nurse scientists, often working collaboratively with other 
health professions, generate the evidence that serves at the foundation 
of the care nurses provide. For over 30 years, NINR has examined ways 
to improve care models to deliver safe, high-quality, and cost-
effective health services to the Nation.
---------------------------------------------------------------------------
    \6\ National Institute of Nursing Research. (2012). FAQ. Retrieved 
from: https://www.ninr.nih.gov.
---------------------------------------------------------------------------
    In addition, NINR allots a generous portion of its budget towards 
training new nursing scientists, thus helping to sustain the longevity 
and success of nursing research. According to 2015-2016 AACN data, 
there are 5,035 doctoral students pursuing their PhD within AACN member 
schools, many of whom will also serve as faculty in our Nation's 
nursing schools.\7\ NINR training opportunities, such as the National 
Research Service Awards, helps new nurse researchers conduct 
independent research and collaborate in interdisciplinary research.\8\ 
These future nurse scientists will help discover new and effective care 
technologies and methods to improve patient wellness.
---------------------------------------------------------------------------
    \7\ American Association of Colleges of Nursing. (2016). 2015-2016 
Enrollment and Graduations in Baccalaureate and Graduate Programs in 
Nursing. Washington, DC.
    \8\ National Institute of Nursing Research. (2015) Extramural 
Training Opportunities. Retrieved from: https://www.ninr.nih.gov/
training/trainingopportunitiesextramural#.VwveIHpl1CA.
---------------------------------------------------------------------------
 aacn respectfully requests at least $34.5 billion for the nih (and of 
         this, $157 million for the ninr) in fiscal year 2017.
National Health Service Corps: Supporting Providers in our Nation's 
        Areas of Need
    According to HRSA, as of December of 2015 there were over 61.2 
million individuals living in Health Professional Shortage Areas 
(HPSAs).\9\ A HPSA designation denotes an area that has a shortage of 
health professionals within primary, dental, or mental healthcare.\9\ 
The NHSC Scholarship Program and Loan Repayment Program provide 
financial support to graduate health professions students and providers 
who are committed to practicing in these health disciplines and within 
HPSAs. Moreover, the NHSC attracts highly-qualified APRNs to serve in 
our Nation's underserved communities, ensuring necessary care services 
reach the millions of patients currently living HPSAs. It is imperative 
that these programs receive an annual discretionary appropriation to 
ensure stability and more importantly, to ensure those necessary care 
services are reaching our patients in all corners of the country.
---------------------------------------------------------------------------
    \9\ U.S. Health Resources and Services Administration. (2016). 
Designated Health Professional Shortage Areas Statistics. Retrieved 
from: https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/
BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false.
---------------------------------------------------------------------------
 aacn respectfully requests a discretionary appropriation for the nhsc 
                          in fiscal year 2017.
    Thank you for considering AACN's requests for fiscal year 2017. If 
you have any questions, or if AACN can be of assistance, please contact 
AACN's Senior Director of Government Affairs and Health Policy, Dr. 
Suzanne Miyamoto, at Smiyamoto@aacn.nche.edu.

    [This statement was submitted by Deborah Trautman, PhD, RN, FAAN, 
President and Chief Executive Officer, American Association of Colleges 
of Nursing.]
                                 ______
                                 
     Prepared Statement of the American Association of Colleges of 
                          Osteopathic Medicine
    The American Association of Colleges of Osteopathic Medicine 
(AACOM) strongly supports restoring funding for discretionary Health 
Resources and Services Administration (HRSA) programs to $7.48 billion; 
funding for key priorities in HRSA's Title VII programs under the 
Public Health Service Act [$59 million for the Primary Care Training 
and Enhancement (PCTE) Program; $4 million for the Rural Physician 
Training Grants; $25 million for the Centers of Excellence (COE); $20 
million for the Health Careers Opportunity Program (HCOP); $49.1 
million for the Scholarships for Disadvantaged Students (SDS) Program; 
$35 million for the Geriatrics Education Centers (GECs); and $40 
million for the Area Health Education Centers (AHECs)]; $527 million in 
mandatory funding for the Teaching Health Center Graduate Medical 
Education (THCGME) Program; funding for the National Health Service 
Corps (NHSC) through the annual appropriations process to create 
stability and sustainability for the Program; $34.5 billion for the 
National Institutes of Health (NIH); and $364 million in base 
discretionary funding for the Agency for Healthcare Research and 
Quality (AHRQ).
    AACOM represents the 31 accredited colleges of osteopathic medicine 
in the United States. These colleges are accredited to deliver 
instruction at 46 teaching locations in 31 States. In the 2015-2016 
academic year, these colleges are educating over 26,100 future 
physicians--more than 20 percent of new U.S. medical students.
    The Title VII health professions education programs, authorized 
under the Public Health Service Act and administered through HRSA, 
support the training and education of health practitioners to enhance 
the supply, diversity, and distribution of the healthcare workforce, 
acting as an essential part of the healthcare safety net and filling 
the gaps in the supply of health professionals not met by traditional 
market forces. Title VII programs are the only Federal programs 
designed to train primary care professionals in interdisciplinary 
settings to meet the needs of special and underserved populations, as 
well as increase minority representation in the healthcare workforce.
    As the demand for health professionals increases in the face of 
impending shortages, combined with faculty shortages across health 
professions disciplines, racial and ethnic disparities in healthcare, a 
growing, aging population, and the anticipated demand for increased 
access to care, these needs strain an already fragile healthcare 
system. AACOM appreciates the investments that have been made in these 
programs, and we urge the Subcommittee for inclusion and/or continued 
support for the following programs: the PCTE Program, the Rural 
Physician Training Grants, the COE, the HCOP, the SDS Program, the 
GECs, and the AHECs.
    The PCTE Program provides funding to support awards to primary care 
professionals through grants to hospitals, medical schools, and other 
entities. AACOM supports a request of $59 million to allow for a new 
fiscal year 2017 competitive grant cycle for the PCTE Program's 
physician training and development.
    The Rural Physician Training Grants will help rural-focused 
training programs recruit and graduate students most likely to practice 
medicine in underserved rural communities. Health professions workforce 
shortages are exacerbated in rural areas, where communities struggle to 
attract and maintain well-trained providers. According to HRSA, 
approximately 65 percent of primary care health professional shortage 
areas are rural. AACOM supports the inclusion of $4 million for the 
Rural Physician Training Grants.
    The COE Program is integral to increasing the number of minority 
youth who pursue careers in the health professions. AACOM supports $25 
million for the COE Program.
    The HCOP Program provides students from disadvantaged backgrounds 
with the opportunity to develop the skills needed to successfully 
compete, enter, and graduate from health professions schools. AACOM 
supports an appropriation of $20 million for HCOP.
    The SDS Program provides scholarships to health professions 
students from disadvantaged backgrounds with financial need, many of 
whom are underrepresented minorities. AACOM supports increased funding 
in the President's fiscal year 2017 budget of $49.1 million for the SDS 
Program.
    GECs are collaborative arrangements between health professions 
schools and healthcare facilities that provide training between health 
professions schools and healthcare facilities that provide the training 
of health professions students, faculty, and practitioners in the 
diagnosis, treatment, and prevention of disease, disability, and other 
health issues. AACOM supports $35 million for the GECs.
    The AHEC Program provides funding for interdisciplinary, community-
based, primary care training programs. Through a collaboration of 
medical schools and academic centers, a network of community-based 
leaders work to improve the distribution, diversity, supply, and 
quality of health personnel, particularly primary care personnel in the 
healthcare services delivery system, specifically in rural and 
underserved areas. AACOM supports an appropriation of $40 million for 
the AHEC Program in fiscal year 2017 and strongly opposes the 
elimination of this vital program in the President's fiscal year 2017 
budget.
    AACOM continues to strongly support the long-term sustainment of 
the THCGME Program, which provides funding to support primary care 
medical and dental residents training in community based settings. THCs 
currently train more than 690 medical and dental residents and are 
caring for more than half a million patients in underserved rural and 
urban communities. This program will also provide long-term benefits. 
According to HRSA, physicians who train in THCs are three times more 
likely to work in such centers and more than twice as likely to work in 
underserved areas as physicians who train in other settings. AACOM 
supports the President's fiscal year 2017 budget request for the THCGME 
Program of $527 million in mandatory funding through fiscal year 2018-
fiscal year 2020. We will continue to work with Congress to support a 
sustainable and viable funding mechanism for the continuation of this 
successful program.
    The NHSC supports physicians and other health professionals who 
practice in health professional shortage areas across the U.S. In 
fiscal year 2015, the NHSC had over 9600 primary care clinicians 
providing healthcare services. The NHSC projects that a field strength 
of more than 15,000 primary care clinicians will be in health 
professional shortage areas in fiscal year 2017. In addition, more than 
1200 students, residents, and health providers receive scholarships or 
participate in the NHSC Loan Repayment Program or Student to Service 
Loan Repayment Program to prepare to practice. While we were pleased to 
see a 2-year extension of this program in the Medicare Access and CHIP 
Reauthorization Act of 2015 (PL: 114-10) for fiscal year 2016 and 
fiscal year 2017, the appropriation committees retain primary 
responsibility for funding the administrative functions of the NHSC and 
for avoiding lapses in future years. Therefore, AACOM supports the 
stability and sustainability of this critical program by requesting 
that the Subcommittee provide a discretionary appropriation for the 
NHSC Program.
    Research funded by the NIH leads to important medical discoveries 
regarding the causes, treatments, and cures for common and rare 
diseases, as well as disease prevention. These efforts improve our 
Nation's health and save lives. To maintain a robust research agenda, 
further investment will be needed. AACOM supports an appropriation of 
$34.5 billion for NIH in fiscal year 2017, which accounts for inflation 
associated with biomedical research plus 5 percent.
    AHRQ supports research to improve healthcare quality, reduce costs, 
advance patient safety, decrease medical errors, and broaden access to 
essential services. AHRQ plays an important role in producing the 
evidence base needed to improve our Nation's health and healthcare. The 
incremental increases for AHRQ's Patient Centered Health Research 
Program in recent years will help AHRQ generate more of this research 
and expand the infrastructure needed to increase capacity to produce 
this evidence; however, more investment is needed. AACOM recommends 
$364 million in base discretionary funding, consistent with the 
President's fiscal year 2017 budget request and fiscal year 2015 
levels. This investment will preserve AHRQ's current programs while 
helping to restore its critical healthcare safety, quality, and 
efficiency initiatives.
    AACOM is grateful for the opportunity to submit its views and looks 
forward to continuing to work with the Subcommittee on these important 
matters.

    [This statement was submitted by Stephen C. Shannon, DO, MPH, 
President and Chief Executive Officer, American Association of Colleges 
of Osteopathic Medicine.]
                                 ______
                                 
 Prepared Statement of the American Association of Colleges of Pharmacy
    The American Association of Colleges of Pharmacy (AACP) is pleased 
to submit this statement for the record regarding fiscal year 2017 
funding. The 135 accredited pharmacy schools are engaged in a wide 
range of programs funded by the agencies of the Department of Health 
and Human Services (HHS) and the Department of Education. Recognizing 
the difficult task of balancing needs and expectations with fiscal 
responsibility, AACP respectfully requests that the following agencies 
and programs be funded appropriately as you undertake your 
deliberations:
  --Health Resources and Services Administration (HRSA)--$7.48 billion
    --Title VII & VIII--$524 million
  --Agency for Healthcare Research and Quality (AHRQ)--$364 million
  --Centers for Disease Control and Prevention (CDC)--$7.8 billion
    --National Center for Health Statistics (NCHS)--$172 million
  --National Institutes of Health (NIH)--$34.5 billion
    In addition, AACP respectfully requests that the Fund for the 
Improvement of Post-Secondary Education (FIPSE) be funded at $100 
million and that the maximum Pell grant appropriated discretionally be 
maintained at $4860.
              u.s. department of health and human services
    Health Resources and Services Administration (HRSA).--AACP supports 
the Friends of HRSA recommendation of $7.48 billion for HRSA in fiscal 
year 2017. Dr. Nathaniel Rickles from Northeastern University Bouve 
College of Health Sciences School of Pharmacy received $161,769 from 
HRSA to research interprofessional geriatric education for team based 
care. Faculty at schools of pharmacy are integral to the success of 
many HRSA programs conducting research on rural health delivery via 
telemedicine. Schools of pharmacy are supported by HRSA to operate some 
of the 55 Poison Control Centers. AACP supports the Bureau of Health 
Workforce (BHW) and the National Center for Health Workforce Analysis 
(NCHWA). Through the Pharmacy Workforce Center, AACP joins HRSA-funded 
efforts to compile national health workforce statistics to better 
inform future health professions workforce needs in the United States. 
AACP supports the Health Professions and Nursing Education Coalition 
(HPNEC) recommendation of $524 million for Title VII and VIII programs 
in fiscal year 2016. AACP member institutions are active participants 
in BHW programs. Schools of pharmacy participate in Title VII programs, 
including Geriatric Education Centers and Area Health Education Centers 
(AHEC). These community-based, interprofessional programs are essential 
for supporting innovative educational models addressing national issues 
at the local level through team-based, patient-centered care. They 
serve as valuable experiential education sites for student pharmacists 
and other health professions students. Pharmacy schools are eligible to 
participate in the Centers of Excellence program and the Scholarships 
for Disadvantaged Students program, to increase the number of 
underserved individuals attending health professions schools and 
increase minority health workforce representation. Colleges of 
pharmacy, including Xavier University of Louisiana, develop and 
maintain centers of excellence in diversity supported by HRSA Centers 
of Excellence grants.
    Agency for Healthcare Research and Quality (AHRQ).--AACP supports 
the Friends of AHRQ recommendation of $375 million in budget authority 
for AHRQ programs in fiscal year 2017. Pharmacy faculty are strong 
partners with the Agency for Healthcare Research and Quality (AHRQ). 
Drs. Margie E. Snyder, Karen Hudmon and Michael Murray received 
$144,197 from PHS-AHRQ for optimizing medication therapy management for 
chronically ill Medicare Part D beneficiaries.
    Centers for Disease Control and Prevention (CDC).--AACP supports 
the CDC Coalition's recommendation of $7.8 billion for CDC core 
programs in fiscal year 2017 and the Friends of NCHS recommendation of 
$172 million for the National Center for Health Statistics. Information 
from the NCHS is essential for faculty engaged in health services 
research and for the professional education of the pharmacist. The 
educational outcomes for pharmacy graduates include those related to 
public health. The opportunity for pharmacists to identify potential 
public health threats through regular interaction with patients 
provides public health agencies with on-the-ground epidemiologists 
providing risk identification measures when patients seek medications 
associated with preventing and treating travel-related illnesses. 
Pharmacy faculty are engaged in CDC-supported research and activities 
including delivery of immunizations, integration of pharmacogenetics in 
the pharmacy curriculum, inclusion of pharmacists in emergency 
preparedness, and the Million Hearts campaign. Dr. Johnnye Lewis at the 
University of New Mexico received $1,000,000 to study uranium exposure 
in the Navajo nation.
    National Institutes of Health.--AACP supports the Adhoc Group for 
Medical Research recommendation of at least $34.5 billion for NIH 
funding in fiscal year 2017. Pharmacy faculty are supported in their 
research by nearly every institute at the NIH. The NIH-supported 
research at AACP member institutions spans the full spectrum from the 
creation of new knowledge through the translation of that new knowledge 
to providers and patients. In fiscal year 2014, pharmacy faculty 
researchers received nearly $343 million in grant support from the NIH. 
Academic pharmacy sustains a strong commitment to increasing the number 
of biomedical researchers. Dr. Jim Wang at the University of Illinois 
received $404,011 to study protein kinase mechanisms for chronic pain 
in sickle cell disease.
                      u.s. department of education
    The Department of Education supports the education of healthcare 
professionals by assuring access to education through student financial 
aid programs, educational research allows faculty to determine 
improvements in educational approaches; and the oversight of higher 
education through the approval of accrediting agencies. AACP supports 
the Student Aid Alliance's recommendations to maintain the 
discretionary contribution to the $4860 maximum Pell grant. Admission 
to a pharmacy professional degree program requires at least 2 years of 
undergraduate preparation. Student financial assistance programs are 
essential to assuring student have access to undergraduate, 
professional and graduate degree programs. AACP recommends a funding 
level of at least $100 million for the Fund for the Improvement of 
Post-Secondary Education (FIPSE) as this is the only Federal program 
that supports the development and evaluation of higher education 
programs that can lead to improvements in higher education quality.

    [This statement was submitted by William Lang, Senior Policy 
Advisor, American Association of Colleges of Pharmacy.]
                                 ______
                                 
    Prepared Statement of the American Association of Immunologists
    The American Association of Immunologists (AAI), the world's 
largest professional society of research scientists and physicians who 
study the immune system, respectfully submits this testimony regarding 
fiscal year 2017 appropriations for the National Institutes of Health 
(NIH). AAI recommends an appropriation of at least $35 billion for NIH 
for fiscal year 2017 to fund new and ongoing research, stabilize and 
strengthen the biomedical research enterprise, and encourage the 
world's most talented scientists, trainees, and students to pursue 
biomedical research careers in the United States.
           the importance of immunology and the immune system
    ``[I]mmunology kind of transcends it all.'' So said Senator Richard 
Shelby (R-AL), a senior member of the Senate Appropriations Committee 
and its subcommittee on Labor, Health and Human Services, Education, 
and Related Agencies, during the committee's April 2, 2014, hearing on 
the fiscal year 2015 budget request for NIH.\1\ What Senator Shelby 
correctly noted is the extraordinary importance--and nearly unlimited 
potential--of the immune system. And the more we learn, the more we 
realize that what was true in 2014 is even more true today.
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    \1\ Http://www.appropriations.senate.gov/hearings/fy15-nih-budget-
request.
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    As the body's primary defense against viruses, bacteria, parasites 
and carcinogens, the immune system can protect its host from a wide 
range of infectious diseases and from many chronic illnesses, including 
cancer, Alzheimer's disease, and cardiovascular disease. But the immune 
system can underperform, leaving the body vulnerable to infections such 
as influenza, Zika virus, HIV/AIDS, tuberculosis, malaria, and the 
common cold. It can also become overactive, attacking normal organs and 
tissues, and causing autoimmune diseases including allergy, asthma, 
inflammatory bowel disease, lupus, multiple sclerosis, rheumatoid 
arthritis, and type 1 diabetes. Understanding how the immune system 
works and how it may be harnessed to help prevent, treat, or cure 
disease: this is the mission of immunologists as we strive to protect 
people and animals from chronic and acute diseases and from natural or 
man-made infectious organisms (including plague, smallpox and anthrax) 
that could be used as bioweapons.
     recent immunological advances provide great hope for tomorrow
New Potential Treatments for Hard-to-Treat Cancers
    Cancer immunotherapies mobilize an individual's immune system to 
destroy cancer cells without harming healthy cells. Less toxic than 
standard chemotherapy and radiation, immunotherapies have already been 
approved for some cancers, including lymphoma and melanoma. Until 
recently, however, immunotherapy had not shown great efficacy against 
some hard-to-treat cancers, like non-small cell lung cancer. The 2015 
approval of Nivolumab and Pembrolizumab (anti PD-1 therapy) \2\ was, 
therefore, a landmark event for the treatment of lung cancer. Because 
this therapy specifically blocks the PD-1/PD-L1 pathway that prevents T 
cells from killing tumor cells, it improves the immune system's ability 
to combat cancer.\3\
---------------------------------------------------------------------------
    \2\ Http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
ucm466576.htm;
http://www.fda.gov/Drugs/InformationOnDrugs/ApprovedDrugs/
ucm465650.htm.
    \3\ Chen, L and Han, X. 2015. Anti--PD-1/PD-L1 therapy of human 
cancer: past, present, and future. The Journal of Clinical 
Investigation 125: 3384-3391.
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Using the Immune System to Control HIV Infection in HIV-Positive 
        Patients
    A recent NIH-funded study demonstrated how the immune systems of 
HIV-positive ``elite controllers,'' people whose natural immunity 
controls HIV infection, produce antibodies that have the potential to 
be developed to treat others infected with HIV.\4\ In this Phase I 
clinical trial, copies of the protective antibodies produced by elite 
controllers successfully reduced HIV viral levels when transferred to 
other HIV-positive patients. This method of harnessing ``broadly 
neutralizing antibodies'' \5\ can potentially be used more widely 
against other viruses, protecting whole populations from dangerous 
infections until vaccines are available.
---------------------------------------------------------------------------
    \4\ Caskey, M. et al. 2015. Viraemia suppressed in HIV-1 infected 
humans by broadly neutralizing antibody 3BNC117. Nature 522: 487.
    \5\ ``In first human study, new antibody therapy shows promise in 
suppressing HIV Infection.'' Newswire. Http://newswire.rockefeller.edu/
2015/04/08/in-first-human-study-new-antibody-therapy-shows-promise-in-
suppressing-hiv-infection/.
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Preventing and Treating Emerging Infectious Diseases
    With increased globalization and worldwide travel, emerging 
infectious diseases can create a serious health threat locally as well 
as an international public health crisis, as evidenced by the recent 
Ebola virus epidemic in Africa, outbreak of dengue fever in Hawaii,\6\ 
and Zika virus outbreaks in Latin America, Central America, the 
Caribbean, and the U.S. territories.\7\ It is essential, therefore, 
that NIH continually fund basic research on pathogens and the host 
response to pathogens, as well as potential medical interventions, in 
order to be able to prevent and respond to both current and future 
epidemics.
---------------------------------------------------------------------------
    \6\ Dengue ``is endemic in Puerto Rico and in many popular tourist 
destinations in Latin America, Southeast Asia and the Pacific 
islands.'' Http://www.cdc.gov/dengue/.
    \7\ Http://www.cdc.gov/zika/geo/index.html.
---------------------------------------------------------------------------
    Because NIH has long supported such basic and clinical research, we 
have made progress on a vaccine against the Ebola virus,\8\ which 
killed more than 11,300 people in West Africa in 2014-2015.\9\ Last 
month, NIH announced that an experimental vaccine against dengue fever 
had protected all of its recipients, an important advance in the fight 
against a disease that infects 390 million people worldwide each 
year.\10\ And because the dengue virus is in the same virus family as 
the Zika virus, scientists are applying what they have learned from 
dengue to their efforts to develop a vaccine for Zika,\11\ which is 
linked to both microcephaly and Guillain-Barre syndrome.\12\ Zika is of 
increasing international concern due to a recent surge in the number of 
cases, particularly in Brazil, where more than 3,000 newborns have been 
affected thus far.\13\
---------------------------------------------------------------------------
    \8\ Http://www.niaid.nih.gov/news/newsreleases/Archive/2003/pages/
ebolahumantrial.aspx;
https://www.niaid.nih.gov/news/newsreleases/2016/Pages/CROI-ZMapp.aspx.
    \9\ Http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-
counts.html.
    \10\ Http://www.nih.gov/news-events/news-releases/experimental-
dengue-vaccine-protects-all-recipients-virus-challenge-study. The 
experimental vaccine was developed primarily by NIH scientists at the 
NIAID Laboratory of Infectious Diseases, with assistance from 
scientists at the FDA Center for Biologics Evaluation and Research.
    \11\ Ibid.
    \12\ Http://www.cdc.gov/zika/about/gbs-qa.html; http://www.cdc.gov/
zika/pregnancy/question-answers.html.
    \13\ Maron, Dina Fine. Surge in Babies Born with Small Heads. 
Scientific American. Http://www.scientificamerican.com/article/what-s-
behind-brazil-s-alarming-surge-in-babies-born-with-small-heads/.
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            nih's essential role in the research enterprise
    As the Nation's main funding agency for biomedical and behavioral 
research, NIH supports the work of ``more than 300,000 members of the 
research workforce, including 35,000 principal investigators'' located 
at universities, medical schools, and other research institutions in 
all 50 States and the District of Columbia. \14\ More than 80 percent 
of its budget supports the work of these ``extramural'' scientists 
through almost 50,000 grants, while about 10 percent of the budget 
supports roughly 6,000 ``intramural'' researchers and clinicians who 
work at NIH research and clinical facilities in Maryland, Arizona, 
Massachusetts, Michigan, Montana and North Carolina.\15\
---------------------------------------------------------------------------
    \14\ Http://www.nih.gov/sites/default/files/about-nih/strategic-
plan-fy2016-2020-508.pdf;
http://www.nih.gov/about-nih/what-we-do/budget.
    \15\ Ibid; https://www.training.nih.gov/resources/intro_nih/
other_locations.
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    NIH funding strengthens the economies of the communities and States 
where these researchers live and work; in 2014, it supported more than 
400,000 jobs across the United States.\16\
---------------------------------------------------------------------------
    \16\ Ehrlich, Everett. NIH's Role in Sustaining the U.S. Economy. 
United for Medical Research, http://www.unitedformedicalresearch.com/
wp-content/uploads/2015/10/UMR-NIH-FY2014-Economic-Update-10.01.15.pdf.
---------------------------------------------------------------------------
    NIH also provides irreplaceable scientific leadership to the 
national and international biomedical research communities. NIH 
personnel and policies are essential to the coordination of scientists 
and scientific projects from academia and government,\17\ and to 
fostering important collaborations with industry, whose own advances in 
drug and medical device development rely heavily on NIH-funded 
discoveries.\18\
---------------------------------------------------------------------------
    \17\ AAI strongly opposes policies that limit government 
scientists' ability to attend privately sponsored scientific meetings 
and conferences and believes that ``the rules have . . . made 
government scientists feel cut off from the rest of the scientific 
community, wreaked havoc with their ability to fulfill professional 
commitments, and undermined the morale of some of the government's 
finest minds.'' Written Testimony (Amended) of Lauren G. Gross, J.D., 
on behalf of The American Association of Immunologists (AAI), Submitted 
to the Senate Homeland Security and Governmental Affairs Committee for 
the Hearing Record of January 14, 2014: ``Examining Conference and 
Travel Spending Across the Federal Government'' (http://aai.org/
Public_Affairs/Docs/2014/AAI_Testimony_to_Senate_HSGAC_01142014.pdf).
    \18\ According to Dr. Marc Tessier-Lavigne, former chief scientific 
officer at Genentech and current president of The Rockefeller 
University, ``if we invest adequately in basic biomedical research, we 
can create the knowledge that will in turn trigger private-sector 
investment to develop therapies to conquer such diseases . . . . For 
every drug approved by the FDA at the top of the pyramid, the 
foundation consists of dozens of insights into diseases generated over 
a period of decades, largely through Federal funding of basic, 
knowledge-driven research.'' Written Testimony of Dr. Marc Tessier-
Lavigne, Submitted to the House Committee on Science, Space, and 
Technology, Subcommittee on Research and Technology, for the Hearing 
Record of July 17, 2014: ``Policies to Spur Innovative Medical 
Breakthroughs from Laboratories to Patients.'' Https://
science.house.gov/sites/republicans.science.house.gov/files/documents/
HHRG-113-SY14-WState-MTessierLavigne-20140717.pdf.
---------------------------------------------------------------------------
   recent funding boost eased, but did not eliminate, erosion of nih 
                            purchasing power
    A $2 billion boost in NIH funding in fiscal year 2016, generously 
provided by this subcommittee and the Congress, has helped restore some 
of the loss in NIH's purchasing power that had resulted from years of 
inadequate budgets eroded further by biomedical research inflation.\19\ 
Although AAI is extremely grateful for this funding increase, NIH's 
purchasing power remains more than 19 percent below what it was in 
fiscal year 2003.\20\ In addition to limiting the advancement of 
important research and the potential treatments or cures that might 
have been discovered, these funding constraints continue to have a 
deleterious impact on many productive researchers: some are being 
forced to lay off staff or close their labs entirely, while others are 
moving overseas, where support for biomedical research continues to 
grow.\21\ Perhaps most importantly, inadequate funding is deterring 
many of our most promising young people from pursuing careers in 
biomedical research; they witness their mentors' unrelenting and time 
consuming search for funding, rather than their conduct of research or 
teaching of the Nation's future researchers, doctors, inventors and 
innovators. Regular and predictable funding increases for NIH would 
provide the stability that science, scientists, and the scientific 
enterprise urgently need.
---------------------------------------------------------------------------
    \19\ Federation of American Societies for Experimental Biology. 
U.S. Biological and Medical Research Fell for Over a Decade. Http://
www.faseb.org/Portals/2/PDFs/opa/2016/
Factsheet_Restore_NIH_Funding.pdf.
    \20\ Federation of American Societies for Experimental Biology. NIH 
Research Funding Trends: fiscal year 1995-2015. Http://www.faseb.org/
Science-Policy-and-Advocacy/Federal-Funding-Data/NIH-Research-Funding-
Trends.aspx
    \21\ Moses, H., et al. 2015. The Anatomy of Medical Research: U.S. 
and International Comparisons. JAMA 313: 174-189. According to Moses et 
al., while U.S. funding for biomedical and health services research 
increased at a rate of 6 percent per year from 1994-2004, it decreased 
to just 0.8 percent annually from 2004-2012.
---------------------------------------------------------------------------
                               conclusion
    AAI greatly appreciates the subcommittee's strong bipartisan 
support for NIH and biomedical research, and for the reasons described 
above, recommends an appropriation of at least $35 billion for NIH in 
fiscal year 2017.

    [This statement was submitted by Clifford V. Harding, M.D., Ph.D., 
American Association of Immunologists.]
                                 ______
                                 
  Prepared Statement of the American Association of Nurse Anesthetists

                                 FISCAL YEAR 2017 APPROPRIATIONS REQUEST SUMMARY
----------------------------------------------------------------------------------------------------------------
                                           Fiscal year 2015         Fiscal year 2016      AANA fiscal year 2017
                                               enacted                  enacted                  request
----------------------------------------------------------------------------------------------------------------
HHS/HRSA/BHPr Title 8 Advanced         No report language.....  No report language.....  Report language
 Education Nursing, Nurse Anesthetist                                                     supporting at least $5
 Education Reserve.                                                                       million for nurse
                                                                                          anesthesia
                                                                                          education
 
Total for Advanced Education Nursing,  $63.581................  $64.581................  $66 million for
 from Title 8.                                                                            advanced education
                                                                                          nursing
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Title 8 HRSA BHPr Nursing Education    $231.622...............  $229.472...............  $244
 Programs.
----------------------------------------------------------------------------------------------------------------

About the American Association of Nurse Anesthetists (AANA) and 
        Certified Registered Nurse Anesthetists (CRNAs)
    The AANA is the professional association for more than 49,000 CRNAs 
and student nurse anesthetists, representing over 90 percent of the 
nurse anesthetists in the United States. Today, CRNAs deliver 
approximately 40 million anesthetics to patients each year in the U.S. 
CRNA services include administering the anesthetic, monitoring the 
patient's vital signs, staying with the patient throughout the surgery, 
and providing acute and chronic pain management services. CRNAs provide 
anesthesia for a wide variety of surgical cases and in some States are 
the sole anesthesia providers in almost 100 percent of rural hospitals, 
affording these medical facilities obstetrical, surgical, and trauma 
stabilization, and pain management capabilities. CRNAs work in every 
setting in which anesthesia is delivered, including hospital surgical 
suites and obstetrical delivery rooms, ambulatory surgical centers 
(ASCs), pain management units and the offices of dentists, podiatrists 
and plastic surgeons.
    Nurse anesthetists are experienced and highly trained anesthesia 
professionals whose record of patient safety is underscored by 
scientific research findings. The landmark Institute of Medicine report 
To Err is Human found in 2000 that anesthesia was 50 times safer then 
than in the 1980s. (Kohn L, Corrigan J, Donaldson M, ed. To Err is 
Human. Institute of Medicine, National Academy Press, Washington DC, 
2000.) Though many studies have demonstrated the high quality of nurse 
anesthesia care, the results of a study published in Health Affairs in 
2010 led researchers to recommend that costly and duplicative 
supervision requirements for CRNAs be eliminated. Examining Medicare 
records from 1999-2005, the study compared anesthesia outcomes in 14 
States that opted-out of the Medicare physician supervision requirement 
for CRNAs with those that did not opt out. (To date, 17 States have 
opted-out.) The researchers found that anesthesia has continued to grow 
more safe in opt-out and non-opt-out States alike. (Dulisse B, Cromwell 
J. No Harm Found When Nurse Anesthetists Work Without Supervision By 
Physicians. Health Aff. 2010;29(8):1469-1475.)
    CRNAs provide the lion's share of anesthesia care required by our 
U.S. Armed Forces through active duty and the reserves, staffing ships, 
remote U.S. military bases, and forward surgical teams without 
physician anesthesiologist support. In addition, CRNAs predominate in 
rural and medically underserved areas, and where more Medicare patients 
live (Government Accountability Office. Medicare and private payment 
differences for anesthesia services. GAO-07-463, Washington DC, Jul. 
27, 2007. Http://www.gao.gov/products/GAO-07-463.) (Liao CJ, Quraishi 
JA, Jordan, LM. Geographical Imbalance of Anesthesia Providers and its 
Impact on the Uninsured and Vulnerable Populations. Nurs Econ. 2015; 
33(5):263-270.)
Importance of and Request for HRSA Title 8 Nurse Anesthesia Education 
        Funding
    Our profession's chief request of the Subcommittee is for $5 
million to be reserved for nurse anesthesia education and $66 million 
for advanced education nursing from the HRSA Title 8 program, out of a 
total Title 8 budget of $244 million. We request that the Report 
accompanying the fiscal year 2017 Labor-HHS-Education Appropriations 
bill include the following language: ``Within the allocation, the 
Committee encourages HRSA to allocate funding of at least $5 million 
for nurse anesthetist education.'' This funding request is justified by 
the safety and value proposition of nurse anesthesia, and by 
anticipated growth in demand for CRNA services as baby boomers retire, 
become Medicare eligible, and require more healthcare services. In 
making this request, we associate ourselves with the request made by 
The Nursing Community with respect to Title 8 and the National 
Institute of Nursing Research (NINR) at the National Institutes of 
Health.
    The Title 8 program, on which we will focus our testimony, is 
strongly supported by members of this Subcommittee in the past, and is 
an effective means to help address nurse anesthesia workforce demand. 
In expectation for dramatic growth in the number of U.S. retirees and 
their healthcare needs, funding the advanced education nursing program 
at $66 million is necessary to meet the continuing demand for nursing 
faculty and other advanced education nursing services throughout the 
U.S. The program funds competitive grants that help enhance advanced 
nursing education and practice, and traineeships for individuals in 
advanced nursing education programs. It also targets resources toward 
increasing the number of providers in rural and underserved America and 
preparing providers at the master's and doctoral levels, thus 
increasing the supply of clinicians eligible to serve as nursing 
faculty, a critical need.
    Demand remains high for CRNA workforce in clinical and educational 
settings, driven by an aging population requiring more care, and a 
growing percentage of surgical procedures requiring anesthesia being 
offered in outpatient settings. The supply of clinical providers has 
increased in recent years, stimulated by increases in the number of 
CRNAs trained. From 2006-2015, the annual number of nurse anesthesia 
educational program graduates increased from 1,900 to 2,468, according 
to the Council on Accreditation of Nurse Anesthesia Educational 
Programs (COA). The number of accredited nurse anesthesia educational 
programs grew from 105 to 115 during this time, and is currently 118. 
We anticipate increased demand for anesthesia services as the 
population ages, the number of clinical sites requiring anesthesia 
services grows, and a portion of the CRNA workforce retires.
    The capacity of our nurse anesthesia educational programs to 
educate qualified applicants is limited by the number of faculty, the 
number and characteristics of clinical practice educational sites, and 
other factors--and they continue turning away hundreds of qualified 
applicants. A qualified applicant to a CRNA program is a bachelor's 
educated registered nurse who has spent at least 1 year serving in an 
acute care healthcare practice environment. They are prepared in nurse 
anesthesia educational programs located all across the country, 
including Connecticut, Kentucky, Maryland, Mississippi, Missouri, New 
York, and Washington. To meet the nurse anesthesia workforce challenge, 
the capacity and number of CRNA schools must continue to grow and 
modernize with the latest advancements in simulation technology and 
distance learning consistent with improving educational quality and 
supplying demand for highly qualified providers. With the help of 
competitively awarded grants supported by Title 8 funding, the nurse 
anesthesia profession is making significant progress, but more is 
required.
    This progress is extremely cost-effective from the standpoint of 
Federal funding. Anesthesia can be provided by nurse anesthetists, 
physician anesthesiologists, or by CRNAs and anesthesiologists working 
together. Of these, the nurse anesthesia practice model is by far the 
most cost-effective, and ensures patient safety. (Hogan P et al. Cost 
effectiveness analysis of anesthesia providers. Nursing Economic$, Vol. 
28 No. 3, May-June 2010, p. 159 et seq.) Nurse anesthesia education 
represents a significant educational cost-benefit for competitively 
awarded Federal funding in support of CRNA educational programs.

    [This statement was submitted by Juan Quintana, DNP, MHS, CRNA, 
President, American Association of Nurse Anesthetists.]
                                 ______
                                 
        Prepared Statement of the American College of Physicians
    The American College of Physicians (ACP) is pleased to submit the 
following statement for the record on its priorities, as funded under 
the U.S. Department of Health & Human Services, for fiscal year 2017. 
ACP is the largest medical specialty organization and the second-
largest physician group in the United States. ACP members include 
143,000 internal medicine physicians (internists), related 
subspecialists, and medical students. Internal medicine physicians are 
specialists who apply scientific knowledge and clinical expertise to 
the diagnosis, treatment, and compassionate care of adults across the 
spectrum from health to complex illness. As the Subcommittee begins 
deliberations on appropriations for fiscal year 2017, ACP is urging 
funding for the following proven programs to receive appropriations 
from the Subcommittee:
  --Health Resources Services Administration (HRSA), $7.48 billion;
  --Title VII, Section 747, Primary Care Training and Enhancement, 
        HRSA, at no less than $71 million;
  --National Health Service Corps (NHSC), HRSA, $380 million in total 
        program funding, including at least $20 million through 
        discretionary appropriations;
  --Agency for Healthcare Research and Quality (AHRQ), $364 million.
    The United States is facing a shortage of physicians in key 
specialties, notably in general internal medicine and family medicine--
the specialties that provide primary care to most adult and adolescent 
patients. With enactment of the Affordable Care Act (ACA), the 
Congressional Budget Office has estimated, as of March 2016, the demand 
for primary care services will increase with the addition of 38 million 
Americans receiving access to health insurance, including an additional 
19 million under Medicaid/CHIP, by 2026. With increased demand, current 
projections indicate there will be a shortage of 14,900 to 35,600 
primary care physicians by 2025. (IHS Inc., prepared for the 
Association of American Medical Colleges. 2016 Update, The Complexities 
of Physician Supply and Demand: Projections from 2013 to 2025. 
April 5, 2016. Accessed at: https://www.aamc.org/download/458082/data/
2016_
complexities_of_supply_and_demand_projections.pdf). HRSA is responsible 
for improving access to health-care services for people who are 
uninsured, isolated or medically vulnerable. Without critical funding 
for vital workforce programs, this physician shortage will only grow 
worse. A strong primary care infrastructure is an essential part of any 
high-functioning healthcare system, with over 100 studies showing 
primary care is associated with better outcomes and lower costs of care 
(http://www.acponline.org/advocacy/where_we_stand/policy/
primary_shortage.pdf). Therefore we urge the Subcommittee to provide 
$7.48 billion for discretionary HRSA programs for fiscal year 2017 to 
improve the care of medically underserved Americans by strengthening 
the health workforce.
    The health professions' education programs, authorized under Title 
VII of the Public Health Service Act and administered through (HRSA), 
support the training and education of healthcare providers to enhance 
the supply, diversity, and distribution of the healthcare workforce, 
filling the gaps in the supply of health professionals not met by 
traditional market forces, and are critical in helping institutions and 
programs respond to the current and emerging challenges of ensuring 
that all Americans have access to appropriate and timely health 
services. Within the Title VII program, we urge the Subcommittee to 
fund the Section 747, Primary Care Training and Enhancement program at 
$71 million, in order to maintain and expand the pipeline for 
individuals training in primary care. The Section 747 program is the 
only source of Federal training dollars available for general internal 
medicine, general pediatrics, and family medicine. For example, general 
internists, who have long been at the frontline of patient care, have 
benefitted from Title VII training models emphasizing interdisciplinary 
training that have helped prepare them to work with other health 
professionals, such as physician assistants, patient educators, and 
psychologists. Without a substantial increase in funding, for the sixth 
year in a row, HRSA will not be able to carry out a competitive grant 
cycle for physician training; the Nation needs new initiatives 
supporting expanded training in multi-professional care, the patient-
centered medical home, and other new competencies required in our 
developing health system.
    The College urges $380 million in total program funding for the 
National Health Service Corps (NHSC), as requested in the President's 
fiscal year 2017 budget; this amount includes $310 million in existing 
mandatory funds under current law, $20 million in discretionary 
spending through new budget authority, and $50 million in new mandatory 
funding. Since the enactment of the ACA, the NHSC has awarded over $1.5 
billion in scholarships and loan repayment to healthcare professionals 
to help expand the country's primary care workforce and meet the 
healthcare needs of underserved communities across the country. With a 
field strength of 9,700 primary-care clinicians, NHSC members are 
providing culturally competent care to over 10 million patients at 
16,000 NHSC-approved healthcare sites in urban, rural, and frontier 
areas. The increase in funds would expand NHSC field strength to over 
10,150 and would serve the needs of more than 10.7 million patients, 
helping to address the health professionals' workforce shortage and 
growing maldistribution. The programs under NHSC have proven to make an 
impact in meeting the healthcare needs of the underserved, and with 
increased appropriations, they can do more. For fiscal year 2016, the 
NHSC's funding situation was particularly dire and faced a funding 
cliff because its mandatory funding was set to expire and was without 
any budget authority to at least temporarily continue operations with 
discretionary funding. The College was therefore pleased that the 
Medicare Access and CHIP Reauthorization Act, H.R. 2, continued the 
NHSC at its fiscal year 2015 funding level for fiscal year 2016 and 
fiscal year 2017 (through an extension of mandatory resources). 
However, with fiscal year 2017 being the last year of enacted dedicated 
mandatory funding, ACP believes that the Corps urgently needs 
discretionary funding to be able continue its operations should it face 
another mandatory funding cliff.
    The Agency for Healthcare Research and Quality (AHRQ) is the 
leading public health service agency focused on healthcare quality. 
AHRQ's research provides the evidence-based information needed by 
consumers, clinicians, health plans, purchasers, and policymakers to 
make informed healthcare decisions. The College is dedicated to 
ensuring AHRQ's vital role in improving the quality of our Nation's 
health and recommends a budget of $364 million, restoring the agency to 
its fiscal year 2015 enacted level after a cut in fiscal year 2016. 
This amount will allow AHRQ to help providers help patients by making 
evidence-informed decisions, fund research that serves as the evidence 
engine for much of the private sector's work to keep patients safe, 
make the healthcare marketplace more efficient by providing quality 
measures to health professionals, and, ultimately, help transform 
health and healthcare.
    In conclusion, the College is keenly aware of the fiscal pressures 
facing the Subcommittee today, but strongly believes the United States 
must invest in these programs in order to achieve a high performance 
healthcare system and build capacity in our primary care workforce and 
public health system. The College greatly appreciates the support of 
the Subcommittee on these issues and looks forward to working with 
Congress as you begin to work on the fiscal year 2017 appropriations 
process.

                                 ______
                                 
   Prepared Statement of the American College of Preventive Medicine
    The American College of Preventive Medicine (ACPM) urges the House 
Labor, Health and Human Services, Education, and Related Agencies 
Appropriations Subcommittee to reaffirm its support for training 
preventive medicine physicians by providing $11 million in fiscal year 
2017 to the Health Resources and Services Administration's (HRSA) 
public health and preventive medicine line-item contained within the 
public health workforce development program. ACPM also supports the 
recommendation of the Health Professions and Nursing Education 
Coalition of restoring HRSA's discretionary budget authority to the 
fiscal year 2010 level of $7.48 billion.
    In today's healthcare environment, the tools and expertise provided 
by preventive medicine physicians play an integral role in ensuring 
effective functioning of our Nation's public health system. These tools 
and skills include the ability to deliver evidence-based clinical 
preventive services, expertise in population-based health sciences, and 
knowledge of the social and behavioral determinants of health and 
disease. These are the tools employed by preventive medicine physicians 
who practice at the health system level where improving the health of 
populations, enhancing access to quality care, and reducing the costs 
of medical care are paramount. As the body of evidence supporting the 
effectiveness of clinical and population-based interventions continues 
to expand, so does the need for specialists trained in preventive 
medicine.
    Organizations across the spectrum have recognized the growing 
demand for preventive medicine professionals. The Institute of Medicine 
released a report in 2007 calling for an expansion of preventive 
medicine training programs by an ``additional 400 residents per year,'' 
and the Accreditation Council on Graduate Medical Education (ACGME) 
recommends increased funding for preventive medicine residency training 
programs. Additionally, the Association of American Medical Colleges 
released statements in 2011 that stressed the importance of 
incorporating behavioral and social sciences in medical education as 
well as announcing changes to the Medical College Admission Test that 
would test applicants on their knowledge in these areas. Such measures 
strongly indicate increasing recognition of the need to take a broader 
view of health that goes beyond just clinical care--a view that is a 
unique focus and strength of preventive medicine residency training.
    In fact, preventive medicine is the only one of the 24 medical 
specialties recognized by the American Board of Medical Specialties 
that requires and provides training in both clinical and population-
based medicine. Preventive medicine residency training programs provide 
a blueprint on how to train our future physician workforce; physicians 
trained to provide individual patient care needs as well as practice at 
the community and population level to identify and treat the social 
determinants of health. Preventive medicine physicians have the 
training and expertise to advance the population health outcomes that 
public and private payers are increasingly promoting to their 
providers. These physicians have a strong focus on quality care 
improvement and are at the forefront of efforts to integrate primary 
care and public health.
    According to the Health Resources and Services Administration 
(HRSA) and health workforce experts, there are personnel shortages in 
many public health occupations, including epidemiologists, 
biostatisticians, and environmental health workers among others. 
According to the 2014 Physician Specialty Data Book released by the 
Association of American Medical Colleges, preventive medicine had the 
biggest decrease (-29 percent) in the number of first-year ACGME 
residents and fellows between 2008 and 2013. This decrease represents a 
worsening trend in the number of preventive medicine residents and is 
not due to a lack of interest or need but is due to a lack of funding. 
ACPM is deeply concerned about the shortage of preventive medicine-
trained physicians and the ominous trend of even fewer training 
opportunities. This deficiency in physicians trained to carry out core 
public health activities will lead to major gaps in the expertise 
needed to deliver clinical prevention and community public health. The 
impact on the health of those populations served by HRSA is likely to 
be profound.
    Despite being recognized as an underdeveloped national resource and 
in shortage for many years, physicians training in the specialty of 
Preventive Medicine are the only medical residents whose graduate 
medical education (GME) costs are not supported by Medicare, Medicaid 
or other third party insurers. Training occurs outside hospital-based 
settings and therefore is not financed by GME payments to hospitals. At 
a time of unprecedented national, State, and community need for 
properly trained physicians in public health, disaster preparedness, 
prevention-oriented practices, quality improvement, and patient safety, 
preventive medicine training programs and their residents are in need 
of enhanced Federal support.
    Currently, residency programs scramble to patch together funding 
packages for their residents. Limited stipend support has made it 
difficult for programs to attract and retain high-quality applicants. 
Support for faculty and tuition has been almost non-existent. Directors 
of residency programs note that they receive many inquiries about and 
applications for training in preventive medicine; however, training 
slots often are not available for those highly qualified physicians who 
are not directly sponsored by an outside agency or who do not have 
specific interests in areas for which limited stipends are available 
(such as research in cancer prevention).
    HRSA--as authorized in Title VII of the Public Health Service Act--
is a critical funding source for a small number of preventive medicine 
residency programs, as it represents the largest Federal funding source 
for these programs.
    Of note, the preventive medicine residency programs directly 
support the mission of the HRSA health professions programs by 
facilitating practice in underserved communities and promoting training 
opportunities for underrepresented minorities:
  --Thirty-five percent of HRSA-supported preventive medicine graduates 
        practice in medically underserved communities, a rate of almost 
        3.5 times the average for all health professionals. These 
        physicians are meeting a critical need in these underserved 
        communities.
  --Nearly one in five preventive medicine residents funded through 
        HRSA programs are under-represented minorities, which is almost 
        twice the average of minority representation among all health 
        professionals.
  --Fourteen percent of all preventive medicine residents are under-
        represented minorities, the largest proportion of any medical 
        specialty.
    In addition to training under-represented minorities and generating 
physicians who work in medically underserved areas, preventive medicine 
residency programs equip our society with health professionals and 
public health leaders who possess the tools and skills needed in the 
fight against the chronic disease epidemic that is threatening the 
future of our Nation's health and prosperity. Correcting the root 
causes of this critical problem of chronic diseases will require a 
multidisciplinary approach that addresses issues of access to 
healthcare; social and environmental influences; and behavioral 
choices. ACPM applauds the initiation of programs such as Care 
Coordination Organizations that take this broad view of the 
determinants of chronic disease. However, any efforts to strengthen the 
public health infrastructure and transform our communities into places 
that encourage healthy choices must include measures to strengthen the 
existing training programs that help produce public health leaders.
    Many of the leaders of our Nation's local and State health 
departments are trained in preventive medicine. Their unique 
combination of expertise in both medical knowledge and public health 
makes them ideal choices to head the fight against chronic disease as 
well as other threats to our Nation's health. Their contributions are 
invaluable. Investing in the residency programs that provide physicians 
with the training and skills to take on these leadership positions is 
an essential part of keeping Americans healthy and productive. As such, 
the American College of Preventive Medicine urges the Labor, Health and 
Human Services, Education, and Related Agencies Appropriations 
Subcommittee to reaffirm its support for training preventive medicine 
physicians by providing $11 million in fiscal year 2017 for preventive 
medicine residency training under the public health and preventive 
medicine line-item at HRSA.
                                 ______
                                 
   Prepared Statement of the American Congress of Obstetricians and 
                             Gynecologists
    The American Congress of Obstetricians and Gynecologists, 
representing more than 57,000 physicians and partners in women's 
health, is pleased to offer this statement to the Senate Committee on 
Appropriations, Subcommittee on Labor, Health and Human Services, 
Education, and Related Agencies. We thank Chairman Blunt, Ranking 
Member Murray, and the entire Subcommittee for this opportunity to 
provide comments on some of the most important programs to women's 
health.
    Today, the U.S. lags behind many other nations in healthy births. 
ACOG believes that Federal research investments, including 
comprehensive data collection and surveillance, biomedical research, 
and translating research into evidence-based care for women and babies 
is necessary to improve maternal and infant health. We urge you to make 
funding of the following programs and agencies a top priority in fiscal 
year 2017.
Data Collection and Surveillance at the Centers for Disease Control and 
        Prevention (CDC)
    In order to conduct robust research, it is critical to collect 
uniform, accurate and comprehensive data. The National Center for 
Health Statistics is the Nation's principal health statistics agency 
and collects raw vital statistics from State records like birth and 
death certificates. This information provides key data about both 
mother and baby during pregnancy, labor, and delivery. Effective data 
collection depends on all States having adequate resources to expand 
technical assistance to maximize electronic death reporting by funeral 
directors and physicians. In addition, States must be able to modernize 
their systems to keep pace with new technology. ACOG requests funding 
to be used to support States in upgrading antiquated systems and 
improving the quality and accuracy of vital statistics reporting. For 
fiscal year 2017, ACOG requests $170 million for the National Center 
for Health Statistics.
    The Pregnancy Risk Assessment Monitoring System (PRAMS) at CDC 
extends beyond vital statistics and surveys new mothers on their 
experiences and attitudes during pregnancy, with questions on a range 
of topics, including what their insurance covered, whether they had 
stressful experiences during pregnancy, when they initiated prenatal 
care, and what kinds of questions their doctor covered during prenatal 
care visits. By identifying trends and patterns in maternal health, CDC 
researchers and State health departments are better able to identify 
behaviors and environmental and health conditions that may lead to 
preterm births. Only 40 States use the PRAMS surveillance system today. 
ACOG requests adequate funding to expand PRAMS to all U.S. States and 
territories.
Biomedical Research at the National Institutes of Health (NIH)
    Biomedical research is critically important to understanding the 
causes of maternal and infant mortality and morbidity and developing 
effective interventions to lower the incidence of mortality and 
morbidity. The Eunice Kennedy Shriver National Institute of Child 
Health and Human Development's (NICHD's) 2012 Scientific Vision 
identified the most promising research opportunities for the next 
decade. Goals include determining the complex causes of prematurity and 
developing evidence-based measures for its prevention within the next 
10 years, understanding the long term health implications of assisted 
reproductive technology, and understanding the role of the placenta in 
fetal health outcomes. The placenta, one of the least studied human 
organs, is essential to the viability and proper growth of the fetus. 
NICHD's Human Placenta Project will help discover the causes of 
placental failures, and ultimately ways to prevent failure and improve 
maternal and fetal birth outcomes.
    In addition, adequate levels of research require a robust research 
workforce. The years of training combined with uncertainty in receiving 
grant funding are major disincentives for students considering a career 
in this field. This has resulted in a huge gap between low number of 
women's reproductive health researchers being trained and the immense 
need for research. We urge continued investments in the Women's 
Reproductive Health Research (WRHR) Career Development program, 
Reproductive Scientist Development Program (RSDP), and the Building 
Interdisciplinary Research Careers in Women's Health (BIRCWH) programs 
to address the shortfall of women's reproductive health researchers. 
ACOG supports a minimum of $34.5 billion for NIH and $1.441 billion 
within that funding request for NICHD in fiscal year 2017.
Public Health Programs at the Health Resources and Services 
        Administration (HRSA) and the Centers for Disease Control and 
        Prevention (CDC)
    Projects at HRSA and CDC serve the essential purpose of translating 
research into evidence-based practice. Where NIH conducts research to 
identify causes of maternal and infant mortality and morbidity, CDC and 
HRSA help ensure those research findings lead to improved maternal and 
infant health outcomes.
    Maternal and Child Health Block Grant (HRSA): The Maternal and 
Child Health Block Grant at HRSA is the only Federal program that 
exclusively focuses on improving the health of mothers and children. 
State and territorial health agencies and their partners use MCH Block 
Grant funds to reduce infant mortality, deliver services to children 
and youth with special healthcare needs, support comprehensive prenatal 
and postpartum care, screen newborns for genetic and hereditary health 
conditions, deliver childhood immunizations, and prevent childhood 
injuries.
    These early healthcare services help keep women and children 
healthy, eliminating the need for later costly care. Every $1 spent on 
preconception care for a woman with diabetes can save up to $5.19 by 
preventing costly complications. Even so, block grant funding has been 
significantly diminished. Over $90 million has been cut from the Block 
Grant since 2003. ACOG requests $880 million for the Block Grant in 
fiscal year 2017 to maintain its current level of services.
    Title X Family Planning Program (HRSA): Family planning and 
interconception care are imperative to ensuring healthy women and 
healthy pregnancies. The Title X Family Planning Program provides 
essential services to more than 4.5 million low income men and women 
who may not otherwise have access to these services. Title X clinics 
accounting for $5.3 billion in healthcare savings in 2010 alone. For 
every $1 spent on publicly funded family planning services, Medicaid 
and other public expenditures saved $7.09. ACOG supports $327 million 
for Title X in fiscal year 2017 to sustain its level of services.
    Fetal Infant Mortality Review (HRSA): HRSA's Healthy Start Program 
promotes community-based programs to reduce infant mortality and racial 
disparities. These programs are encouraged to use the Fetal and Infant 
Mortality Review (FIMR), which brings together ob-gyn experts, local 
health departments, consumers and community stakeholders to address 
local issues contributing to infant mortality. Today, more than 172 
local programs in over 30 States find FIMR a powerful tool to help 
reduce infant mortality and address issues related to preterm delivery. 
ACOG has partnered with the Maternal and Child Health Bureau to sponsor 
the National FIMR Program for over 25 years. ACOG supports $0.5 million 
in fiscal year 2017 for HRSA to increase the number of Healthy Start 
programs that use FIMR.
    Maternal Health Initiative (HRSA): The Maternal and Child Health 
Bureau launched the Maternal Health Initiative to foster the notion of 
``healthy moms make healthy babies.'' As part of this effort, ACOG has 
convened the National Partnership on Maternal Safety to identify key 
factors to reduce maternal morbidity and mortality. For fiscal year 
2017, ACOG requests, at a minimum, level funding for MCHB to advance 
this important work.
    Safe Motherhood, Maternity and Perinatal Quality Collaboratives 
(CDC): The Safe Motherhood Initiative at CDC works with State health 
departments to collect information on pregnancy-related deaths, track 
preterm births, and improve maternal outcomes. Through Safe Motherhood, 
CDC funds State-based Maternity and Perinatal Quality Collaboratives 
that improve birth outcomes by encouraging use of evidence-based care, 
including reducing early elective deliveries. For instance, through the 
Ohio Perinatal Quality Collaborative, started in 2007 with funding from 
CDC, 21 OB teams in 25 hospitals have significantly decreased early 
non-medically necessary deliveries, in accordance with ACOG guidelines, 
reducing costly and dangerous pre-term births. Avalere Health estimated 
that reducing early elective deliveries can save from $2.4 million to 
$9 million per year. Currently, there are active Perinatal Quality 
Collaboratives in many States, like Maryland and Washington, that have 
demonstrated significant progress in reducing early elective 
deliveries, among other quality improvement initiatives. They do so 
without Federal funds, and face major financial stability challenges. 
Many States do not yet have collaboratives, and could benefit greatly 
using active, successful, and well-funded collaboratives as a model to 
build a collaborative tailored to unique and local needs. The PREEMIE 
Reauthorization Act, enacted in 2013, authorizes funding to increase 
the number of States receiving assistance for Perinatal Quality 
Collaboratives. ACOG urges you to reinstate the pre-term birth sub-line 
at a funding level of $2 million, as authorized by PREEMIE, and fund 
the Safe Motherhood Initiative at $46 million to implement PREEMIE and 
help States expand or establish Maternity and Perinatal Quality 
Collaboratives.
Advancing Maternal Therapeutics at the Department of Health and Human 
        Services (HHS)
    Each year, more than 4 million women give birth in the United 
States and more than 3 million breastfeed their infants. However, 
little is known about the effects of most drugs on the woman and her 
child, or the ways in which pregnancy and lactation alter the uptake, 
metabolism, and effect of medication. Pregnant and breastfeeding women 
have historically been excluded from most research trials. Although 
there have been substantial encouraging developments in this arena, 
including the recently updated drug labeling rule on pregnancy and 
lactation by FDA and relevant research at NIH and CDC, significant gaps 
remain. In order to achieve meaningful progress, HHS must ensure the 
coordination of all efforts being made at the agency level. As such, 
ACOG supports the establishment of a Federal work group to improve 
coordination and provide guidance on how clinical research might be 
done appropriately in this area.
Quality Assessment Programs at the Agency for Healthcare Research and 
        Quality (AHRQ)
    Consumer Assessment of Healthcare Providers and Systems (CAHPS): 
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) 
program was established within AHRQ in 1995 to address concerns 
regarding the lack of available consumer health plan reviews. The 
information collected through the CAHPS program can be a critical 
element of patient decisionmaking, while also informing providers and 
insurers about the impact and reception of their initiatives and 
services. Unfortunately, the CAHPS program has not yet established a 
survey to collect data about maternity care. Given the frequency and 
complex nature of interactions that an expectant mother will have with 
an effective healthcare system, we support the creation of a CAHPS 
survey focused on maternity care. ACOG encourages the CAHPS program to 
direct funds towards the development of a maternity care-oriented 
assessment.
    Again, we would like to thank the Committee for its commitment to 
improving women's health, and we urge you to fund the programs we have 
identified in fiscal year 2017.
U.S. Government Response to Zika Virus
    In order to continue to adequately respond to and better understand 
the Zika virus' origins, transmission, and public health risks, 
particularly to pregnant women, ACOG urges Congress to fund a robust 
and comprehensive public health response to the rapid spread of the 
Zika virus.
    ACOG applauds the Administration's recent steps to bolster U.S. 
capacity to combat Zika by previously committed Federal funds, but 
additional funding is desperately needed. ACOG urges Congress to 
prioritize emergency supplemental funding to combat Zika and replenish 
funds that have been transferred by the Administration. The health of 
women and infants is central to ACOG's mission, and we believe that 
these funding measures are essential to ensure execution of a 
comprehensive Zika response.
                                 ______
                                 
    Prepared Statement of the American Dental Education Association
    The American Dental Education Association (ADEA) represents all 66 
U.S. dental schools, 700 dental residency training programs, nearly 600 
allied dental programs, as well as more than 12,000 faculty who educate 
and train the nearly 50,000 students and residents attending these 
institutions. ADEA submits this testimony for the record and for your 
consideration as you begin prioritizing fiscal year 2017 appropriation 
requests.

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ADEA's dental schools' clinics and extramural dental school facilities 
provide care to more than 3 million patients annually. America's dental 
schools are one of the Nation's largest oral health care safety nets, 
providing more than $74 million in uncompensated healthcare annually to 
the uninsured and under-insured.

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

    ADEA's academic dental institutions educate and train future oral 
health providers and dental and craniofacial researchers. As one of the 
largest safety-net providers of dental care in the United States, these 
dental schools provide significant care to the uninsured and 
underserved populations. Given the fact that research has proven that 
there is an indivisible link between good oral health and overall 
health, it is imperative that adequate funding be provided to programs 
that facilitate access to dental care and continues cutting-edge dental 
and craniofacial research which seeks to reduce the burden of oral 
disease.
    ADEA urges you to adequately fund and protect funding for Title VII 
of the Public Health Service Act and the National Institute of Dental 
and Craniofacial Research (NIDCR). Title VII, through its various 
grants and programs, facilitates access to dental care to millions of 
Americans and NIDCR fosters globally recognized cutting-edge dental and 
craniofacial research.
    Specifically, we are requesting funding for the following: (1) 
Title VII of the Public Health Service Act; (2) National Institute of 
Dental and Craniofacial Research (NIDCR); (3) Centers for Disease 
Control and Prevention (CDC), Division of Oral Health; (4) Ryan White 
HIV/AIDS Treatment and Modernization Act, Part F: Dental Reimbursement 
Program (DRP) and the Community-Based Dental Partnerships Program.
    As you deliberate funding for fiscal year 2017, ADEA respectfully 
makes the following funding requests:
I. $35.9 million: Title VII, Section 748, Public Health Service Act

    The dental programs in Title VII, Section 748 of the Public Health 
Service Act, provide critical training in general, pediatric and public 
health dentistry and dental hygiene. Support for these programs will 
help ensure an adequately prepared dental workforce. The funding 
supports predoctoral dental education and postdoctoral pediatric, 
general and public health dentistry residency training. The investment 
made by Title VII not only educates dentists, dental therapists and 
dental hygienists, but also expands access to care for underserved 
communities since much of the care is provided in community-based 
settings located in health profession shortage areas.
    Additionally, Section 748 addresses the shortage of professors in 
dental schools with the dental faculty loan repayment program and 
faculty development courses for those who teach pediatric, general or 
public health dentistry and dental hygiene. There are currently more 
than 200 open, budgeted faculty positions in dental schools. These two 
programs provide schools with assistance in recruiting and retaining 
faculty. ADEA is increasingly concerned that with projected restrained 
funding, the dental research community will not be able to grow and 
that the pipeline of new researchers will not meet future need.
    Title VII Diversity and Student Aid programs play a critical role 
in diversifying the health professions student body and, thereby, the 
healthcare workforce. For the last several years, these programs have 
not received adequate funding to sustain the progress necessary to meet 
the challenges of an increasingly diverse U.S. population.
    We are pleased that the budget request this year contained funding 
for the Health Careers Opportunity Program (HCOP). This program 
provides a vital source of support for dental professionals serving 
underserved and disadvantaged patients by providing a pipeline for 
individuals from these populations. This unique workforce program 
encourages young people from diverse and disadvantaged backgrounds to 
explore careers in healthcare generally and dentistry specifically. 
ADEA requests that this program continue to be funded.
    ADEA is most concerned that the Administration did not request any 
funds for the Area Health Education Centers (AHEC) program. This vital 
program is targeted at enhancing high quality, culturally competent 
care in community-based Interprofessional clinical training settings. 
The infrastructure development grants and point of service maintenance 
and expansion grants ensure that patients from underserved populations 
receive quality care and that health professionals receive training 
with diverse populations. ADEA strongly encourages the Committee to 
continue funding the vitally important AHEC program.
II. $452 million: National Institute of Dental and Craniofacial 
        Research (NIDCR)
        
        

    Dental research serves as the foundation of the profession of 
dentistry. Discoveries stemming from dental research have reduced the 
burden of oral diseases, led to better dental health for millions of 
Americans and uncovered important links between oral and systemic 
health. ADEA and dental school researchers are grateful for the 
increase NIDCR received in fiscal year 2015, however the increased 
funding was allocated to required NIH-wide initiatives. The requested 
increase will provide for a 6 percent real growth to ensure continued 
growth of the Precision Medicine Initiative and progress to meet the 
goals outlined in the 21st Century Cares Act and the Biomedical 
Innovation Agenda legislation currently being debated by Congress. 
Through NIDCR grants, dental researchers in academic dental 
institutions have enhanced the quality of the Nation's dental and 
overall health. Dental researchers are poised to make dramatic 
breakthroughs, such as restoring natural form and function to the mouth 
and face as a result of disease, accident, or injury; and diagnosing 
systemic disease (such as HIV and certain types of cancer) from saliva 
instead of blood and urine samples. These breakthroughs and countless 
others, which continue America's role as a global scientific leader, 
require adequate funding.
III. $19 million: Centers for Disease Control and Prevention (CDC) 
        Division of Oral Health
    The CDC Division of Oral Health expands the coverage of effective 
prevention programs. The Division increases the basic capacity of state 
oral health programs to accurately assess the needs of the State, 
organize and evaluate prevention programs, develop coalitions, address 
oral health in State health plans and effectively allocate resources to 
the programs. This strong public health response is needed to meet the 
challenges of dental disease affecting children and vulnerable 
populations. The current path of decreased funding will have a 
significant negative effect upon the overall health and preparedness of 
the Nation's States and communities.
IV. $18 million: Ryan White HIV/AIDS Treatment and Modernization Act, 
        Part F: Dental Reimbursement Program (DRP) and Community-Based 
        Dental Partnerships Program
    Patients with compromised immune systems are more prone to oral 
infections like periodontal disease and tooth decay. The Dental 
Reimbursement Program (DRP) is a cost-effective Federal/institutional 
partnership providing partial reimbursement to academic dental 
institutions for costs incurred in providing dental care to people 
living with HIV/AIDS. Simultaneously, the program provides educational 
and training opportunities to dental students, residents and allied 
dental students. However, DRP reimbursement only averages 26 percent of 
the dental schools' unreimbursed costs. The current reimbursement rate 
is unsustainable. Adequate funding of the Ryan White Part F programs 
will help ensure that people living with HIV/AIDS receive necessary 
oral healthcare.
    ADEA thanks you for your consideration of these funding requests 
and looks forward to working with you to ensure the continuation of 
these critical programs to ensure the health and well-being of the 
Nation.
    Please use ADEA as a resource on any matter pertaining to dental 
education and training of the dental workforce under your purview. For 
additional information contact: Yvonne Knight, J.D., ADEA Chief 
Advocacy Officer at Knighty@adea.org.
                                 ______
                                 
   Prepared Statement of the American Dental Hygienists' Association
                              introduction
    The American Dental Hygienists' Association (ADHA) appreciates this 
opportunity to provide testimony of fiscal year 2017 appropriations. 
Oral health is a part of total health and authorized oral healthcare 
programs require appropriations support in order to increase the 
accessibility of oral health services, particularly for the 
underserved. While virtually all dental disease is fully preventable, 
nearly 25,000,000 children eligible for dental Medicaid benefits (60 
percent) did not receive any preventive dental services in fiscal year 
2014.\1\ With the Nation confronting an oral health access crisis, 
there is no dispute that new types of dental providers are needed; the 
disagreement relates to what types of new providers are needed. This 
underscores the need for demonstration projects under Section 340G-1 of 
the Public Health Service Act in order to explore what types of new 
providers work best in various settings. Regrettably, there is a 
persistent appropriations statutory provision blocking funding 
specifically for this grants program at the Health Resources and 
Services Administration (HRSA). There is simply no legal or health 
policy justification to perpetuate this funding block. Indeed, it is 
only organized dentistry that actively works to block funding for 
Section 340G-1. ADHA, along with State dental hygiene associations 
across the Nation, urges that the block on funding for Section 340G-1 
be lifted, that $2,000,000 be appropriated for Section 340G-1 and that 
the following report language be included in the fiscal year 2017 HHS 
funding bill:
---------------------------------------------------------------------------
    \1\ Https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Benefits/Early-and-Periodic-Screening-Diagnostic-and-
Treatment.html.
---------------------------------------------------------------------------
    Requested Report Language: ``The Nation continues to confront an 
oral health access crisis, which will not be ameliorated without better 
utilization of existing dental providers and exploration of new types 
of licensed dental providers. The Committee urges a stakeholder meeting 
be convened in order to determine how best to create new entry points 
into the oral healthcare delivery system for rural and other 
underserved populations, better utilization of existing dental 
personnel, and exploration of new types of dental providers.''
    Lifting the block on this dental workforce grants program, 
officially titled the Alternative Dental Health Care Providers 
Demonstration Program, would send an important signal to States and to 
HRSA that innovation in dental workforce is a meritorious undertaking. 
Even lifting the block and not funding the program would be a positive 
message to States. Importantly, the authorizing language requires that 
the grants be conducted in compliance with State law, that they must 
increase access to dental healthcare in rural and other underserved 
communities, and that the Institute of Medicine provide a qualitative 
and quantitative evaluation of the grants. Importantly, nothing in 
Section 340 G-1 would enable oral health practitioners to perform 
dental surgery or ``irreversible procedures,'' unless a State 
specifically allowed such services. Further, because the authorizing 
language requires HRSA to begin the dental workforce grant program 
under Section 340G-1 within 2 years of its 2010 enactment (i.e., by 
2012) and to conclude it within 7 years of enactment (2017), language 
directing HRSA to move forward with Section 340G-1 grants despite this 
timeline is needed.
Widespread Support for Dental Workforce Innovation
    The American Dental Association (ADA), ADHA and numerous other 
groups have called for new types of dental providers. Innovative oral 
health practitioner models were authorized in Minnesota in 2009, 
followed by Maine in 2014. A February 2014 Report to the Minnesota 
Legislature on the early impact of the new providers found that 
benefits include ``direct cost savings, increased dental team 
productivity, improved patient satisfaction and lower appointment fail 
rates.'' \2\ Several States have mid-level oral health practitioner 
legislation pending including Connecticut, Georgia, Hawaii, Kansas, 
Massachusetts, New Mexico, North Dakota, South Carolina, Texas, Vermont 
and Washington State. Both the W.K. Kellogg Foundation and the PEW 
Charitable Trust Dental Campaign are investing in State efforts to 
increase oral healthcare access by adding new types of dental providers 
to the dental team. Groups as disparate as Families USA, Americans for 
Tax Reform, and Americans for Prosperity have called for exploration of 
new dental providers. In a January 2015 report, Families USA called for 
``improving access to care through greater use of mid-level providers 
such as nurse practitioners and dental therapists.'' \3\ Grover 
Norquist, President of Americans for Tax Reform, observed in March 2015 
that ``It is undeniable that there is a dentist shortage''. Norquist 
further noted that ``Innovative ideas like this [mid-level dental 
provider] faced intense opposition but are very similar to the fights 
that took place decades ago with the emergence of nurse 
practitioners.'' Americans for Prosperity wrote in January 2015 that 
States should be ``free to innovate'' in the dental workforce to solve 
access issues. The National Dental Association, representing 6,000 
Black dentists, released its ``Position on Access to Care and Emerging 
Workforce Models'' in July 2014, which stated that the NDA ``supports 
the development and continuation of demonstration projects that can 
demonstrate the impact and effectiveness of Emerging Workforce Models 
[expanded function dental hygienists, expanded function dental 
assistants, or dental therapists] on access to care, and total health 
outcomes.'' \4\
---------------------------------------------------------------------------
    \2\ Http://www.health.state.mn.us/divs/orhpc/workforce/dt/
dtlegisrpt.pdf.
    \3\ Http://familiesusa.org/press-release/2015/families-usa-
proposes-health-reform-20.
    \4\ (Http://ndaonline.org/position-on-access-to-care-and-emerging-
workforce-models).
---------------------------------------------------------------------------
    The U.S. Federal Trade Commission (FTC) supported dental workforce 
expansion in November 2014, noting that expanding the supply of dental 
therapists is ``likely to increase the output of basic dental services, 
enhance competition, reduce costs and expand access to dental care.'' 
\5\ In January, 2016, the FTC noted that ``By eliminating the direct 
supervision requirement for dental hygienists' services delivered in 
expanded safety-net setting . . . H.B. 684 will likely promote greater 
competition in the provision of preventive dental care services, 
leading to increased access and more cost-effective care . . . .'' \6\ 
Importantly, the FTC observed that ``authoritative sources have found 
no countervailing health or safety benefits to healthcare consumers 
from such [direct supervision] requirements.'' \7\
---------------------------------------------------------------------------
    \5\ Https://www.ftc.gov/system/files/documents/advocacy_documents/
ftc-staff-comment-commission-dental-accreditation-concerning-proposed-
accreditation-standards-dental/141201codacomment.pdf.
    \6\ Https://www.ftc.gov/system/files/documents/advocacy_documents/
ftc-staff-comment-georgia-state-senator-valencia-seay-concerning-
georgia-house-bill-684/160201gadentaladvocacy.pdf?
utm_source=govdelivery.
    \7\ Ibid.
---------------------------------------------------------------------------
    The National Governors Association's January 2014 issue brief on 
``The Role of Dental Hygienists in Providing Access to Oral Health 
Care'' found that ``innovative State programs are showing that 
increased use of dental hygienists can promote access to oral 
healthcare, particularly for underserved populations, including 
children'' and that ``such access can reduce the incidence of serious 
tooth decay and other dental disease in vulnerable populations.'' \8\ 
The Department of Health and Human Services, in its Oral Health 
Strategic Framework, called for expanding the number of health-care 
settings that provide oral healthcare and urged strengthening the oral 
health workforce and expanding the capabilities of existing 
providers.\9\
---------------------------------------------------------------------------
    \8\ Http://www.nga.org/files/live/sites/NGA/files/pdf/2014/
1401DentalHealthCare.pdf.
    \9\ HHS Oral Health Strategic Framework, 2014-2017, Public Health 
Reports, Vol. 131, March-April 2016, pp248-249. http://
www.publichealthreports.org/issueopen.cfm?articleID=3498.
---------------------------------------------------------------------------
Dentist Shortage and Dental Hygienist Surplus Demand Better Utilization 
        of Dental Hygienists
    In February 2015, HRSA projected that all 50 States and the 
District of Columbia will experience a shortage of dentists by 2025. In 
contrast, there will be an excess supply of dental hygienists at the 
national level while five States (MI, MT, ND, SD, and WV) will 
experience dental hygienist shortages from 21-93 FTEs.\10\
---------------------------------------------------------------------------
    \10\ HRSA March 2015 ``National and State-Level Projections of 
Dentists and Dental Hygienists in the U.S., 2012-2025''http://
bhpr.hrsa.gov/healthworkforce/supplydemand/dentistry/national
statelevelprojectionsdentists.pdf.
---------------------------------------------------------------------------
Title VII Program Grants to Expand and Educate the Dental Workforce--
        ADHA Urges Funding at a Level of $35.8 Million in Fiscal Year 
        2017
    A number of existing grant programs offered under Title VII support 
health professions education programs, students, and faculty. ADHA is 
pleased dental hygienists are recognized as primary care providers of 
oral health services and are included as eligible to apply for several 
grants offered under the ``General, Pediatric, and Public Health 
Dentistry'' grants. With millions more Americans eligible for dental 
coverage in coming years, it is critical that the oral health workforce 
is bolstered. Dental and dental hygiene education programs currently 
struggle with significant shortages in faculty and there is a dearth of 
providers pursuing careers in public health dentistry and pediatric 
dentistry. Securing appropriations to expand the Title VII grant 
offerings to additional dental hygienists and dentists will provide 
much needed support to programs, faculty, and students in the future.
Oral Health Programming Within the Centers for Disease Control--Fund at 
        a Level of $19 Million in Fiscal Year 2017
    ADHA joins with others in the dental community in urging $19 
million for oral health programming within the Centers for Disease 
Control. This funding level will enable CDC to continue its vital work 
to control and prevent oral disease, including vital work in community 
water fluoridation. Federal grants will serve to facilitate improved 
oral health leadership at the State level; support the collection and 
synthesis of data regarding oral health coverage and access, promote 
the integrated delivery of oral health and other medical services; 
enable States to be innovative and promote a data-driven approach to 
oral health programming.
National Institute of Dental and Craniofacial Research (NIDCR)--Fund at 
        a Level of $452 Million in Fiscal Year 2017
    NIDCR cultivates oral health research that leads to greater 
understanding of oral diseases and their treatments and the link 
between oral health and overall health. ADHA joins with others in the 
oral health community to support NIDCR funding at a level of $452 
million in fiscal year 2016.
                               conclusion
    ADHA is the largest national organization representing the 
professional interests of more than 185,000 licensed dental hygienists 
across the country. Thirty-nine States enable patients to directly 
access oral health services provided by dental hygienists in settings 
outside the private dental office. Seventeen State Medicaid programs 
(AZ, CA, CO, CT, ME, MA, MI, MN, MO, MT, NE, NM, NV, OR, RI, WA and WI) 
provide direct reimbursement to dental hygienists for oral health 
services provided to Medicaid-eligible individuals. ADHA urges the 
Subcommittee to lift the block on funding for Section 340G-1 of the 
PHSA, dental workforce demonstration grants, in its fiscal year 2017 
HHS funding bill. It is time for an evidence-based decision to be made 
on this grant program for the underserved. Lifting the block on funding 
for these dental workforce grants would be an important signal to 
States and to healthcare stakeholders that exploring new ways of 
bringing oral health services to the underserved is a meritorious 
expenditure of resources. Without the appropriate supply, diversity and 
distribution of the oral health workforce, the current oral health 
access crisis will only be exacerbated. In closing, ADHA recommends 
funding at a level of $2 million for fiscal year 2017 to support these 
vital dental workforce demonstration projects. ADHA also requests that 
report language (see page 2) be included noting that the Committee 
recognizes that the oral health access crisis will not be ameliorated 
without better utilization of existing dental providers and exploration 
of new types of licensed dental providers. In addition, ADHA urges that 
this Subcommittee convene a stakeholder meeting in order to move beyond 
the tired appropriations rider that blocks funding for Section 340G-1, 
a dental workforce demonstration program to improve access to care for 
vulnerable and underserved populations. Thank you for the opportunity 
to submit the views of the ADHA.

    [This statement was submitted by Jill Rethman, RDH, BA, President, 
American Dental Hygienists' Association.]
                                 ______
                                 
        Prepared Statement of the American Diabetes Association
    For fiscal year 2017, the American Diabetes Association 
(Association) urges the Subcommittee to deepen its investment in 
research and prevention to find a cure, and improve the lives of those 
living with, and at risk for, diabetes. We ask the Subcommittee to 
provide $2.165 billion for the National Institute of Diabetes and 
Digestive and Kidney Diseases (NIDDK) at the National Institutes of 
Health (NIH), $170.129 million for the Division of Diabetes Translation 
(DDT) at Centers for Disease Control and Prevention (CDC), and $25 
million for the National Diabetes Prevention Program (National DPP) at 
CDC.
    Nearly 30 million Americans live with diabetes and 86 million 
Americans have prediabetes. I have been living with type 1 diabetes 
since was 10 years old. I remember listening as the doctor told my mom 
that I would never be able to have children and that diabetes would 
shorten my life. Thanks to the many medical discoveries and 
advancements at the NIH and translational research from CDC, I have 
proven her wrong. I have two beautiful, healthy children and have lived 
36 years with diabetes, without complications.
    I also remember a more recent conversation about diabetes with my 
family. Two years ago, my sister was diagnosed with type 1 diabetes at 
age 38. As we talked that day and I helped to console her and then 
connect her to the healthcare she would need to live with diabetes, I 
couldn't help but think how much farther we need to go to ensure that 
no one has to receive a diagnosis of diabetes again.
    As a person living with diabetes who is also an emergency 
department nurse and president of a charitable clinic, I see the human 
and economic toll diabetes extracts from my patients and their 
families. The lives of people living with, and at risk for, diabetes 
are better because of NIH research and CDC prevention activities. 
Progress has been great, but much more must be done to stop diabetes 
and the devastating complications I see every day. I am proud to share 
my testimony with you on behalf of my sister, my patients, and the 
millions of American adults and children living with diabetes or 
prediabetes.
    The diabetes epidemic is one of our country's biggest challenges 
and one touching all of our lives. According to the CDC, as many as one 
in three adults in our country--closer to one in two among minority 
populations--will have diabetes in 2050 if present trends continue. The 
sobering cost of this horrific disease is lived everyday by those who 
face blindness, suffer heart attacks and strokes, struggle with kidney 
failure and lose limbs, along with other deadly complications. Every 
year, 1.7 million Americans aged 20 years or older are diagnosed with 
diabetes. That means every 23 seconds someone in this country is 
diagnosed with diabetes. Today, diabetes will cause 200 Americans to 
undergo an amputation, 136 to enter end-stage kidney disease treatment, 
and 1,795 to develop severe retinopathy that can lead to vision loss.
    In addition to the horrendous physical toll, diabetes is 
economically devastating to our country. A 2017 report found the total 
annual cost of diagnosed and undiagnosed diabetes, prediabetes, and 
gestational diabetes in our country has skyrocketed by an astonishing 
78 percent over 5 years--to $322 billion. People with diagnosed 
diabetes have healthcare costs 2.3 times higher than those without 
diabetes. One in three Medicare dollars is spent caring for people with 
diabetes. Despite the escalating cost of diabetes to our Nation, the 
Federal investment for diabetes research and programs at the NIH and 
CDC has not equaled the shocking pace of the diabetes epidemic. It 
doesn't have to be this way. America has the power to stop the diabetes 
epidemic and make the final chapter a success story for the ages. The 
state of our Nation's diabetes epidemic justifies increased Federal 
funding in fiscal year 2017 for diabetes research and prevention 
programs.
                               background
    Diabetes is a chronic disease impairing the body's ability to 
utilize food. The hormone insulin, which is made in the pancreas, is 
needed for the body to change food into energy. In people with 
diabetes, either the pancreas does not create insulin, which is type 1 
diabetes, or the body does not create enough insulin and/or cells are 
resistant to insulin, which is type 2 diabetes. Diabetes results in too 
much glucose in the blood stream. Blood glucose levels that are too 
high or too low (as a result of medication to treat diabetes) can be 
life threatening in the short term. In the long term, diabetes is the 
leading cause of kidney failure, new cases of adult-onset blindness, 
and non-traumatic lower limb amputations, and a leading cause of heart 
disease and stroke. Additionally, up to 9.2 percent of women are 
affected by gestational diabetes, a form of glucose intolerance 
diagnosed during pregnancy placing both mother and baby at risk for 
complications and for type 2 diabetes. Those with prediabetes have 
higher than normal blood glucose levels and are at risk for type 2 
diabetes, but can take action to lower that risk.
the national institute of diabetes and digestive and kidney diseases at 
                                  nih
    The American Diabetes Association requests funding for NIDDK of 
$2.165 billion in fiscal year 2017 to support groundbreaking research. 
Research at NIDDK has led to many discoveries helping Americans prevent 
or better manage diabetes. For example, people with diabetes now manage 
their disease with a variety of insulin formulations and regimens far 
superior to those used in decades past, which have reduced the risk for 
the serious complications of diabetes: heart disease, stroke, lower 
extremity amputation, blindness, and kidney disease. NIDDK research has 
led to the availability of tools to prevent life-threatening high and 
low blood glucose levels such as continuous glucose monitors and 
insulin pumps.
    Further, the transformative Diabetes Prevention Program (DPP) at 
NIDDK showed individuals with prediabetes can lower their risk of 
developing type 2 diabetes by 58 percent through dietary changes and 
increased physical activity. Building on these results, the CDC, 
working with community, healthcare, and faith-based organizations, 
private insurers, employers, and government agencies has put this 
research into practice through the National Diabetes Prevention 
Program. The Centers for Medicare and Medicaid Services (CMS) has 
recognized the value of this approach to prevent type 2 diabetes and 
has proposed Medicare coverage of the National DPP. This would not have 
been possible without NIDDK's clinical trial.
    Additional research is needed to build on these advancements. 
Diabetes researchers across the country are poised for further 
innovation to transform diabetes prevention and care. With fiscal year 
2017 funding of $2.165 billion, the NIDDK would be able to fund 
additional investigator-initiated research grants to meet critical 
needs in areas such as expansion of NIDDK's comparative effectiveness 
clinical trial testing different medications to determine the best 
treatments for type 2 diabetes and continued development of the 
artificial pancreas, a closed looped system combining continuous 
glucose monitoring with insulin delivery. Additionally, the NIDDK would 
be able to move forward with research to improve the treatment of 
diabetic foot ulcers to reduce amputations, understand the relationship 
between diabetes and neuro-cognitive conditions like dementia and 
Alzheimer's disease, and discover how drugs to treat diabetes may help 
those facing heart disease and cancer.
              the division of diabetes translation at cdc
    The Federal Government's role in coordinating efforts to prevent 
diabetes and its serious complications through the Division of Diabetes 
Translation and its evidenced-based, outcomes-focused diabetes programs 
is essential. In fiscal year 2016, Congress recognized this by 
providing $170.129 million for DDT, whose mission is to eliminate the 
preventable burden of diabetes through research, education, and by 
translating science into clinical practice. DDT has a proven record of 
success in primary prevention efforts as well as programs to help those 
with diabetes manage their disease and avoid complications.
    We urge Congress to again provide $170.129 million in fiscal year 
2017. With these resources, the DDT will be able to continue diabetes 
prevention activities at the State and local levels. Funding will 
support these efforts through the State and Local Public Health Actions 
to Prevent Obesity, Diabetes, and Heart Disease grants, with a focus on 
improving prevention at the community and health system levels in 
populations with highest risk for diabetes. It will support basic and 
enhanced diabetes prevention efforts under the State Public Health 
Actions grant program for cross-cutting approaches to prevent and 
control diabetes, heart disease and stroke. It will also enable the DDT 
to expand its translational research activities to improve diabetes 
prevention, and continue its valuable diabetes surveillance work.
            the national diabetes prevention program at cdc
    I am alarmed 86 million Americans have prediabetes and are on the 
cusp of developing type 2 diabetes. Nine of ten individuals with 
prediabetes do not know they have it, and 15-30 percent of individuals 
with prediabetes develop type 2 diabetes within 5 years. Managed by the 
CDC, the National Diabetes Prevention Program (National DPP) is a 
public-private partnership of community organizations, private 
insurers, employers, healthcare organizations, faith-based 
organizations, and government agencies focused on type 2 diabetes 
prevention.
    The National DPP grew out of a successful NIDDK clinical study 
showing weight loss of 5 to 7 percent of body weight, achieved by 
reducing calories and increasing physical activity to at least 150 
minutes per week, reduced risk of developing type 2 diabetes by 58 
percent in people with prediabetes and by 71 percent for those over 60 
years old. Additional translational research was then done, showing the 
program also works in the less-costly community setting--at a cost of 
about $725 per participant.
    The National DPP supports a national network of local sites where 
trained staff provides those at high risk for diabetes with cost-
effective, group-based lifestyle intervention programs. There are four 
key components to the National DPP. First, community-based diabetes 
prevention sites where those at high risk for diabetes attend the 
intervention program. Second, a national recognition program 
coordinated by CDC to establish evidence-based standards for 
participating intervention sites, and provide the quality monitoring to 
ensure success. Third, public and healthcare provider education efforts 
giving trustworthy information on the availability of high quality 
diabetes prevention programs in communities so people understand what 
they need to do when they are diagnosed with prediabetes. Fourth, 
informed referral networks so healthcare providers can refer patients 
with prediabetes to the local intervention sites.
    Recently the Secretary of HHS announced that the CMS Office of the 
Actuary found that seniors participating in a National DPP program have 
Medicare costs that are $2,650 less than nonparticipants over a 15 
month period. Through a demonstration project administered by the YMCA, 
we now know that this program not only improves health, but lowers 
healthcare costs and will have a valuable impact on our Nation's 
economy. The Secretary will now take steps to implement coverage for 
this program as a Medicare benefit.
    We urge Congress to provide $25 million for the National DPP in 
fiscal year 2017 to continue its nationwide expansion. This level of 
funding for the National DPP will allow CDC to increase the number of 
sites that offer this critical program and continue to manage its 
recognition program to ensure sites follow the evidence-based 
curriculum and achieve the same high level of results.
                               conclusion
    We can and must change our country's story with regard to diabetes. 
We urge the Subcommittee's fiscal year 2017 appropriations decisions to 
reflect the necessity of taking action in light of the human and 
economic burden of this horrendous disease. The Association looks 
forward to working with you to stop diabetes.

    [This statement was submitted by Gina Gavlak, RN, Chair, National 
Advocacy Committee, American Diabetes Association.]
                                 ______
                                 
        Prepared Statement of the American Economic Association
    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, I am Robert Moffitt, Professor of Economics at the Johns 
Hopkins University and Chair of the Committee on Economic Statistics of 
the American Economic Association (AEA), the primary professional 
association of economists in the United States. On behalf of the 
Committee, I am pleased to provide this testimony in support of the 
programs of the Bureau of Labor Statistics, U.S. Department of Labor.
    The AEA has about 20,000 members. As the Bureau of Labor Statistics 
(BLS) indicates that the Nation has 21,500 jobs for economists, it is 
reasonable to suggest that the AEA represents a sizable proportion of 
the profession.
    The charter of the AEA states our organization's mission:
  --The encouragement of economic research, especially the historical 
        and statistical study of the actual conditions of industrial 
        life.
  --The issue of publications on economic subjects.
  --The encouragement of perfect freedom of economic discussion. The 
        Association as such will take no partisan attitude, nor will it 
        commit its members to any position on practical economic 
        questions.
    Succinctly put, the AEA promotes the conduct, publication, and 
discussion of economic research based on historical and statistical 
study. In 1885, the AEA's founders sought to migrate the economics 
profession from the realm of philosophy to that of the social sciences. 
Since that time, the results of AEA members' work has guided the 
development of the U.S. economy to become the largest and one of the 
most dynamic in the world.
    As the AEA charter indicates, statistics are the lifeblood of 
economic research. The growth and achievements of our profession would 
not have been possible without the sustained work over two centuries of 
the U.S. Congress to create, direct, and fund a robust, inventive, 
adaptive national statistical system.
    At the core of that system is the Bureau of Labor Statistics, the 
Nation's oldest continuously operating principal Federal statistical 
agency--created by Congress 1 year before the AEA's founding. In a real 
sense, the BLS and the economics profession have grown up together. 
Each has made the work of the other possible.
    Since Congress established the BLS, it has regularly expanded the 
agency's mandated duties.\1\ The topics of these responsibilities are 
reflected in the four BLS program accounts--labor force statistics, 
prices and cost of living, compensation and working conditions, and 
productivity and technology. Congress has made clear that it has given 
the BLS these responsibilities in order to promote several important 
public policy goals:
---------------------------------------------------------------------------
    \1\ Congress added current BLS responsibilities to the U.S. Code in 
1888, 1913, 1940, 1966, 1970, 1975, and 1998. Congress most recently 
re-affirmed broad BLS labor force statistics responsibilities with the 
passage of the Workforce Innovation and Opportunity Act of 2014.
---------------------------------------------------------------------------
  --Effective fiscal and monetary policy
  --U.S. businesses competitive in world markets
  --Efficient U.S. markets for labor, goods, and services
  --Research that describes and explains the current and historical 
        dynamics of the U.S. economy
    Given the breadth of these aims, it is fair to say that the health 
of the U.S. economy very much depends upon the value of the statistics 
produced by the BLS. In my view, that value historically has been 
extraordinarily high.
    In recent years, however, the BLS has not received resources 
sufficient to fulfill its mandated duties. BLS appropriations peaked in 
fiscal year 2010 at $611.4 million. Accounting for inflation, its 
fiscal year 2016 appropriation of $609.0 million represents a decline 
of 8.9 percent in real terms (using BLS price data). The current BLS 
staffing level is 8.3 percent below that of 2010.
    As a result of 6 years of significant budget shortfalls, the BLS 
has eliminated several data programs, reduced the reliability of a 
number of others, and curtailed investments in research, information 
technology, and staff. In fiscal year 2014, BLS ended the International 
Labor Comparisons and Mass Layoff Statistics programs, despite the fact 
that the latter is congressionally mandated. It also announced plans to 
stop publishing Export Price Indexes, a Principal Federal Economic 
Indicator, but then found temporary funding from another Federal 
agency. Last fall, faced with uncertain appropriations, BLS considered 
eliminating the Job Openings and Labor Turnover Survey, the National 
Longitudinal Survey, the American Time Use Survey, and Employment 
Projections (another congressionally mandated program).
    The AEA Statistics Committee strongly believes that the 
continuation of insufficient BLS funding is likely to have severe 
consequences for the capacity of the agency to serve the Nation's 
economic policymakers, research economists, and market participants. 
Further, the Statistics Committee believes that the BLS's inability to 
measure trends in two important aspects of the economy--contingent work 
and employer-provided training--is detrimental to economic research 
that informs good economic and workforce policy. Therefore, the 
Statistics Committee strongly urges this Subcommittee to provide 
sufficient support for the BLS to continue its current programs and add 
surveys on the important two subjects just mentioned.
    As the Subcommittee considers this request, I ask that it keep in 
mind some version of ``dynamic scoring,'' that is, the full fiscal and 
economic impacts of appropriations to the BLS. Compared to other public 
policy tools, statistics is remarkably inexpensive and has an 
extraordinarily high return on taxpayer investment.
    Thank you for your consideration of the AEA Statistics Committee's 
request. I very much appreciate the opportunity to provide this 
testimony, hope the Subcommittee finds it of value, and look forward to 
the Subcommittee's decision with regard to the BLS.

    [This statement was submitted by Professor Robert Moffitt, Chair, 
Committee on Economic Statistics, American Economic Association.]
                                 ______
                                 
  Prepared Statement of the American Educational Research Association
    Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee, thank you for the opportunity to submit written testimony 
on behalf of the American Educational Research Association. 
Appreciative of these stringent times, we recommend that the Institute 
of Education Sciences (IES) receive $728 million in fiscal year 2017. 
This recommendation is consistent with the request from the Friends of 
IES coalition, in which we are a leading member.
    AERA is the major national scientific association of 25,000 
faculty, researchers, graduate students, and other distinguished 
professionals dedicated to advancing knowledge about education, 
encouraging scholarly inquiry related to education, and promoting the 
use of research to improve education and serve the public good.
    With the passage of the Every Student Succeeds Act (ESSA) as well 
as the Evidence-Based Policymaking Commission Act, we see a bipartisan 
commitment to evidence-based decisionmaking. In 2016, the budget for 
IES was just over 1 percent of the Department of Education budget, 
underscoring the underinvestment in research on education as compared 
with comparable research and development investments in other fields. 
As we look ahead to 2017, we anticipate that the ESSA requirements that 
States, districts, and schools assess the evidence when selecting 
interventions should if anything amplify the demand for the very work 
of IES.
    Since IES was created in 2002, it has made dramatic contributions 
to the progress of education. Yet, we in the U.S. have a far way to go 
to provide high-quality education to all of our students. In addition 
to old questions that remain unanswered--such as how to best prepare 
teachers--we have barely begun to understand the opportunities provided 
by advances in technology. IES needs increased funding to continue our 
progress, using rigorous research to inform education policy. IES 
comprises the four national centers listed below. Each serves a 
critical role in improving the quality of education in the U.S.
National Center for Education Statistics (NCES)
    Established by an Act of Congress in 1867, NCES is one of the 13 
principal Federal statistical agencies in the United States. It 
collects, analyzes, and reports on education data and statistics on the 
condition of education in our country; conducts long-term longitudinal 
studies and surveys; and supports international assessments in 
accordance with the highest methodological standards and practices for 
data confidentiality and data security.
    Federal, State, and local policy makers rely on over two dozen 
NCES-supported survey programs, assessments, and administrative data 
sets, as do schools, educators, and researchers across the country. 
NCES's annual report, The Condition of Education, provides a 
comprehensive statistical overview of U.S. early childhood, K--12, and 
postsecondary education.
    NCES also provides technical assistance to public and private 
education agencies and to States improving their statistical systems. 
Grants from the Statewide Longitudinal Data Systems (SLDS) program 
supports States to build quality data systems that span early 
childhood, K--12, and postsecondary education into the labor force. In 
recent testimony to the House Education and the Workforce Committee, 
Robert Swiggum, Deputy Superintendent, Georgia Department of Education 
spoke of the tremendous value of the Federal SLDS grant that enabled 
Georgia to construct a statewide longitudinal system. In his testimony 
he said that the teachers access to the data has improved their 
teaching and has been a major factor in the dramatic increase in the 
State graduation rate from 59 percent in 2009 to 78 percent in 2015.
    The President has requested a significant increase for this program 
from $35 million in fiscal year 2016 to $81 million in fiscal year 
2017. This would enable States and districts to build on existing work 
and make possible a new competition in fiscal year 2017, allowing more 
States to leverage existing data to examine local education issues and 
concerns and achieve improvements in educational outcomes as have been 
achieved in Georgia.
    NCES is home to the National Assessment of Educational Progress 
(NAEP), known as the ``Nation's Report Card.'' NAEP is an important 
resource for identifying long-term trends in educational proficiency in 
each State and--through the Trial Urban District Assessment--in the 
largest school districts in the Nation.
    Furthermore, NCES manages the U.S. participation in international 
assessments and surveys, which prominently include the Program for 
International Student Assessment (PISA), the Trends in International 
Mathematics and Science Study (TIMSS), and the Progress in 
International Reading Literacy Study (PIRLS). Continued adequate 
funding for these international assessments, enable NCES to accurately 
gauge U.S. performance in reading, math, and science in comparison to 
other countries. This information is particularly useful in a time of 
increasing global economic competition.
    The proposed budget increase would enable NCES to adequately fund 
the most timely information on several high-priority education policy 
issues: early childhood development and education, student loan 
repayment and default, and the development of P-12 and postsecondary 
information hubs to make accessible actionable data and research.
National Center for Education Research (NCER)
    Over the past decade, NCER-funded research has made significant 
advances in our understanding on a broad range of questions, from how 
to increase math achievement in pre-school; improve literacy skills in 
third grade, and reduce drop-out rates. The investments in the research 
are leading to measurable improvements in classrooms across the 
country. The Building Blocks curriculum, born out of IES and NSF funded 
research, has recently been adopted by Boston, New York City, and 
several California districts, and is showing positive effects on young 
children's mathematics and literacy skills.
National Center for Special Education Research (NCSER)
    NCSER supports research that investigates how to improve 
developmental and education outcomes for infants, toddlers, children, 
and youth with, or at risk of developing, disabilities. Since its 
creation in 2004 under the Individuals with Disabilities Education Act, 
NCSER has made important contributions to research goals such as 
identifying effective interventions for children and youth with autism 
and supporting the independence of youth with disabilities post high 
school. Another example of an IES-funded work that is leading to 
tangible improvements for students is the development of the Early 
Literacy Skills Builder program, currently being used in nearly 1,300 
school districts, has been demonstrating improvements in reading 
outcomes for students with significant intellectual disabilities.
National Center for Education Evaluation and Regional Assistance (NCEE)
    NCEE conducts evaluations of large-scale educational projects and 
Federal education programs and advances the use of IES knowledge by 
informing the public and reaching out to practitioners with a variety 
of dissemination strategies and technical assistance programs. The 
Education Resources Information Center (ERIC) is a well-used resource 
throughout the Department of Education. In the past year, there were 
more than 18 million individual sessions--more than 49,500 per day. In 
addition, the What Works Clearinghouse (WWC) provides valuable 
information on the findings and methodologies of evaluations of various 
education practices and policies. The most viewed practice guides 
include Assisting Students Struggling with Mathematics: Response to 
Intervention (RtI) for Elementary and Middle Schools; Reducing Behavior 
Problems in the Elementary School Classroom; and Improving Reading 
Comprehension in Kindergarten Through 3rd Grade--being viewed between 
30,000 to 50,000 times each.
    The investment in resources for IES is small in comparison to the 
challenging issues that our country faces with respect to quality 
education and learning. Only the most competitive research, capacity 
building programs, and data assets are supported by IES, and the yield 
from IES projects has been high for well more than a decade. Further, 
IES funding and emphases are a resource for the very concerns that 
drive this committee and its work. Improving the educational outcomes 
of our citizens would not only help to solve or prevent future labor 
and workforce problems but also improve the health and wellbeing of our 
citizens.
    Thank you for the opportunity to submit written testimony in 
support of $728 million for the Institute of Education Sciences in 
fiscal year 2017. AERA welcomes working with you and your subcommittee 
on strengthening investments in essential research, data, and 
statistics related to education and learning.

    [This statement was submitted by Felice J. Levine, Ph.D., Executive 
Director, American Educational Research Association.]
                                 ______
                                 
         Prepared Statement of the American Geriatrics Society
    Mr. Chairman and Members of the Subcommittee: We submit this 
testimony on behalf of the American Geriatrics Society (AGS), a non-
profit organization of nearly 6,000 geriatrics healthcare professionals 
dedicated to improving the health, independence, and quality of life of 
all older Americans. As the Subcommittee works on its fiscal year 2017 
Labor-HHS Appropriations Bill, we ask that you prioritize funding for 
the geriatrics education and training programs under Title VII and 
Title VIII of the Public Health Service (PHS) Act, additional primary 
care programs under the Health Resources and Services Administration 
(HRSA), and for aging research within the National Institutes of Health 
(NIH)/National Institute on Aging (NIA).
    We ask that the subcommittee consider the following funding levels 
for these programs in fiscal year 2017:
  --$45 million for the Geriatrics Workforce Enhancement Program (PHS 
        Act Title VII, Sections 750 and 753(a) and PHS Act Title VIII, 
        Section 865)
  --$9.7 million for additional primary care workforce programs under 
        HRSA
  --An increase of $500 million over the fiscal year 2016 enacted level 
        for aging research across the NIH, in addition to the funding 
        allocated for Alzheimer's disease and related dementias
    Sustained and enhanced Federal investments in these initiatives are 
essential to delivering high quality, better coordinated, and more cost 
effective care to our Nation's seniors, whose numbers are projected to 
increase dramatically in the coming years. According to the U.S. Census 
Bureau, the number of people age 65 and older will more than double 
between 2010 and 2050 to 88.5 million or 20 percent of the population; 
and those 85 and older will increase threefold to 19 million. To ensure 
that our Nation is prepared to meet the unique healthcare needs of this 
rapidly growing population, we request that Congress provide additional 
investments necessary to expand and enhance the geriatrics workforce, 
which is an integral component of the primary care workforce, and to 
foster groundbreaking medical research.
         programs to train geriatrics healthcare professionals
    Our Nation is facing a critical shortage of geriatrics faculty and 
healthcare professionals across disciplines. This trend must be 
reversed if we are to provide our seniors with the quality care they 
need and deserve. Care provided by geriatrics healthcare professionals, 
who are trained to care for the most complex and frail individuals who 
account for 80 percent of our Medicare expenditures, has been shown to 
reduce common and costly conditions that are often preventable with 
appropriate care, such as falls, polypharmacy, and delirium.
Geriatrics Workforce Enhancement Program ($45 million)
    The Geriatrics Workforce Enhancement Program (GWEP) is currently 
the only Federal program designed to increase the number of providers, 
in a variety of disciplines, with the skills and training to care for 
older adults.
    In May 2015, HRSA announced 41 three-year grant funded programs 
that consolidated the Title VIII Comprehensive Geriatric Education 
Program and the Title VII Geriatric Academic Career Award, Geriatric 
Education Centers, and Geriatric Training for Physicians, Dentists and 
Behavioral and Mental Health Providers programs.
    This consolidation--a change made by HRSA in December 2014--
provides greater flexibility to grant awardees by allowing applicants 
to develop programs that are responsive to the specific 
interprofessional geriatrics and training needs of their communities. 
While the AGS is encouraged by elements of this new approach, we are 
concerned that there is no longer a sufficient focus on the training 
and education of health professionals who wish to pursue academic 
careers in geriatrics or gerontology. The Geriatric Academic Career 
Award (GACA) program is the only Federal program that is intended to 
increase the number of faculty with geriatrics expertise in a variety 
of disciplines. In the past, the number of GACA awardees has ranged 
from 52 to 88 in a given grant cycle; in the most recent round of GWEP 
grants, it appears that only a small number of the grantees will be 
dedicating resources to train faculty in geriatrics and gerontology.
    At a time when our Nation is facing a severe shortage of both 
geriatrics healthcare providers and academics with the expertise to 
train these providers, the AGS believes the number of educational and 
training opportunities in geriatrics and gerontology should be 
expanded, not reduced.
    To address this issue, we request additional funding for the Title 
VII and Title VIII geriatrics professions programs for fiscal year 
2017:

  --Geriatrics Workforce Enhancement Program ($45 million)

    GWEP seeks to improve high-quality, interprofessional geriatric 
        education and training to the health professions workforce, 
        including geriatrics specialists, as well as increase 
        geriatrics competencies of primary care providers and other 
        health professionals to improve care in medically underserved 
        areas. It supports the development of a healthcare workforce 
        that improves health outcomes for older adults by integrating 
        geriatrics with primary care, maximizing patient and family 
        engagement and transforming the healthcare system. We ask the 
        subcommittee to provide a fiscal year 2017 appropriation of $45 
        million for the Geriatrics Workforce Enhancement Program. With 
        more resources available, we also ask for a renewed emphasis to 
        address the severe shortfall of faculty with expertise in 
        geriatrics and gerontology.
Additional Workforce Programs under the Health Resources and Services 
        Administration ($9.7 million)

  --National Health Care Workforce Commission ($3 million)

    The National Health Care Workforce Commission was established in 
        the Affordable Care Act to identify barriers to healthcare 
        workforce development and to formulate a national strategy to 
        address the shortage; however, Congress has not provided 
        funding for the Commission to be convened. The AGS believes 
        that the Commission's work--including research on topics such 
        as workforce priorities and goals; current and projected 
        workforce supply; and needs and assessments of current 
        education and training activities--is an important first-step 
        in the effort to bolster the healthcare workforce in order to 
        meet the needs of the burgeoning number of older Americans. We 
        request $3 million for the Commission so that it can accomplish 
        its essential mission.

  --Geriatric Career Incentive Awards Program ($3.3 million)

    Congress authorized this program under the Affordable Care Act to 
        provide financial support to foster greater interest among a 
        variety of health professionals entering the field of 
        geriatrics, long-term care, and chronic care management. Our 
        funding request includes $3.3 million for this program.

  --Training Opportunities for Direct Care Workers ($3.4 million)

    Under the Affordable Care Act, Congress approved a program that 
        will offer advanced training opportunities for direct-care 
        workers. The AGS believes this program should be funded to 
        improve training and enhance the recruitment and retention of 
        direct care workers, particularly those in long-term care 
        settings. As our population ages, these workers are an integral 
        part of efforts to ensure that older adults have access to 
        high-quality care. We are requesting $3.4 million for this 
        program.
                      research funding initiatives
National Institutes of Health (additional $500 million over fiscal year 
        2016)
    The institutes that make up the NIH and specifically the NIA lead 
the national scientific effort to understand the nature of aging and to 
extend the healthy, active years of life. As a member of the Friends of 
the NIA, a broad-based coalition of aging, disease, research, and 
patient groups committed to the advancement of medical research that 
affects millions of older Americans--the AGS urges a minimum increase 
of $500 million over the enacted fiscal year 2016 level in the fiscal 
year 2017 budget for biomedical, behavioral, and social sciences aging 
research efforts across the NIH. The AGS also supports an additional 
$400 million for NIH-funded Alzheimer's disease and related dementias 
research over the enacted fiscal year 2016 level.
    The Federal Government spends a significant and increasing amount 
of funds on healthcare costs associated with age-related diseases. By 
2050, for example, the number of people age 65 and older with 
Alzheimer's disease and related dementias is estimated to reach 13.8 
million--nearly triple the number in 2016--and is projected to cost 
more than $1 trillion. Further, chronic diseases related to aging, such 
as diabetes, heart disease, and cancer continue to afflict 80 percent 
of people age 65 and older and account for more than 75 percent of 
Medicare and other Federal health expenditures. Continued and increased 
Federal investments in scientific research will ensure that the NIH and 
NIA have the resources to conduct groundbreaking research related to 
the aging process, foster the development of research and clinical 
scientists in aging, provide research resources, and communicate 
information about aging and advances in research on aging.
    Strong support such as yours will help ensure that every older 
American is able to receive high-quality care.
    Thank you for your consideration.
                                 ______
                                 
          Prepared Statement of the American Heart Association
    On behalf of our 30 million volunteers and supporters, the American 
Heart Association commends Congress for providing a major fiscal year 
2016 boost for the National Institutes of Health and for the Centers 
for Disease Control and Prevention's heart disease and stroke programs, 
and for placing an enhanced focus on disease burden. The association 
strongly believes that fact-based disease burden measures should be a 
guide when Congress and policymakers allocate research and prevention 
funding and set program priorities for NIH and CDC for fiscal year 
2017.
    Measuring how much actual harm and suffering a specific disease 
exacts upon our society--through numbers of deaths, disability and 
associated medical costs--is an invaluable tool in making better 
informed funding decisions. By aligning resources to these analytics, 
we can have the greatest impact in improving the health and well-being 
of tens of millions of Americans while reducing healthcare costs.
    Sadly, cardiovascular disease (CVD), including heart disease and 
stroke, rank at the top of the disease burden list. Today, nearly 86 
million U.S. adults suffer from some form of CVD and it is projected 
that by the year 2030, nearly 44 percent of U.S. adults will live with 
CVD at a cost over $1 trillion annually. For example, stroke deaths 
have fallen, but there has been little stroke risk reduction. So, more 
people are living with permanent cognitive or physical disability post 
stroke.
    Yet inexplicably, research and prevention remain disproportionately 
underfunded when compared to the crushing burden CVD inflicts upon our 
Nation's physical and economic health--one that we all shoulder. 
Despite a whopping $30-to-$1 return on investment, NIH funds a meager 4 
percent of its budget on heart research, a mere 1 percent on stroke 
research, and a scant 2 percent on other CVD research. This glaring 
disparity must be addressed--and addressed soon--beginning with the 
fiscal year 2017 appropriations process.
    AHA and its millions of volunteers want to work with Congress to 
protect, preserve, and restore funding for NIH-funded research. We want 
to build healthier lives free of cardiovascular diseases and stroke. 
Leveraging disease burden measures is crucial to achieving that goal
     funding recommendations: investing in the health of our nation
    Despite the very real threat CVD poses to our Nation's health and 
economy, research that could ultimately develop a cure goes unfunded. 
Inadequate and unreliable funding are two of the most intractable 
problems we face. However, the American Heart Association's funding 
recommendations are both fiscally responsible and reflect the burden 
CVD imposes.
Capitalize on Investment for the National Institutes of Health (NIH)
    Robust NIH-funded research helps prevent and cure disease, 
transforms patient care, inspires economic growth, advances innovation, 
and maintains U.S. leadership in pharmaceuticals and biotechnology. NIH 
is the world's leader of basic research--the foundation for all medical 
advances--and an essential Federal Government function the private 
sector cannot replace. But, our Nation's competitive edge in research 
has been eroded in recent years by scarce resources.
    In addition to improving health, NIH produces a solid return on 
investment. In 2014, NIH supported more than 400,000 U.S. jobs and over 
$58 billion in economic activity. Every $1 in NIH funding created $2 in 
economic activity in 2007. Yet, due to inadequate resources since 2003, 
NIH has lost more than 19 percent of its purchasing power. Ironically, 
this decline has occurred at a time of unprecedented scientific 
opportunity as other countries, like China, wisely increased investment 
in science--some by double digits. These cuts have disheartened early 
U.S. career scientists who may decide against pursuing careers in 
research unless Congress acts.
    American Heart Association Advocates.--We urge Congress to 
appropriate $34.5 billion for NIH to continue to restore its purchasing 
power and advance cardiovascular disease research.
Enhance Funding for NIH Heart and Stroke Research: A Proven and Wise 
        Investment
    NIH research plays a vital role in cutting CVD death rates. Today, 
scientists are closer to discoveries that could result in revolutionary 
treatments and even cures. In addition to saving lives, NIH studies can 
produce substantial cost savings. For example, investments in the NIH 
Women's Health Initiative postmenopausal estrogen plus progestin trial 
generated an economic return of $140 for every $1 invested and led to 
76,000 fewer cases of cardiovascular disease. The first NIH tPA drug 
trial led to a 10-year net $6.47 billion cut in stroke care costs.
Cardiovascular Disease Research: National Heart, Lung, and Blood 
        Institute (NHLBI)
    Much of the decline in CVD death rates is a result of NHLBI 
research. However, current funding is not commensurate with CVD disease 
burden, nor does it allow us to capitalize on investments that have led 
to major advances. For example, a landmark clinical trial showed 
setting a systolic blood pressure goal of 120 mm Hg in adults over age 
50 cut cardiovascular events (heart attack, heart failure, and stroke) 
by 25 percent and reduced the risk of death by 27 percent, compared to 
the standard treatment target of 140 mm Hg.
Stroke Research: National Institute of Neurological Disorders and 
        Stroke (NINDS)
    Stroke continues to place an immense burden on our society and 
economy. An estimated 795,000 Americans will suffer a stroke this year, 
and nearly 129,000 will die. Many of the 7 million survivors face grave 
physical, mental, and emotional distress. In addition, stroke costs an 
estimated $33 billion in medical expenses and lost productivity each 
year and a study projects that direct costs of stroke will triple 
between 2012 and 2030.
    NINDS funding must be substantially increased if we are to exploit 
advances in stroke research, including studies showing that a specific 
molecule plays a key role in brain repair after stroke. More stroke 
funding could also boost the NIH Stroke Clinical Trials Network, 
including early stroke recovery; hasten translation of preclinical 
animal models into clinical studies; prevent vascular cognitive damage; 
expedite comparative effectiveness research trials; develop imaging 
biomarkers; refine clot-busting treatments; achieve robust brain 
protection; and promote the use of neural interface devices. Additional 
resources are needed to support the BRAIN Initiative.
    American Heart Association Advocates.--We recommend that NHLBI be 
funded at $3.4 billion and NINDS at $1.8 billion.
Increase Funding for the Centers for Disease Control and Prevention 
        (CDC)
    Prevention is the best way to protect against the ravages of CVD. 
Yet, proven efforts are not fully executed due to insufficient 
resources. In addition to funding research and evaluation and 
developing a surveillance system, the Division for Heart Disease and 
Stroke Prevention directs Sodium Reduction in Communities and the Paul 
Coverdell National Acute Stroke programs. DHDSP and the CMS coordinate 
the Million HeartsTM initiative to prevent 1 million heart 
attacks and strokes by 2017. DHDSP also runs WISEWOMAN, serving 
uninsured and under-insured, low-income women ages 40 to 64 through 
preventive health services, referrals to local healthcare, and tailored 
lifestyle plans to foster lasting behavioral change.
    American Heart Association Advocates.--We join the CDC Coalition in 
asking for $7.8 billion for the agency. AHA requests $160.037 million 
for the DHDSP to intensify work on the State Public Health Actions and 
on the State and Local Public Health Actions To Prevent Obesity, 
Diabetes, and Heart Disease, and Stroke; and $37 million for WISEWOMAN 
for expansion to additional and currently-funded States. We ask for $5 
million for Million HeartsTM to support enhanced ways to 
implement ABCS: aspirin when appropriate, blood pressure control, 
cholesterol management, and smoking cessation; and activities to 
increase the use of cardiac rehabilitation. Although cardiac 
rehabilitation can reduce cardiovascular deaths by nearly 30 percent, 
and re-hospitalizations by more than 30 percent, less than 20 percent 
of eligible patients participate.
                               conclusion
    Cardiovascular disease, including heart disease and stroke, 
inflicts the highest disease burden on Americans. Our budgetary 
recommendations for NIH and CDC will save lives and reduce healthcare 
costs. We respectfully ask Congress to enact our recommendations that 
are a wise investment for the long-term health and economic well-being 
of our Nation.

    [This statement was submitted by Mark Creager, M.D., President, 
American Heart Association.]
                                 ______
                                 
 Prepared Statement of the American Indian Higher Education Consortium
    This statement includes the fiscal year 2017 requests of the 
Nation's Tribal Colleges and Universities (TCUs). The following is a 
summary of our requests including Department, program, and amount 
requested:

_______________________________________________________________________
Department of Education
    Office of Postsecondary Education
  --HEA Title III-A, Sec. 316: $60,000,000 (discretionary and 
        mandatory)
  --Perkins Career and Technical Education Programs (Sec. 117): 
        $10,000,000
    Office of Career, Technical, and Adult Education
  --American Indian Adult and Basic Education: $8,000,000, from 
        existing funds
Department of Health And Human Services
  --Administration for Children and Families/Office of Head Start: 
        $8,000,000, from existing funds
  --Substance Abuse and Mental Health Services Administration (SAMHSA): 
        $10,000,000
_______________________________________________________________________
                      u.s. department of education
I. Higher Education Act Programs
  --Strengthening Developing Institutions, Title III-A Sec. 316.--TCUs 
        urge the Subcommittee to restore the discretionary and 
        mandatory funding for HEA Title III-A, Sec. 316 to $60,000,000 
        in fiscal year 2017. Titles III and V of the Higher Education 
        Act support institutions that enroll large proportions of 
        financially disadvantaged students. The TCUs, which are truly 
        developing institutions, are funded under Title III-A Sec. 316 
        and provide quality higher education opportunities to some of 
        the most rural, impoverished, and historically underserved 
        people in the country. In fact, more than 50 percent of our 
        students are first generation. Average family income is 
        $15,260; local unemployment rates often exceed 50 percent. The 
        goal of HEA-Titles III/V programs is ``to improve the academic 
        quality, institutional management and fiscal stability of 
        eligible institutions . . .  to increase their self-sufficiency 
        and strengthen their capacity to make a substantial 
        contribution to the higher education resources of the Nation.'' 
        The TCU Title III-A program is specifically designed to address 
        the critical, unmet needs of American Indian students and their 
        communities, to effectively prepare them to succeed in a 
        globally competitive workforce. Yet, in fiscal year 2011 this 
        program was cut by over 11 percent and received subsequent 
        cuts, including sequestration, until last year. Despite a small 
        increase in fiscal year 2016, TCUs still have not recovered 
        from the earlier cuts to this vitally important program. In 
        fiscal year 2016, the TCU section (Sec.316) was the only Title 
        III/V program that emerged from Conference with a funding level 
        BELOW the level passed by either the House or Senate in their 
        respective appropriations bills.
  --TRIO.--Retention and support services are vital to achieving the 
        national goal of having the highest proportion of college 
        graduates in the world by 2020. TRIO programs were created out 
        of a recognition that college access is not enough to ensure 
        advancement and that multiple factors work to prevent 
        successful completion by many low-income and first-generation 
        students and students with disabilities. In addition to 
        providing the maximum Pell Grant award level, it is critical 
        that Congress sustain and increase support for TRIO programs so 
        that low-income and minority students have the support they 
        need to access and complete postsecondary education programs.
  --Pell Grants.--The importance of Pell Grants to TCU students cannot 
        be overstated. Eighty-five percent of TCU students receive Pell 
        Grants, primarily because student income levels are so low and 
        they have far less access to other sources of financial aid 
        than students at State-funded and other mainstream 
        institutions. At TCUs, Pell Grants are doing exactly what they 
        were intended to do: they are serving the needs of the lowest 
        income students by helping them gain access to quality 
        postsecondary education, an essential step toward becoming 
        active, productive members of the workforce.
II. Carl D. Perkins Career and Technical Education Programs
  --Tribally Controlled Postsecondary Career and Technical 
        Institutions.--AIHEC requests $10,000,000 to fund grants under 
        Sec. 117 of the Perkins Act. Section 117 of the Carl D. Perkins 
        Career and Technical Education Act provides a competitively 
        awarded grant opportunity for tribally chartered and controlled 
        career and technical institutions, which are providing vitally 
        needed workforce development and job creation education and 
        training programs to American Indians and Alaska Natives (AI/
        ANs) from tribes and communities with some of the highest 
        unemployment rates in the Nation. Jayvion Chee of Rabbitbrush, 
        NM is an example of a young Native student benefiting from this 
        modest program. In March, Jayvion was named as Navajo Technical 
        University's (NTU) Student of the Year. Jayvion spent much of 
        last year working on a geographic information technology (GIT) 
        degree project that assessed the potential impacts on water 
        resources posed by hydraulic fracturing in San Juan County, NM. 
        Jayvion used his education in NTU's Associate of Applied 
        Science-GIT degree program to map current natural gas fracking 
        wells to better understand the potential risks associated with 
        the fracking process. Through his research, he found that 87 
        documented wells within the San Juan region could possibly lead 
        to adverse impacts on local communities--including the land of 
        which his grandfather resides. He has now presented the results 
        of his research at national STEM and education conferences 
        around the country.
  --Native American Career and Technical Education Program (NACTEP).--
        NACTEP (Sec. 116) reserves 1.25 percent of appropriated funding 
        to support American Indian career and technical programs. The 
        TCUs strongly urge the Subcommittee to continue to support 
        NACTEP, which is vital to the continuation of career and 
        technical education programs offered at TCUs that provide job 
        training and certifications to remote reservation communities.
III. Adult Education and Family Literacy Act--Adult Education, Basic 
        Grants to States
  --American Indian Adult and Basic Education.--AIHEC requests the 
        Subcommittee to direct that $8,000,000 of the approximately 
        $582,000,000 appropriated for Adult Education & Literacy State 
        Formula Grants be made available to make competitive awards to 
        TCUs to help meet the growing demand for adult basic education 
        and GED training services in tribal communities. This program, 
        which Congress stopped funding in the mid-1990s, was designed 
        to support much-needed adult basic education (ABE) and GED 
        training for AI/ANs through federally recognized Indian Tribes 
        and TCUs. (A specific Tribal/TCU set-aside within any Federal-
        to-State block grant program is necessary, because States 
        generally do not provide funding to Indian tribes or TCUs for 
        programs on Federal trust land, even when there is no 
        comparable Federal program for tribes.) In the absence of 
        dedicated funding for American Indians and a severe constraint 
        on--and in many cases, a complete lack of--funding allocated 
        from State programs to TCUs, our colleges must find a way, 
        often using already insufficient institutional operating funds, 
        to provide ABE and GED classes for AI/ANs that the present K-12 
        Indian education system has failed. TCUs, like most community 
        colleges, are open door institutions. More than 71 percent of 
        all TCU students need developmental education in at least one 
        subject (math, science, or reading/composition) before 
        beginning college-level coursework and 15 percent of all first-
        time entering TCU students must first prepare for and pass a 
        high school equivalency test, yet little or no funding is 
        available for these critical programs. Challenges have 
        intensified since the GED test was revamped in January 2014. 
        The new computer-based and more rigorous test has posed 
        difficulties for many TCUs to implement (with little or no 
        funding for staff professional development or technical 
        assistance) and much more difficult for American Indians to 
        pass. One TCU, Oglala Lakota College, reports that prior to the 
        new GED test, an average of 29 students successfully passed the 
        GED test each year and enrolled in the college. Often, these 
        students became some of the OLC's most successful graduates. 
        However, since the new GED was implemented, only seven students 
        passed in 2014 and two in 2015. OLC and all of the TCUs are in 
        critical need of adequate and stable funding to provide rural 
        AI/ANs the preparation and testing they need to move from 
        victims of generational poverty and unemployment to productive 
        and tax-paying members the U.S. workforce.
         u.s. department of health and human services programs
I. Administration for Children and Families--Office of Head Start
  --Tribal Colleges and Universities Head Start Partnership Program.--
        AIHEC requests that $8 million of the $9.6 billion proposed for 
        making payments under the Head Start Act be designated for the 
        TCU-Head Start Partnership program, as reauthorized in PL 110-
        134, so that TCUs can provide high-quality, culturally 
        appropriate training for teachers and workers in Indian Head 
        Start programs. With the reauthorization of the Head Start 
        program in the mid-1990s, Congress mandated that by 2013, 50 
        percent of Head Start teachers nationwide must have at least a 
        baccalaureate degree in Early Childhood Education and all 
        teacher assistants must have a child development associate 
        credential or be enrolled in an associate's degree program. 
        Today, 73 percent of Head Start teachers nationwide hold the 
        required bachelor's degree; but only 39 percent of Head Start 
        teachers in Indian Country (Region 11) meet the requirement, 
        and only 38 percent of workers met the associate-level 
        requirements. This disparity in preparation and teaching 
        demands our attention: AI/AN children deserve--and desperately 
        need--qualified teachers. TCUs are ideal catalysts for filling 
        this inexcusable gap. From 2000 to 2007, the U.S. Department of 
        Health and Human Services provided modest funding for the TCU-
        Head Start Program, which helped TCUs build capacity in early 
        childhood education by providing scholarships and stipends for 
        Indian Head Start teachers and teacher's aides to enroll in TCU 
        early childhood programs. Before the program ended in 2007 
        (ironically, the same year that Congress specifically 
        authorized the program in the Head Start Act), TCUs had trained 
        more than 400 Head Start workers and teachers, many of whom 
        have since left for higher paying jobs in elementary schools. 
        Today, Tribal Colleges such as Salish Kootenai College in 
        Pablo, Montana are providing culturally based early childhood 
        education free of charge to local Head Start workers. With 
        restoration of this modestly funded program, similar programs 
        could be available to the teachers and aides throughout Indian 
        Country.
II. Substance Abuse and Mental Health Services Administration (SAMHSA)
  --New TCU Opioid/Substance Abuse Research and Prevention Program.--
        AIHEC requests that as part of the ongoing national opioid/
        prescription drug initiative, $10 million be appropriated to 
        establish a Tribal Colleges and Universities Substance Abuse/
        Behavioral Health Research and Prevention Initiative within 
        SAMHSA to strategically identify and address the drug abuse and 
        behavioral health issues impacting Native youth. The most at-
        risk population in the United States is American Indian and 
        Alaska Native college-aged youth (ages 15-24). Suicide of 
        friends, classmates, and relatives; alcohol and substance 
        abuse; domestic violence and abuse; bullying and extreme 
        poverty are all too common to Tribal College students. In fact, 
        a seminal behavior health survey of TCU students,\1\ revealed 
        that 50.4 percent of TCU students surveyed reported being 
        physically intimidated, assaulted, or bullied/excessively 
        teased by a peer. Twenty-four percent--one-quarter--reported 
        having used opioids, compared to less than 9 percent of 
        mainstream college students (in a 2013 national survey, which 
        is the only comparable data available). Of the TCU students who 
        had used opioids, 25 percent reported feeling signs of 
        addiction, and nearly 34 percent had taken opioids without a 
        prescription in the last 3 months. AIHEC and partnering 
        entities are on the leading edge nationally in collecting data 
        of this type due in large part to modest grants from the under-
        funded ``Native American Research Centers on Health'' program 
        operated by the National Institutes of Health and the Indian 
        Health Service (and in needed of increased funding). Data of 
        this type has never been collected nationally among college 
        students, but the TCUs know that we must get a handle on this 
        problem before it spirals out of control. Without serious, 
        sustained, and community-based intervention, it will rapidly 
        spiral out of control. Already, the death rates among American 
        Indians from heroin overdose has increased 236 percent between 
        2010 and 2014. The Centers for Disease Control and Prevention 
        (CDC) reported that in 2014, American Indians were dying at 
        double or triple the rates of African-Americans and Latinos 
        from opioid, including heroin, addiction.
---------------------------------------------------------------------------
    \1\ TCU-CCC Baseline Survey Conducted in 22 TCUs Nationally between 
March 2015 and Feb 2016. Preliminary Data. This research is supported 
by grants from the NIAAA, 1R01AA022068 and the NIMHD, 5P60-MD006909 
through the National Institutes of Health.

    ``Administrators at Fort Peck Community College estimate that our 
        decreasing enrollment of degree seeking students is attributed 
        to the increasing number of community members who are addicted 
        to meth, heroin and prescription drugs,'' stated Fort Peck 
        Community College (Poplar, MT) president, Haven Gourneau. 
        ``[N]o one wants to be an addict, and if asked every addict 
        would willingly take a `magic' pill that would cure them if 
        they could. With that said, we know there is no `magic' pill 
        and so we will continue to see a decline in our community 
        socially and economically unless we can beat addictions that 
---------------------------------------------------------------------------
        are sucking the life out of our communities.''

    As engaged, place-based institutions, Tribal Colleges are committed 
        to addressing the many challenges facing our communities, 
        including the growing opioid epidemic. TCUs are leading the way 
        through student-based participatory research to identify the 
        specific needs of tribal communities (youth and students), so 
        that community-relevant solutions can be identified and 
        culturally adapted, tested, and then shared with others. 
        SAMHSA, which has modest tribal drug abuse prevention programs 
        and an ongoing effort with Historically Black Colleges and 
        Universities, seems an appropriate agency to administer a TCU 
        Behavioral Health Research and Prevention Initiative to assist 
        TCUs, working with local communities and researchers, in taking 
        strategic steps to identify the behavioral health challenges, 
        develop or adapt innovative and community-practiced 
        intervention strategies, forge relationships with local and 
        regional non-profit providers, and create and test models that 
        can be replicated and adapted at other TCUs and tribal 
        communities. This targeted approach will help ensure that 
        tribal youth have the same chance as others to become healthy, 
        productive adults who will greatly benefit their local 
        communities and the Nation as a whole.
    We respectfully request that the Members of the Subcommittee 
recognize the significant contribution of the Tribal Colleges and 
Universities to our students, their communities, and the Nation as a 
whole by continuing and expanding the Federal investment our 
institutions and careful consideration our fiscal year 2017 
appropriations needs and requests.
                                 ______
                                 
         Prepared Statement of the American Library Association
    The American Library Association (ALA) is the oldest and largest 
library association in the world, with more than 58,000 members in 
academic, public, school, government, and special libraries. Our 
mission is to provide leadership for the development, promotion and 
improvement of library and information services and the profession of 
librarianship in order to enhance learning and ensure access to 
information for all. On behalf of ALA, I want to thank the Labor, 
Health and Human Services, Education, and Related Agencies Subcommittee 
for the opportunity to provide comments in support of two important, 
long-standing, cost-effective and highly successful programs that 
assist and empower students, families, businesses, veterans, families 
with differently-abled members, and many others.
    Specifically, we urge the Subcommittee to include in its 
appropriations bill $186.6 million for the Library Services and 
Technology Act (LSTA) under the Institute of Museum and Library 
Services (IMLS) and $27 million for the Innovative Approaches to 
Literacy (IAL) program under the Department of Education (DOE). Both 
LSTA and IAL are authorized by Congress. Below are just a few examples, 
among hundreds, of the profound, day-to-day impact that Congress' 
modest but essential investment LSTA produces for Americans everywhere 
every day:
  --One of the most fundamental roles of the public library is to help 
        young children become future readers. To aid in this effort, 
        the Missouri State Library leveraged its LSTA grant to embark 
        on a statewide initiative called Racing to Read. The Racing to 
        Read program, developed by the Springfield-Greene Public 
        Library in Springfield features fun activities that help 
        children get ready to learn to read by focusing on five basic 
        skills: telling stories, talking and reading, singing and 
        rhyming, playing with letters, and loving books. These 
        activities are easily incorporated into a library's preschool 
        story times, and are shared with parents and caregivers for use 
        at home, at day care centers and with partner agencies.
  --When returning soldiers in Modesto, CA, needed help readjusting to 
        [reentering] the civilian world, the Stanislaus Public Library 
        was able to step in and provide the transitional assistance 
        they needed. The library used its LSTA grant to create a 
        program educating veterans about the array of services and 
        benefits available to them and their families. The library also 
        has assisted vets with their online education and employment 
        needs. The Stanislaus Public Library is one of 38 California 
        public libraries offering a Veterans Resource Center, all of 
        them made possible in part by LSTA funding.
  --New businesses in Kings Mountain, NC struggled to survive yet were 
        closing at a high rate. Local businesses in this rural 
        community needed resources to more effectively compete. The 
        Mauney Memorial Library used its LSTA grant to create the 
        Downtown Kings Mountain Small Business Success Project, hiring 
        a business librarian all of whose time was dedicated to 
        assisting local businesses in development of a successful 21st 
        century market online presence. The Success Project's business 
        librarian worked with businesses on learning to: develop 
        business plans, manage social media, analyze marketing and 
        other data, conduct market research, plan more effectively, and 
        to improve safety and security audits. The librarian also 
        helped individual businesses to develop professional caliber 
        websites.
    Without LSTA funding, these and many other specialized programs 
targeted to the needs of their communities across the country likely 
will be entirely eliminated, not merely scaled back. In most instances, 
LSTA funding (and its required but smaller State match) allows 
libraries to create new programs for their patrons, like those 
described above. Without LSTA underwriting, however, tight State and 
local budgets mean that libraries simply will not have the resources to 
institute and keep these programs, which are so valuable to so many 
Americans.
    The beneficiaries of the many services that libraries offer are by 
no means limited, however, to the targeted participants in special 
programs like the ones just described, Mr. Chairman. Rather, America's 
nearly 17,000 public libraries serve an astonishing 4 million people 
daily in communities of every size and in every corner of the country. 
In addition to the kinds of veterans outreach and business-building 
assistance described above, libraries routinely also offer Americans 
from every walk of life ready and free access to all types of 
information, career and workforce skills training, digital and print 
literacy instruction, job searching databases, resume workshops, summer 
reading projects, creative programming for children, best practices 
training for local librarians, access to teleconferencing facilities, 
and 3D printers, and so much more. Indeed, according to an ALA report, 
more than 92 percent of public libraries offer services that help 
patrons complete job applications, create resumes, and access job 
databases and research. Libraries also provide resources and 
specialized collections for small businesses, which help them create 
business plans, develop new growth strategies, and research target 
markets.
    Perhaps most critically, however, every day thousands of libraries 
across the country also provide no-fee public access to computers and 
the Internet in some of our most distressed communities, both rural and 
urban. For the approximately 19 million Americans who cannot afford 
broadband at home, or who live in rural areas where the infrastructure 
does not support home broadband, libraries are an indispensable access 
point to the Internet. According to a recent ALA report, 65 percent of 
all libraries nationwide are the only provider of free Internet access 
in their communities. In rural areas, public libraries are even more 
critical, with 73 percent serving as their community's only free 
Internet provider. Increasingly, the Internet is the only means by 
which an individual can research job opportunities, take their GED, 
apply for a job, or submit government forms, such as tax filings or 
benefit claims. Many individuals could not even submit comments to this 
Subcommittee without access to broadband at their local library. LSTA 
funding often is what makes these services possible.\1\
---------------------------------------------------------------------------
    \1\ LSTA also funds: the Native American and Native Hawaiian 
Library Services program to support improved access to library services 
for those populations; National Leadership Grants to support activities 
of national significance that enhance the quality of library services 
nationwide, and provide pilots for coordination between libraries; and 
the Laura Bush 21st Century Librarians program, used to help develop 
and promote the next generation of librarians.
---------------------------------------------------------------------------
    The bulk of LSTA funds are distributed to each State through IMLS 
according to a population-based grant formula. Each State must match 
the Federal funds received and determines for itself how to best 
allocate its LSTA awards, As the examples above merely hint at, 
libraries have used LSTA funding myriad diverse and innovative programs 
that profoundly touch and better the lives of tens of millions of 
Americans in every State in the Nation. LSTA is truly a local 
decisionmaking success story.
    During this time of increased and increasing demand, many libraries 
are under severe budget pressure. The support they receive through the 
LSTA, the primary source of annual funding for libraries in the Federal 
budget, is thus critical to meeting the needs of Americans everywhere 
and, in so doing, building our economy one job and one community at a 
time.
    Accordingly, Mr. Chairman, ALA asks that you and the Committee 
provide $186.6 million for LSTA in fiscal year 2017 to ensure that 
Americans of all ages continue to have access to the life- sustaining, 
-affirming and -expanding resources that their trusted local libraries 
provide. ALA respectfully submits, Mr. Chairman, that there can be few, 
if any, more democratic, cost-effective and impactful uses of Federal 
dollars than LSTA in the entirety of the Federal budget.
    Libraries, of course, also have tremendous impact upon the Nation's 
children, especially our most needy, opening their eyes and minds to 
books and information of all kinds that help them gain and enhance 
literacy skills. Surveys show that many of our Nation's children living 
in poverty have no books at home. These children depend on their local 
libraries' story-time and summer reading programs to help them prepare 
to learn in school and to succeed.
    In addition to supporting LSTA, ALA also asks that you maintain 
fiscal year 2016's modest, but critical, Federal investment of $27 
million in the Innovative Approaches to Literacy (IAL) program. IAL 
provides competitive awards to school libraries and national not-for-
profit organizations (including partnerships that reach families 
outside of local educational agencies) to put books into the hands of 
children and their families in high-need communities. Providing books 
and childhood literacy activities to such children is crucial to their 
learning to read, which is crucial to their--and the Nation's--economic 
futures. The program also supports parental engagement in their 
children's' reading life, and focuses on promoting student literacy 
from birth through high school. IAL was authorized under the Every 
Student Succeeds Act of 2015.
    Congress first recognized the importance of this program in fiscal 
year 2012 when $28.6 million was appropriated for early literacy 
support. In 2012, the U.S. Department of Education awarded 2-year IAL 
grants to 46 nonprofit organizations and school districts in 21 States 
and the District of Columbia. In 2014, the Department made 32 new 
awards to national non-profits and school libraries. As with LSTA 
funds, school libraries and others are doing remarkable, valuable work 
with IAL support, as these brief examples reveal:
  --The Waukegan Community Unit School District in Illinois sought to 
        improve literacy achievement in this lower income community 
        with a high percentage of families where English is the second 
        language. The school's library used an IAL grant to implement 
        its ``Ladders to Literacy'' program, and innovative print and 
        e-book based curriculum that also provided targeted literacy 
        coaching and development for teachers. It measurably succeeded 
        in improving participants' reading achievement.
  --In the Milwaukee Public Schools, an IAL grant supported a project 
        by its Focus on Literacy Foundation (nicknamed ``FLF''). FLF 
        sought to improve kindergarten through 4th grade literacy 
        through innovative uses of technology, encouraging family 
        reading-involvement opportunities, and the distribution of 
        books to students with which they could expand their own home 
        libraries. FLF was implemented at four low-achieving schools 
        serving economically disadvantaged children who often had no 
        books at home at all.
    Studies show that strong literacy skills and year-round access to 
books is a critical first-step towards literacy and life-long learning. 
For American families living in poverty, access to reading materials is 
severely limited. These children have fewer books in their homes than 
their peers, which hinders their ability to prepare for school and to 
stay on track.
    Congress has taken an important step in supporting the needs of 
disadvantaged students by providing IAL funding for book distribution, 
early literacy services, and effective school library programs. We urge 
the Subcommittee and full Committee to continue this important work by 
maintaining a $27 million investment in IAL in the fiscal year 2017 
Labor, Health and Human Services, Education, and Related Agencies bill.
    ALA urges and appreciates the Subcommittee's continued strong 
support of LSTA and IAL, Mr. Chairman. Thank you for your commitment to 
sustaining and strengthening our communities and our Nation by 
sustaining and strengthening America's libraries.
                                 ______
                                 
          Prepared Statement of the American Lung Association
    The American Lung Association was founded in 1904 to fight 
tuberculosis and is one of the oldest voluntary health organization in 
the United States. Since the beginning, the organization has been on 
the front lines advocating for laws that protect the air we breathe and 
our lungs. Accordingly, the Lung Association is the leading 
organization working to save lives by improving lung health and 
preventing lung disease through education, advocacy and research. As 
the result of funding from this Committee, public health and research 
programs will help to work to prevent lung disease, improve health and, 
by extension save lives of millions of Americans.
   improving public health and maintaining our investment in medical 
                                research
    The American Lung Association strongly supports an increase in 
funding to $34.5 billion for the National Institute of Health (NIH). We 
need sustained and robust investments for NIH so that the promise of 
biomedical research can be achieved. While our focus is on lung disease 
research, we support robust, sustained and predictable investments in 
research funding across the entire NIH with particular emphasis on the 
National Cancer Institute, the National Heart, Lung and Blood 
Institute, the National Institute of Allergy and Infectious Diseases, 
the National Institute of Environmental Health Sciences, the National 
Institute of Nursing Research, the National Institute on Minority 
Health & Health Disparities, the National Institute on Drug Abuse and 
the Fogarty International Center.
                              lung disease
    Lung disease is the third highest killer in America. It takes the 
lives of almost 419,000 Americans each year, and is responsible for one 
in every six deaths. It has been estimated that more than 33 million 
Americans suffer from a chronic lung disease and lung disease costs the 
economy $129 billion each year.
                 the prevention and public health fund
    The Lung Association strongly supports the Prevention and Public 
Health Fund that was established in the Affordable Care Act. We ask the 
Committee to oppose any attempts to divert or use the Fund for any 
purposes other than what it was originally intended. The Prevention 
Fund provides funding to the Centers for Disease Control and Prevention 
(CDC) and its critical public health initiatives, such as the necessary 
community programs that provide resources for those who want to quit 
smoking, support groups for lung cancer patients, and classes that 
educate people on ways to avoid asthma attacks. The Prevention Fund 
also supports CDC's media campaign ``Tips from Former Smokers.''
                              lung cancer
    Lung cancer is the number one cancer killer of both women and men. 
It is estimated that 224,390 new cases of lung cancer will be diagnosed 
in 2016, and over 156,000 Americans will die from the disease--85,710 
in men and 70,542 in women. Survival rates for lung cancer tend to be 
lower than those of leading cancers, due to the lack of early detection 
and diagnosis. African Americans are more likely to die from lung 
cancer than persons of any other racial group.
    Personalized and targeted therapies hold tremendous potential in 
the fight against lung cancer. As the result of previous investments in 
biomedical research, in 2015, the Food and Drug Administration approved 
seven new medications for patients with metastatic lung cancer. The 
American Lung Association thanks the Committee for its 5 percent 
increase in funding for NIH, including funds for the President's 
Precision Medicine Initiative with its ALCHEMIST and Lung-MAP trials 
that target lung cancer. We ask the Committee to continue to build on 
this momentum by increasing funding for the National Institutes of 
Health to $34.5 billion in fiscal year 2017.
                              tobacco use
    The use of tobacco is the number one preventable cause of death in 
the United States. It kills approximately half a million people every 
year. 40 million American adults smoke and 4.7 million children use 
tobacco products. Annual healthcare and lost productivity costs total 
$332 billion in the U.S. each year. Each day, over 2,500 kids under 18 
years of age try their first cigarette and close to 600 kids become 
new, regular daily smokers.
    The CDC Office on Smoking and Health (OSH) must continue to receive 
robust funding to help combat the tobacco-caused diseases that are 
burdening the Nation. Public health interventions have been 
scientifically proven to reduce tobacco use, the leading cause of 
preventable death in the United States. The American Lung Association 
urges that $220 million be appropriated to OSH for fiscal year 2017.
    The American Lung Association respectfully requests the Committee's 
support for the Office of Smoking and Health and the ``Tips from Former 
Smokers'' Campaign. Over the past 5 years, hundreds of thousands of 
Americans have successfully quit smoking because of ``Tips'' and 
millions more have made quit attempts. The ``Tips'' campaign has been 
an incredible return on investment that continues to generate positive 
outcomes. An accepted threshold for cost-effective public health 
interventions is approximately $50,000. The 2012 Tips campaign spent 
$480 per smoker who quit and $393 per year of life saved.
                                 asthma
    Twenty-four million Americans have asthma, including 6.3 million 
children. It is highly prevalent and a costly disease. The Nation is 
making progress to combat against asthma but this advancement can only 
continue with sustained investment. Asthma prevalence rates are over 45 
percent higher among African Americans than whites. Asthma costs our 
healthcare system over $50.1 billion annually and indirect costs from 
lost productivity add another $5.9 billion, for a total of $56 billion 
dollars annually.
    The American Lung Association thanks the Committee for its increase 
in fiscal year 2016 and asks to appropriate $30.596 million to the 
CDC's National Asthma Control Program (NACP) in fiscal year 2017. The 
NACP tracks asthma prevalence, promotes asthma control and prevention 
and builds capacity in State programs. This program has been highly 
effective: the rate of asthma has increased, yet asthma mortality and 
morbidity rates have decreased. Currently, only 23 States receive 
funding--leaving a nationwide public health void that can lead to 
unnecessary asthma-related attacks and healthcare costs. Increased 
funding could help develop asthma programs in the remaining 27 States 
and the District of Columbia.
    Additionally, we recognize the importance of a robust and sustained 
increases for the National Heart, Lung and Blood Institute and National 
Institute of Allergy and Infectious Diseases. With increased support, 
both agencies will be able to continue their investments in asthma 
research in pursuit of treatments and cures.
                 chronic obstructive pulmonary disease
    COPD (Chronic Obstructive Pulmonary Disease) is the third leading 
cause of death in the U.S. More than 24 million U.S. adults had 
evidence of impaired lung function, indicating an under diagnosis of 
COPD. In 2013, 145,575 people in the U.S. died of COPD, representing 
one COPD death every 4 minutes. The American Lung Association also asks 
the Committee to continue its support of the National Heart, Lung and 
Blood Institute working with the CDC and other appropriate agencies to 
act on its national action plan to address COPD, which should include 
public awareness and surveillance activities. The American Lung 
Association requests sustained and robust funding for the National 
Heart, Lung and Blood Institute.
                        pneumonia and influenza
    In 2013, there were a combined 56,979 deaths due to pneumonia and 
influenza combined. While other infectious diseases may receive much 
more public attention, a moderate flu epidemic could result in hundreds 
of thousands of deaths in the U.S. To prepare for a potential pandemic, 
the American Lung Association supports funding the Federal CDC 
Influenza efforts of at least $187.558 million.
                              tuberculosis
    TB (Tuberculosis), an airborne infectious disease, is now the 
leading global infectious killer, ahead of HIV/AIDS, causing 1.5 
million deaths annually. In the U.S., every State reports cases of TB 
annually, with California, Texas, Hawaii and Alaska having the highest 
burdens. TB outbreaks continue to occur across the country in schools, 
workplaces and prisons.
    Drug resistant TB poses a particular challenge to TB control due to 
the high costs of treatment and intensive healthcare resources 
required. Treatment costs for multidrug-resistant (MDR) TB range from 
$100,000 to $300,000 per case and can be over $1 million for treatment 
of extensively drug resistant (XDR) TB, which can outstrip State and 
local public health department budgets. The U.S. had 17 cases of 
extensively XDR- TB between 2008 and 2015.
    Funding for CDC's national TB program has been cut back to the 
fiscal year 2005 level. We are deeply concerned that this funding level 
is eroding State TB programs and leaving communities vulnerable to TB, 
including drug resistant TB. We request that Congress increase funding 
for tuberculosis programs at CDC to $243 million for fiscal year 2017.
                impact of climate change on lung health
    CDC's Climate and Health Program is the only HHS program devoted to 
identifying the risks and develop effective responses to the health 
impacts of climate change, including worsening air pollution; diseases 
that emerge in new areas; stronger and longer heat waves; more frequent 
and severe droughts, and provides guidance to States in adaptation. 
Pilot projects in 16 States and two city health departments use CDC's 
Building Resilience Against Climate Effects (BRACE) framework to 
develop and implement health adaptation plans and address gaps in 
critical public health functions and services. As climate-related 
challenges intensify, CDC must have increased resources to support 
States and cities in meeting the challenge. The Lung Association 
supports $10 million for the Center for Disease Control and 
Prevention's Climate and Health Program.
                               conclusion
    Lung disease remains a growing problem in the United States and is 
leading the Nation as the third highest killer. There has been 
advancements in technology and medications, however, progress against 
lung disease has been overshadowed by developments against other major 
causes of death in the U.S. Significant strides must be taken to combat 
the lung disease. The level of support this committee approves for lung 
disease programs should be reflective of the urgency and magnitude that 
lung disease has had on Americans.
    The American Lung Association respectively requests that the 
Committee supports funding requests and strongly encourages you to 
oppose all policy riders on appropriations bills. The Lung Association 
is appreciative of your support and we thank you for your consideration 
of our recommendations.

    [This statement was submitted by Harold Wimmer, National President 
and CEO, American Lung Association.]
                                 ______
                                 
    Prepared Statement of the American Mosquito Control Association
    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, thank you for your continued leadership and support for 
mosquito control.
    The American Mosquito Control Association (AMCA) appreciates this 
opportunity to submit our views regarding the fiscal year 2017 Labor, 
Health and Human Services, and Education, and Related Agencies 
appropriations bill, and respectfully requests this statement be made 
part of the official hearing record. AMCA is a nonprofit organization 
of 1600 members dedicated to enhancing health and quality of life 
through the suppression of mosquitoes and other vectors of public 
health importance.
    With the emergence and spread of the Zika virus in the western 
hemisphere on the heels of diseases such as dengue, West Nile and 
chikungunya, it would appear prudent to increase a sustainable 
nationwide capacity for the surveillance and control of their mosquito 
vectors. In the absence of vaccines for these diseases, vector control 
remains the first line of defense. To increase that defense, we ask for 
your consideration and favorable support for the following 
appropriations recommendations:
      Increase the Centers for Disease Control (CDC)--Division of 
        Vector-Borne Diseases (DVBD) annual budget for arbovirus work 
        from its current level of about $26.8 million/year to at least 
        $50 million/year. Of this overall sum, it would be beneficial 
        to ensure that substantial sums are dedicated to on-the-ground 
        activities. AMCA suggests the Committee provide direction in 
        the following manner:
    --$13.75 million for State, county or municipal public health 
            agencies or labs to help support arbovirus testing and 
            reporting.
    --$13.75 million for State, county, district or municipal mosquito 
            control programs to help support mosquito control-related 
            work on the frontlines.
    --$22.5 million (or 45 percent of the total) will be kept by the 
            CDC/DVBD to help support myriad arbovirus-related programs 
            and activities at the Federal level.
    The Epidemiology and Laboratory Capacity (ELC) grant program 
provides local health jurisdictions with personnel, equipment and 
resources to detect and respond to mosquito transmitted diseases, but 
the program in its current state is insufficient to prevent the spread 
of the Zika virus.
      Funding for the Mosquito Abatement for Safety and Health Act 
        (MASH) of at least $100,000,000:
    --The Mosquito Abatement for Safety and Health (MASH) Act was 
            designed to support local government mosquito control 
            activities and was originally passed during the first West 
            Nile Virus outbreak. This bill authorized Federal funds for 
            local governments to protect our communities from 
            mosquitoes and other disease vectors. Local program funds 
            were to be matched by Federal funding by a ratio of at 
            least 1 to 3 and additional funding was to be for each 
            State to monitor the local program funding. But by the time 
            the MASH Act was signed into law no funds were ever 
            appropriated. Today we face another imminent outbreak of a 
            disease for which mosquito control is the only viable 
            solution. Fortunately, Congress has the means readily at 
            hand to help prevent or minimize the risk, if it chooses to 
            devote dollars to the existing authority.
      Funding for data collection efforts to support the vector control 
        toolbox: At least $27,000,000:
    --At least $12,000,000 to bolster the Food Quality Protection Act 
            of 1996 (FQPA) that helps retain registrations of existing 
            public health pesticides facing increasingly stringent data 
            collection requirements to prove safety to humans and the 
            environment.
    --At least $15,000,000 to support the development and registration 
            of new vector control tools effective against Aedes aegypti 
            and Aedes albopictus.
    In 1996 Congress unanimously approved FQPA (PL 104-170) to 
modernize the regulation of pesticides and expand data requirements to 
demonstrate their safety to people and the environment. A key element 
was authorization to use Federal funds when the cost of new data for 
public health pesticides--those for mosquitoes and similar disease 
vectors--was more than their producers could afford, putting 
registration at risk. Unfortunately, these essential funds have never 
been appropriated.
    Given the Federal commitment to ensuring the health of Americans, 
we believe these small preventative investments are vastly preferable 
to the enormous healthcare costs required after large mosquito-borne 
disease outbreaks. Establishing sustainable training research and 
suppression programs for vector-borne disease surveillance and control 
will ensure a robust capacity to mitigate the impacts of not only the 
current Zika threat but also dangerous exotic viruses yet to reach our 
shores.
    AMCA thanks you in advance for considering these critical proposals 
and we urge their inclusion in the pending appropriations process. We 
sincerely appreciate the opportunity to share our views on these 
important public health matters.
                                 ______
                                 
         Prepared Statement of the American National Red Cross
    Chairman Roy Blunt, Ranking Member Patty Murray, and Members of the 
Subcommittee, the American Red Cross and the United Nations Foundation 
appreciate the opportunity to submit testimony in support of measles 
control activities of the U.S. Centers for Disease Control and 
Prevention (CDC). The American Red Cross and the United Nations 
Foundation recognize the leadership that Congress has shown in funding 
CDC for these essential activities. For fiscal year 2017, we request 
that this subcommittee support CDC's global measles control activities 
at $50 million.
    In 2001, CDC--along with the American Red Cross, the United Nations 
Foundation, the World Health Organization (WHO), and UNICEF--founded 
the Measles Initiative, a partnership committed to reducing measles 
deaths globally. In 2012, the Initiative expanded to include rubella 
control and adopted a new name, the Measles & Rubella Initiative. In 
2013, all WHO regions established measles elimination goals by 2020. 
The Measles & Rubella Initiative is committed to reaching these goals 
by providing technical and financial support to governments and 
communities worldwide.
    The Measles & Rubella Initiative has achieved impressive results by 
supporting the vaccination of more than 2 billion children since 2001. 
In part due to the Measles & Rubella Initiative, global measles 
mortality dropped 79 percent, from an estimated 548,000 deaths in 2000 
to 114,900 in 2014 (the latest year for which data is available). 
During this same period, measles deaths in Africa fell by 88 percent. 
However, about 315 children still die from measles each day from a 
virus that can be countered with a safe, effective and inexpensive 
vaccine. Measles is among the most contagious diseases ever known, and 
a top killer of children in low-income countries where children have 
little or no access to medical treatment and are often malnourished. 
Measles spreads much more easily than the flu or the Ebola virus. In 
fact, one person infected with measles can infect up to 18 others if s/
he has not been vaccinated. In addition, each year more than 100,000 
children are born with congenital rubella syndrome (CRS). CRS can cause 
severe birth defects, including blindness, deafness, heart defects and 
mental retardation. CRS treatment is very costly to treat, yet very 
inexpensive to prevent.
    Working closely with host governments, the Measles & Rubella 
Initiative has been the main international supporter of mass measles 
immunization campaigns since 2001. The Initiative mobilized more than 
$1.3 billion and provided technical support in more than 88 developing 
countries on vaccination campaigns, surveillance and improving routine 
immunization services. From 2000 to 2014, an estimated 17.1 million 
measles deaths were averted as a result of these accelerated measles 
control activities, making measles mortality reduction one of the most 
cost-effective public health interventions.
    The majority of measles vaccination campaigns have been able to 
reach more than 90 percent of their target populations. Countries 
recognize the opportunity that measles vaccination campaigns provide in 
accessing mothers and young children, and ``integrating'' the campaigns 
with other life-saving health interventions has become the norm. In 
addition to measles vaccine, other health interventions are often 
distributed during campaigns including vitamin A which is crucial for 
preventing blindness in under nourished children, de-worming medicine 
to reduce malnutrition, and screening for malnutrition. Doses of oral 
polio vaccines are also frequently distributed during measles campaigns 
in polio endemic and high-risk countries. The delivery of polio 
vaccines in conjunction with measles vaccines in these campaigns 
strengthens the reach of elimination and eradication efforts of these 
diseases. The delivery of multiple child health interventions during a 
single campaign is far less expensive than delivering the interventions 
separately, and this strategy increases the potential positive impact 
on children's health from a single campaign.
    The extraordinary reduction in global measles deaths greatly 
contributed to reducing under-five child mortality. However, large 
outbreaks in several African, European and Asian countries from 2011 to 
2014 compromised 2015 measles elimination goals of 90 percent national 
coverage rates and 95 percent reduction in mortality, resulting in a 
plateau in progress towards measles elimination due in large part to 
decreased funding support from donors and host governments. These 
outbreaks highlight the fragility of the last decade of progress. If 
mass immunization campaigns are not continued with robust funding and 
support, measles deaths will rapidly increase.
    In addition to the lifesaving benefits of measles vaccines, 
immunization makes sound economic sense. A recent study by Johns 
Hopkins University revealed the economic benefits of increased 
investment in global vaccination programs. The study compared the costs 
for vaccinating against 10 disease antigens in 94 low- and middle-
income countries during the period 2011-2020 versus the costs for 
estimated treatments of unimmunized individuals during the same period. 
Their findings show that--across the board--prevention of diseases 
results in an average return on investment, with $58 saved in future 
costs for every $1 spent.
    To achieve 2020 elimination goals and avoid a resurgence of 
measles, the following actions are required:
  --Sustaining the gains in reduced measles deaths, especially in 
        Africa, by strengthening immunization programs to ensure that 
        more than 90 percent of infants are vaccinated against measles 
        through routine health services as well as conducting timely, 
        high quality mass immunization campaigns. Routine immunization 
        is the foundation to achieving and sustaining high levels of 
        immunity to measles in the community.
  --Accelerating the introduction of a second dose of measles 
        containing vaccine into the routine immunization program of 
        eligible countries with support from Gavi, the Vaccine 
        Alliance.
  --Fully implementing activities, both campaigns and strengthening 
        routine measles vaccination coverage, in Democratic Republic of 
        Congo, Ethiopia, India, Indonesia, Nigeria, and Pakistan which 
        together account for the majority of measles cases and 65 
        percent of measles deaths.
  --Securing sufficient funding for measles and rubella-control 
        activities both globally and nationally. This year the Measles 
        & Rubella Initiative faces a funding shortfall of an estimated 
        U.S. $73 million. Implementation of timely measles campaigns is 
        increasingly dependent upon countries funding these activities 
        locally. The decrease in donor funds available at a global 
        level to support measles elimination activities makes increased 
        political commitment and country ownership of the activities 
        critical for achieving and sustaining the goal of reducing 
        measles mortality by 95 percent.
    If these challenges are not addressed, the remarkable gains made 
since 2000 will be lost and a major resurgence in measles deaths will 
occur.
    By controlling measles and rubella cases in other countries, U.S. 
adults and children are also being protected from the diseases. Measles 
can cause severe complications such as pneumonia, encephalitis, and 
even death. A resurgence of measles occurred in the United States 
between 1989 and 1991, with more than 55,000 cases reported. This 
resurgence was particularly severe, accounting for more than 11,000 
hospitalizations and 123 deaths.
    Measles is one of the most contagious diseases know to humans and, 
due to our highly interconnected world, measles can be spread globally 
including to countries that have already eliminated the disease. The 
threat of importation of measles was one of the reasons that the Global 
Health Security Agenda has selected measles as an important indicator. 
The occurrence of measles cases in a country is a reliable indication 
that a country's routine immunization system is not vaccinating all 
children. Additionally, the ability of a country to rapidly detect and 
respond to measles cases is a marker of the quality of a routine 
immunization system to identify and respond to disease outbreaks more 
generally.
    In the United States, measles control measures have been 
strengthened, and endemic transmission of measles cases have been 
eliminated since 2000 and rubella in 2002. However, importations of 
measles cases into this country continue to occur each year. Since 
2000, the annual number of people reported to have measles ranged from 
a low of 37 in 2004 to a high of 667 people across 27 States in 2014; 
the greatest number of cases reported in the U.S. since measles was 
declared eliminated in 2000. Additionally, on July 2, 2015, Washington 
State Department of Health confirmed a measles-related death. The human 
and financial impact of measles cases, deaths, and outbreaks are 
substantial, both in terms of the costs to public health departments to 
conduct contact tracing and in terms of productivity losses among 
people with measles and parents of sick children. Studies show that a 
single case of measles in the United States can cost between $100,000 
and $200,000 in government expenditures to control.
         the role of cdc in global measles mortality reduction
    Since fiscal year 2001 and until 2015, Congress has provided 
funding for the purchase of measles vaccine for use in large-scale 
measles vaccination campaigns in more than 88 countries in Africa and 
Asia, and for the provision of technical support to Ministries of 
Health. Specifically, this technical support includes:
  --Planning, monitoring, and evaluating large-scale measles 
        vaccination campaigns;
  --Conducting epidemiological investigations and laboratory 
        surveillance of measles outbreaks; and
  --Conducting operations research to guide cost-effective and high 
        quality measles control programs.
    In addition, CDC epidemiologists and public health specialists have 
worked closely with WHO, UNICEF, the United Nations Foundation, and the 
American Red Cross to strengthen measles control programs at global and 
regional levels, and will continue to work with these and other 
partners in implementing and strengthening rubella control programs. 
While it is not possible to precisely quantify the impact of CDC's 
financial and technical support to the Measles & Rubella Initiative, 
there is no doubt that CDC's support--made possible by the funding 
appropriated by Congress--was essential in helping achieve the sharp 
reduction in measles deaths in just 13 years.
    The American Red Cross and the United Nations Foundation would like 
to acknowledge the leadership and work provided by CDC and recognize 
that CDC brings much more to the table than just financial resources. 
The Measles & Rubella Initiative is fortunate to have a partner that 
provides critical personnel and technical support for vaccination 
campaigns and in response to disease outbreaks. CDC personnel have 
routinely demonstrated their ability to work well with other 
organizations and provide solutions to complex problems that help 
critical work get done faster and more efficiently.
    In fiscal year 2015, Congress appropriated $49.8 million to fund 
CDC global measles control activities, and $50 million in fiscal year 
2016 for such activities. In fiscal year 2017, the American Red Cross 
and the United Nations Foundation request sustained funding at the 
level approved by this committee last year for CDC's measles and 
rubella control activities to protect the investment of the last 
decade, prevent measles cases and deaths in the United States. We hope 
this committee will also look at how we can address the shortfall in 
funding within the Measles and Rubella Initiative in future years.
    Your commitment has brought us unprecedented victories in reducing 
measles mortality around the world. In addition, your continued support 
for this initiative helps prevent children from suffering from this 
preventable disease both abroad and in the United States.
    Thank you for the opportunity to submit testimony.

    [This statement was submitted by Harold Brooks, Senior Vice 
President of International Operations, American National Red Cross, and 
Kathy Calvin, President, United Nations Foundation.]
                                 ______
                                 
        Prepared Statement of the American Physiological Society
    The American Physiological Society (APS) thanks the subcommittee 
for its ongoing support of the National Institutes of Health (NIH). The 
$2 billion funding boost you provided in fiscal year 2016 provided a 
much needed restoration of resources at a critical time, but great 
challenges are still before us. In order to continue meeting those 
challenges, the APS urges you to make every effort to provide the NIH 
with at least $35 billion in fiscal year 2017.
    Federal investment in research is critically important because 
breakthroughs in basic and translational research are the foundation 
for new drugs and therapies that help patients, fuel our economy, and 
provide jobs. Moreover, the Federal Government is the primary funding 
source for discovery research through competitive grants awarded by the 
NIH. The private sector may develop new treatments, but it relies upon 
federally-funded research to identify where innovation opportunities 
can be found. This system of public-private partnership has been 
critical to U.S. leadership in the biomedical sciences. However, this 
position of leadership is at risk because other nations have been 
increasing their investments in research and development while the 
United States investment has been stagnant.
    Federal research dollars also have a significant impact at the 
local level: Approximately 84 percent of the NIH budget is awarded 
throughout the country to some 35,000 researchers. They in turn use 
these grant funds to pay research and administrative staff, purchase 
supplies and equipment, and cover other costs associated with their 
research.
    The $2 billion increase provided for fiscal year 2016 was an 
important first step toward correcting the effects of sequestration and 
several years of declining budgets at the NIH. To set the agency on a 
more sustainable path forward, we urge you to provide predictable 
annual budget increases that will allow the scientific enterprise to 
keep up with the rate of inflation and move in new directions.
    The fiscal year 2017 budget request for the NIH highlights 
important initiatives for the agency, including the National Cancer 
Moonshot, the Precision Medicine Initiative and the Brain Research 
through Advancing Innovative Neurotechnologies (BRAIN) Initiative. 
These initiatives will focus resources on critical areas of scientific 
opportunity that are ripe for innovation, but it is important to bear 
in mind that these projects are only possible because of decades of 
basic research. NIH must continue to invest in creative investigator-
initiated research to advance our knowledge and create future 
opportunities for innovation.
    Over the past several decades, NIH has used a merit-based peer 
review system to identify and fund the best research proposals. As a 
result, Americans can expect to live longer and healthier lives. 
However, significant challenges still loom for our Nation: Researchers 
are already working to understand emerging diseases such as the Zika 
virus; learning how it spreads, what effects it has on people who 
become infected, and what sort of threat it poses in the United States. 
An aging population will continue to strain an already stressed system 
of healthcare in the U.S. As the baby boom generation continues to age, 
we can expect to see increases in diseases that affect an aging 
population including diabetes, heart disease, and cancer. Developing 
better ways to detect and treat these diseases will reduce disease 
burden and ultimately help manage the strain that will be placed on the 
American healthcare system. To continue to be able to address these and 
other challenges, the NIH needs additional resources.
    This year the NIH issued the agency's first ever NIH-wide Strategic 
Plan.\1\ This document lays out NIH's plans to address the needs of the 
Nation while maximizing scientific opportunity and supporting the 
biomedical research enterprise. Implementing the plan will require 
predictable, sustainable funding increases over the next several years. 
The APS joins the Federation of American Societies for Experimental 
Biology (FASEB) in urging that NIH be provided with no less than $35 
billion in fiscal year 2017.
---------------------------------------------------------------------------
    \1\ Http://www.nih.gov/sites/default/files/about-nih/strategic-
plan-fy2016-2020-508.pdf.
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    The American Physiological Society is a professional society 
dedicated to fostering research and education as well as the 
dissemination of scientific knowledge concerning how the organs and 
systems of the body work. The Society was founded in 1887 and now has 
more than 10,000 member physiologists. APS members conduct NIH-
supported research at colleges, universities, medical schools, and 
other public and private research institutions across the U.S.

    [This statement was submitted by Patricia E. Molina, Ph.D., 
President, American Physiological Society.]
                                 ______
                                 
      Prepared Statement of the American Psychological Association
    The American Psychological Association (APA) is the largest 
scientific and professional organization representing psychology in the 
U.S.: its membership includes over 123,000 researchers, educators, 
clinicians, consultants and students. Many programs in the Labor-HHS-
Education bill impact science, education, and the populations served by 
clinical psychologists.
                department of health and human services
    National Institutes of Health (NIH).--APA thanks this subcommittee 
for its leadership in securing $32.1 billion for NIH in the fiscal year 
2016 omnibus spending bill. As a member of the Ad Hoc Group for Medical 
Research, APA requests $34.5 billion for NIH in fiscal year 2017. If 
this Nation is to continue to accelerate the development of life-
changing cures, pioneering treatments, and innovative prevention 
strategies, it is essential to sustain predictable increases in the NIH 
budget. Psychological scientists are supported by research grants or 
training programs in almost all of NIH's 27 institutes and centers. 
Behavioral research is critical to NIH's mission: the Institute of 
Medicine recently reaffirmed that over 50 percent of premature 
mortality in the U.S. is due to behaviors such as smoking, sedentary 
lifestyle, and alcohol and other drug consumption. Two areas of great 
scientific opportunity at NIH are research on Alzheimer's disease and 
related dementias, and health disparities research at the National 
Institute of Minority Health and Health Disparities.
    Centers for Disease Control and Prevention (CDC).--As a member of 
the CDC Coalition, APA supports an appropriation of at least $7.8 
billion for core programs in fiscal year 2017. APA strongly supports 
the President's request for increased funding for the National Injury 
Prevention and Control Center, including $25 million for the National 
Violent Death Reporting System to allow for its expansion to all 50 
States and DC, $20 million for core injury prevention programs, and $10 
million for research into the causes and prevention of gun violence. As 
a member of the Friends of the National Center for Health Statistics, 
APA recommends $170 in budget authority for the agency. APA also 
supports the Administration's $30 million mandatory funding request for 
implementation and evaluation of comprehensive suicide prevention 
programs.
    Agency for Healthcare Research and Quality (AHRQ).--APA requests 
that the Subcommittee support $364 million in budget authority--
consistent with the president's discretionary funding request and 
fiscal year 2015 level. AHRQ plays a critical role in the research 
continuum--helping patients get the most from new discoveries in basic 
and clinical research by improving healthcare delivery. For example, 
with the burgeoning opioid epidemic AHRQ research will help optimize 
delivery of behavioral and pharmacotherapies for the treatment of this 
devastating substance use disorder. In a variety of healthcare 
settings, AHRQ funded research is reducing medical errors and the 
incidence of Hospital Acquired Infections.
    Health Resources and Services Administration (HRSA).--APA 
recommends that a portion of funding for the Maternal and Child Health 
Bureau be used to raise awareness of the availability of depression 
screening to pregnant women. APA encourages the subcommittee to fund 
the Melanie Blocker Stokes Act and to support incorporation of 
depression screening into the Title V programs administered by HRSA. We 
also encourage the Subcommittee to urge the Secretary to prioritize the 
issue of PPD by raising awareness, expanding research, and establishing 
grants to operate and coordinate cost-effective services to afflicted 
women and their families.
    APA strongly supports funding of $327 million for the Title X 
Family Planning program. Title X is the sole source of Federal funding 
for family planning for underserved populations, and provides vital 
access to birth control, cancer screenings, and testing for sexually 
transmitted infections for those who would otherwise not have access to 
these services.
    APA recommends continued investments in the mental and behavioral 
health workforce, including $12 million for the interprofessional 
Graduate Psychology Education Program to increase the number of health 
service psychologists (including doctoral-level clinical, counseling 
and school psychologists) trained to provide integrated services to 
high-need underserved populations in rural and urban communities. This 
program supports the training of doctoral psychology students, interns 
and postdoctoral residents with other health professionals while they 
provide supervised mental and behavioral health services to underserved 
and vulnerable populations, including: children, older adults, veterans 
and their families, individuals with chronic illnesses, and victims of 
abuse and trauma. APA encourages HRSA to invest in geropsychology 
training programs to serve the aging population and to help integrate 
health service psychology trainees at federally Qualified Health 
Centers.
    APA supports the transfer of the Behavioral Health Workforce 
Education and Training Program to HRSA and the broadened target 
populations of people to be served. In light of the new competition 
that will be held in 2017, APA requests that eligible entities for this 
program include accredited programs that train Master's level social 
workers, psychologists, counselors, marriage and family therapists, 
doctoral psychology students and interns, as well as behavioral health 
paraprofessionals. APA is concerned about the uneven distribution of 
funds among specialties resulting from the initial grant competition in 
2014 and therefore encourages HRSA to ensure that funding is 
distributed relatively equally among the participating health 
professions and to consider strategies such as issuing separate funding 
opportunity announcements for each participating health profession.
       substance abuse and mental health services administration
    APA strongly supports the President's fiscal year 2017 budget 
proposal that supports increased initiatives to address prescription 
and opioid abuse. APA encourages Congress to adopt the President's 
fiscal year 2017 request for a $500 million mental health initiative. 
This investment would increase access to early intervention programs 
for serious mental illness, expand the Community Behavioral Health 
Clinic demonstration, and provide substantial funding for suicide 
prevention in collaboration with the CDC. APA recommends funding the 
National Child Traumatic Stress Network (NCTSN) at the President's 
requested level of $46.9 million. We urge increased funding of the 
Minority Fellowship Program to reach a level of $20 million by 2020. 
While ethnic minorities represent 30 percent of the U.S. population and 
are projected to increase to 40 percent by 2025, only 23 percent of 
recent doctorates in psychology, social work and nursing were awarded 
to ethnic minorities. APA urges the continued support of the Minority 
AIDS Initiative funding which enhances and expands effective, 
culturally-competent HIV/AIDS-related behavioral services in minority 
communities.
    APA strongly supports the Garrett Lee Smith Memorial Act programs--
Campus Suicide Prevention, State and Tribal Youth Suicide Prevention 
and the Suicide Prevention Resource Center. These effective national 
programs help meet the mental and behavioral health needs of youth and 
young adults by increasing access to prevention, education, and 
outreach services to reduce suicide risk in States, tribes, and 
institutions of higher education. First authorized in 2004, the Garrett 
Lee Smith Memorial Act has supported 370 youth suicide prevention 
grants in 50 States, 48 Tribes or Tribal organizations, and 175 
institutions of higher education.
                administration on children and families
    We urge support for the existing funding level of $1.7 billion for 
the Social Services Block Grant for fiscal year 2017.
      administration for community living administration on aging
    We urge support of an additional $5 million authorized under the 
Elder Justice Act for the Long-Term Care Ombudsman Program, which was 
previously requested by the President. We urge support for $197 million 
in funding for programs that support the vital role of family 
caregivers in providing care for older adults.
                        department of education
    Institute of Education Sciences (IES).--As a member of the Friends 
of IES, APA requests $728 million for the Institute of Education 
Sciences which supports programs to evaluate the effects of Federal and 
local education policies, gather and analyze data on student outcomes, 
develop and promote evidence-based practices for schools and teachers, 
and advance rigorous education research. APA also supports increasing 
funding for the National Center for Special Education Research (NCSER) 
which did not see an increase in fiscal year 2016. NCSER's research 
informs evidence-based interventions to support the development and 
academic success of children with disabilities, which includes 
strategies for improving early childhood special education; advancing 
reading, writing, and language development; educating students with 
autism spectrum disorders; and helping students transition to post-
secondary education and careers.
    We support the proposed funding level for IDEA and urge you to 
maintain this amount without negatively impacting funding for other 
education programs. IDEA is the major--but not sole--vehicle for 
providing education to students with disabilities. In fact, students 
with disabilities are general education students first, with nearly 
two-thirds of students with disabilities spending at least 80 percent 
of their time in a general education setting.
    APA encourages the subcommittee to make a significant investment in 
the newly reauthorized Student Support and Academic Enrichment Grants 
program (SSAEG), found in Title IV, Part A of the bipartisan Every 
Student Succeeds Act (ESSA). This program is a consolidation of over 20 
Federal programs that is intended to be more widely accessible to more 
students. It will now support: safe and healthy students activities, 
such as providing mental health services to students; increasing 
student access to STEM, computer science and accelerated learning 
courses, physical education, art, music, foreign languages and college 
and career counseling; funds for an effective school library program; 
and providing students with access to technology and digital materials 
and educators with technology professional development opportunities. 
Authorized at $1.65 billion, this formula grant program to States and 
LEAs, if appropriately funded, will make a significant difference in 
the academic achievements of all students.
    APA supports increased funding for the Graduate Assistance in Areas 
of National Need (GAANN) program. GAANN supports fellowships to 
institutions of higher education for outstanding students with 
financial need pursuing degrees in areas of national need, including 
psychology. Supporting our Nation's graduate students is an investment 
worth making. APA urges the Committee not to shortchange this 
population of students and to support programs that make graduate study 
more affordable and accessible to students with financial need. 
Investments in graduate study are part of an effective strategy of 
ensuring our Nation's future economic competitiveness as well as 
ensuring we have a highly trained workforce to meet the healthcare 
needs of the Nation's population.
                         indian health service
    APA supports increased funding for the American Indians Into 
Psychology Program (In Psych). The In Psych program addresses the need 
for culturally competent psychologists in the American Indian community 
to help address extremely high rates of suicide and substance use. We 
ask that the program be funded at $1.5 million up from $715,078 as it 
has not kept up with the need. Thank you again for the opportunity to 
submit this testimony for the record.
                                 ______
                                 
      Prepared Statement of the American Public Health Association
    APHA is a diverse community of public health professionals who 
champion the health of all people and communities. We are pleased to 
submit our request to fund the Centers for Disease Control and 
Prevention at $7.8 billion and the Health Resources and Services 
Administration at $7.48 billion in fiscal year 2017.
               centers for disease control and prevention
    We believe Congress should support CDC as an agency and urge a 
funding level of $7.8 billion in fiscal year 2017. We are disappointed 
President Obama's budget request would cut CDC's program level by $194 
million below fiscal year 2016. We acknowledge that the president's 
budget provides increased funding for important programs and 
initiatives such as combating antibiotic resistance, preventing 
prescription drug overdose and research into the causes and prevention 
of gun violence. In addition, we are pleased his budget would fully 
allocate the Prevention and Public Health Fund for public health 
activities. Unfortunately, the president's budget cuts or eliminates 
other important programs including the REACH program, the Preventive 
Health and Health Services Block Grant, cancer prevention and control, 
immunizations and environmental health tracking and we urge you to 
maintain the funding for these important programs.
    CDC provides the foundation for our State and local public health 
departments, supporting a trained workforce, laboratory capacity and 
public health education communications systems. It is notable that more 
than 70 percent of CDC's budget supports public health and prevention 
activities by State and local health organizations and agencies, 
national public health partners and academic institutions.
    CDC serves as the lead agency for bioterrorism and other public 
health emergency preparedness and response programs and must receive 
sustained support for its preparedness programs. Given the challenges 
of terrorism and disaster preparedness we urge you to provide adequate 
funding for the Public Health Emergency Preparedness grants.
    CDC serves as the command center for the Nation's public health 
defense system against emerging and reemerging infectious diseases. 
From aiding in the surveillance, detection and prevention of the Zika 
virus to playing a lead role in the control of Ebola in West Africa and 
detecting and responding to cases in the U.S., to monitoring and 
investigating last year's multi-State measles outbreak to pandemic flu 
preparedness, CDC is the Nation's--and the world's--expert resource and 
response center, coordinating communications and action and serving as 
the laboratory reference center for identifying, testing and 
characterizing potential agents of biological, chemical and 
radiological terrorism, emerging infectious diseases and other public 
health emergencies. States, communities and the international community 
rely on CDC for accurate information and direction in a crisis or 
outbreak.
    Programs under the National Center for Chronic Disease Prevention 
and Health Promotion address heart disease, stroke, cancer, diabetes 
and arthritis that are the leading causes of death and disability in 
the U.S. These diseases, many of which are preventable, are also among 
the most costly to our health system. The center provides funding for 
State programs to prevent disease, conduct surveillance to collect data 
on disease prevalence, monitor intervention efforts and translate 
scientific findings into public health practice in our communities.
    The National Center for Environmental Health protects public health 
by helping to control asthma, protect from threats associated with 
natural disasters and climate change, reduce, monitor and track 
exposure to lead and other hazards and ensure access to safe and clean 
water. We urge you to support the president's request for the Climate 
and Health and Safe Water programs, increase funding for Childhood Lead 
Poisoning Prevention, Environmental Health Laboratory and Asthma 
programs, restore proposed cuts to the National Environmental and 
Public Health Tracking Network and restore funding for the Built 
Environment and Health program which was eliminated in 2016.
    Prescription drug overdose is an ongoing public health problem in 
the U.S. killing more than 145,000 over the past decade. We urge you to 
support the president's request for increased funding to prevent and 
reduce prescription drug and heroin overdose deaths.
    The development of antimicrobial resistance is occurring at an 
alarming rate and far outpacing the struggling research and development 
of new antibiotics. We urge you to support the president's request for 
the CDC Antibiotic Resistance Initiative that will expand fiscal year 
2016 healthcare-associated infections and AR prevention efforts from 25 
States to up to 50 States, six large cities and Puerto Rico.
    We strongly support the president's request to provide $10 million 
in unrestricted funding to CDC to conduct research into the causes and 
prevention of gun violence.
              health resources and services administration
    HRSA (Health Resources and Services Administration) operates 
programs in every State and U.S. territory and has a strong history in 
improving the health of Americans through the delivery of quality 
health services and supporting a well-prepared workforce, serving 
people who are medically underserved or face barriers to needed care. 
While Congress has restored a portion of HRSA's discretionary budget 
authority over the past 3 years, funding for HRSA remains far too low--
at 18 percent under the fiscal year 2010 level--significantly limiting 
the agency's ability to meaningfully respond to growing or emerging 
health demands such as the Zika virus and the opioid epidemic, while 
still addressing persistent health needs. The Nation faces a shortage 
of health professionals, and a growing and aging population which will 
demand more healthcare. HRSA grantees are well positioned to address 
these issues, but additional funding is required to effectively do so.
    HRSA has contributed to the decrease in infant mortality rate, a 
widely used indicator of the Nation's health, which is now at a 
historic low of 5.8 deaths per 1,000 live births. People receiving care 
through the Ryan White HIV/AIDS Program achieve significantly higher 
viral suppression in comparison to the national average, which is 
central to preventing new HIV infections. The Title X Family Planning 
Program has helped prevent over 941,000 unintended pregnancies in 2014 
and 1,176 cases of sexually transmitted disease-related infertility.
    A strong investment from Congress is needed to build on these 
health improvements and pave the way for new achievements by supporting 
critical HRSA programs, including:
  --Primary Care programs support more than 9,000 health center sites 
        in every State and U.S. territory, improving access to care for 
        more than 22.9 million patients in geographically isolated and 
        economically distressed communities. Close to half of these 
        health centers serve rural populations. Health centers deliver 
        comprehensive, cost-effective care and have demonstrated their 
        ability to reduce the use of costlier providers of care.
  --Health Workforce supports the education, training, scholarship and 
        loan repayment of a broad range of health professionals. These 
        are the only Federal programs focused on filling the gaps in 
        the supply of health professionals, and improving the 
        distribution and diversity of the workforce. The programs are 
        responsive to the changing delivery systems, models of care and 
        healthcare needs, and encourage collaboration between 
        disciplines to provide effective and efficient coordinated 
        care.
  --Maternal and Child Health including Title V Maternal and Child 
        Health Block Grant, Healthy Start and others support 
        initiatives designed to promote optimal health, reduce 
        disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare for more 
        than 34.3 million children, including children with special 
        healthcare needs such as autism and developmental disabilities.
  --HIV/AIDS programs provide assistance to States and communities most 
        severely affected by HIV/AIDS. The programs deliver 
        comprehensive care, prescription drug assistance and support 
        services for 512,000 people living with HIV/AIDS, nearly half 
        of the total population living with the disease in the U.S. 
        Additionally, the programs provide education and training for 
        health professionals treating people with HIV/AIDS and work 
        toward addressing the disproportionate impact of HIV/AIDS on 
        racial and ethnic minorities.
  --Family Planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive healthcare for more 
        than 4.1 million low-income women, men and adolescents. This 
        program promotes healthy families and helps improve maternal 
        and child health outcomes and reduce unintended pregnancies, 
        infertility and related morbidity.
  --Rural Health improves access to care for people living in rural 
        areas that experience a persistent shortage of healthcare 
        services. These programs are designed to support community-
        based disease prevention and health promotion projects, help 
        rural hospitals and clinics implement new technologies and 
        strategies and build health system capacity in rural and 
        frontier areas.
                               conclusion
    In closing, we emphasize that the public health system requires 
stronger financial investments at every stage. This funding makes up 
less than 1 percent of Federal spending. Cuts to public health and 
prevention programs will not balance our budget and will only lead to 
increased costs to our healthcare system. Successes in biomedical 
research must be translated into tangible prevention opportunities, 
screening programs, lifestyle and behavior changes and other 
population-based interventions that are effective and available for 
everyone so that we can meet the mounting health challenges facing our 
Nation.

    [This statement was submitted by Georges C. Benjamin, MD, Executive 
Director, American Public Health Association.]
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology
    The American Society for Microbiology (ASM) asks that Congress give 
special consideration and high priority to increasing the fiscal year 
2017 budget for the Centers for Disease Control and Prevention (CDC), 
the Nation's leading health protection agency. The CDC's 
responsibilities, particularly in the area of infectious diseases, 
continue to expand annually because of globalization and biosecurity 
issues, including antimicrobial resistance and the Ebola and Zika virus 
outbreaks. The fiscal year 2017 CDC overall program level request of 
$7.013 billion is $164 million below the fiscal year 2016 level, due to 
changes in block grant funding. Within the CDC budget request, the ASM 
strongly supports the targeted increases for the following programs 
related to infectious diseases: combating antibiotic resistant bacteria 
(+$40 million), Vaccines for Children Program (+$225.9M), global health 
(+$10 million), polio eradication (+$5 million), quarantine activities 
like expanded refugee vaccination and electronic health records (+$15 
million), viral hepatitis (+$5 million), new grants to increase use of 
HIV pre-exposure prophylaxis among high burden communities (+$20 
million), additional resources to upgrade CDC's Select Agent Program 
(+$5.4M) and greater support for continued enhancement of CDC lab 
safety and quality (+$5 million). The ASM urges Congress to approve 
these proposed program increases in the fiscal year 2017 budget for 
CDC.
    The ASM would like to highlight programs that require additional 
resources and show CDC's enormous contributions to science and public 
health, both in the United States and worldwide.
            cdc programs defend against infectious diseases
    Many of CDC's programs and initiatives are related to infectious 
diseases, including offensives against the Zika virus, the Ebola virus, 
field and laboratory investigations of foodborne outbreaks and drug 
resistant infections. The following statistics from CDC's surveillance 
networks and the World Health Organization (WHO) reveal the enormity of 
CDC's protective tasks and point to the importance of adequate funding 
for CDC programs:
  --Respiratory infectious diseases are the leading cause of pediatric 
        hospitalizations and outpatient visits in the United States.
  --More than 1.2 million Americans live with HIV infection, an 
        estimated 13 percent unaware of their status; about 50,000 are 
        newly infected each year. Lifetime costs to treat HIV infection 
        currently exceed $400,000 per person.
  --U.S. cases of sexually transmitted diseases keep increasing, 
        despite highly effective prevention measures available. CDC 
        estimates that nearly 20 million new STDs occur every year, 
        costing nearly $16 billion in healthcare.
  --Drug resistant pathogens are thought responsible for an estimated 2 
        million U.S. illnesses and about 23,000 deaths annually. More 
        than 400,000 Americans acquire antibiotic-resistant Salmonella 
        or Campylobacter bacteria each year.
  --During 2000-2014, about 43 million lives were saved by the global 
        campaign to diagnose and treat tuberculosis, yet the infectious 
        disease persists as a leading cause of death worldwide. The 
        pathogen infected about 1 million children in 2014, causing 
        140,000 deaths.
  --One in six Americans becomes sick from contaminated foods or 
        beverages, year after year. CDC officials point out that 
        reducing foodborne illness by just 10 percent would prevent 
        five million illnesses annually.
  --Nearly half of the world's population, about 3.2 billion, is at 
        risk of mosquito transmitted malaria. Between 2000 and 2015, 
        health agency collaborations that included CDC reduced the 
        annual rate of new cases and mortality by 37 percent and 60 
        percent respectively.
  --Last year, 15.8 million people living with HIV infection were 
        receiving antiretroviral therapy, a global effort with strong 
        assistance from CDC and other U.S. agencies. WHO estimates 
        suggest today there are >40 million HIV positive people 
        worldwide.
  --Foodborne illnesses caused by Salmonella bacteria alone account for 
        $365 million in direct U.S. medical costs annually.
  --An estimated >50 percent of antibiotics prescribed for upper 
        respiratory infections in outpatient settings are unnecessary.
  --One in 25 hospitalized patients develops healthcare-associated 
        infections.
  --Of the $2.5 trillion spent on healthcare each year in the United 
        States, preventable conditions, which include infectious 
        diseases, account for 75 percent of costs.
    The CDC Office of Infectious Diseases focuses on protecting against 
infectious disease, overseeing the National Center for Emerging and 
Zoonotic Infectious Diseases (NCEZID), the National Center for HIV/
AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP) and the National 
Center for Immunization and Respiratory Diseases (NCIRD). Other CDC 
centers and offices also address infectious diseases, such as the 
Center for Global Health and the Center for Surveillance, Epidemiology 
and Laboratory Services (CSELS). Each of these must have the resources 
to readily access the latest computing, communication and laboratory 
technologies needed for optimal responses to microbial threats. The 
fiscal year 2017 budget must provide adequate resources to fully 
realize these new capabilities through additional equipment and highly 
specialized personnel like bioinformaticians. For example, CDC must 
develop cutting-edge capabilities and collaborative partnerships as 
sampling techniques evolve, such as receiving and processing whole 
genome sequences of suspected pathogens from clinical and public health 
laboratories across the country.
    The CDC's 2014-2015 Ebola effort included activation of the CDC 
Emergency Operations Center (EOC), definitive lab testing of patient 
specimens, travel warnings for the affected region, a CDC laboratory 
established in Sierra Leone, multiple CDC outbreak teams deployed, 
expanded Ebola testing at U.S. labs and airports, CDC facilitated 
health worker safety courses and improved hospital readiness in Africa 
and the United States, public education campaigns and strategic 
partnerships initiated with health agencies and governments.
    Similar CDC activities are focused today against the Zika virus, 
just the latest examples of CDC's unique skillset to counter emerging 
and vector borne threats. It has confirmed cases in this country and 
other nations, issued travel advisories, already shipped 62,000 Zika 
diagnostic tests for pregnant women to U.S. health departments, 
accelerated surveillance data analyses and released guidelines for 
prevention. CDC researchers are working to confirm suspected 
neurotropic links between Zika infection and medical conditions like 
microcephaly and Guillain-Barre syndrome. Others are developing more 
accurate, faster diagnostic tests.
    In response to the explosive spread of Zika in South America, the 
highest Level 1 activation of the Emergency Operations Center follows 
similar designations for the recent Ebola epidemic, the 2009 HINI 
influenza pandemic, and post-Hurricane Katrina. The EOC currently is 
coordinating more than 300 CDC staff at the agency's laboratories and 
in affected nations, in collaboration with local, national and 
international response partners.
        cdc leadership prevents illness, saves health care costs
    CDC programs, laboratories and staff provide leadership in sectors 
of public health and national security. The Federal Select Agent 
Program, both at CDC and the Department of Agriculture, oversees the 
use and transfer of biological select agents and toxins that might pose 
a risk. The agency's Vaccines for Children program, annual influenza 
response planning and immunization campaigns are guiding the Nation 
toward better health. There have been dramatic declines in vaccine 
preventable diseases, both in the United States and abroad. A goal now 
within reach is eradication of polio; CDC is leading the U.S. 
contribution to the global immunization program. Such efforts not only 
safeguard individuals but also demonstrably reduce health costs.
    CDC laboratories can definitively identify suspected pathogenic 
agents, the contaminated products causing disease outbreaks and disease 
clusters in populations like hospitalized patients or consumers of 
certain foods. Detective work by CDC staff has repeatedly exposed 
causes and effects: Last year, microbe-contaminated cucumbers, 
restaurant chain meals, and packaged salad greens were among dozens of 
culprits identified. Other investigations involved a dengue fever 
outbreak in Hawaii, increased Legionnaires' disease in Michigan and a 
report concluding that nearly half a million Americans were infected 
with Clostridium difficile.
    CDC's science based disease prevention prompts new agency guidance 
documents distributed to healthcare workers, industry, public health 
agencies or others. CDC prevention guidelines, along with CDC testing 
and surveillance, have helped reduce incidences of hospital acquired 
infections, foodborne illnesses and vaccine preventable diseases. The 
agency anticipates that similar recommendations for drug resistant 
pathogens will likewise reduce case numbers. In 2015, for example, CDC 
released its interim protocol for healthcare facilities that responded 
to carbapenem resistant Enterobacteriaceae transmission via 
duodenoscopes.
             cdc partnerships build public health capacity
    CDC contributes to national health initiatives and congressional 
mandates like the Food Safety Modernization Act (FSMA). A notable 
example is the National Action Plan for Combating Antibiotic Resistance 
Bacteria (CARB). Among its many CARB activities, CDC joined with the 
Food and Drug Administration last year to launch a precedent setting 
Antimicrobial Resistance Isolate Bank, providing its partners with 
specimens for R&D of new diagnostic tests and antimicrobial drugs. CDC 
also utilizes a network of regional labs able to characterize emerging 
resistance and identify outbreaks. One near term goal is greatly 
increased drug susceptibility testing for high priority pathogens. 
Another is expanding local capability to detect and prevent these 
infections in all 50 States, six large U.S. cities and Puerto Rico. CDC 
has set a national goal of 100 percent of all U.S. hospitals having 
antibiotic stewardship programs by 2020.
    At both State and Federal levels, CDC education efforts routinely 
include laboratory and field training that help prepare the Nation's 
next generation of disease detectives.
    CDC partnerships are important to building stronger public health 
infrastructures in the United States and in other nations. The agency 
provides its partners with testing and surveillance, onsite field 
teams, portable labs, medical supplies like vaccines and diagnostics 
and direct financial assistance. Last August, it announced awards of 
nearly $110 million to help States under the Epidemiology and 
Laboratory Capacity for Infectious Diseases Cooperative Agreement. In 
July, it distributed $216 million to community based organizations to 
improve HIV prevention.
    By effectively using its own capabilities and collaborating with 
others, CDC has a long tradition of effectively improving our quality 
of life. The ASM encourages Congress to provide CDC with the resources 
needed to respond aggressively against any risk, whether familiar or 
unexpected.
                                 ______
                                 
      Prepared Statement of the American Society for Microbiology
    The American Society for Microbiology (ASM) urges Congress to 
continue its bipartisan support for biomedical research as it considers 
the fiscal year 2017 budget for the National Institutes of Health 
(NIH). We appreciate the $2 billion increase for NIH that Congress 
approved for fiscal year 2016. This increased investment will help 
improve public health, will lead to progress in scientific discovery 
and will help sustain U.S. leadership in biomedical research. We 
believe it is critical that sustained increases continue for the NIH 
budget and, therefore, join with the Ad Hoc Group for Medical Research 
in recommending that Congress appropriate at least $34.5 billion for 
the NIH in the fiscal year 2017 appropriations bill for the Department 
of Health and Human Services. This proposed level of funding would 
provide 5 percent real growth for NIH as a further step to ensuring 
that biomedical research fulfills its promise to discover new cures, 
treatments and preventions for infectious and chronic diseases that 
continue to result in human tragedy. ASM is firmly convinced that a 
steady, predictable, growth of the biomedical research budget is the 
correct funding strategy to maximize the benefits from research 
investments, and to optimize the workforce pipeline. The recommended 
increase would enable NIH to take advantage of exciting scientific 
opportunities to make medical advances as well as contribute to 
substantial economic and societal returns on investments in innovative 
research.
    The ASM would like to highlight some important areas of biomedical 
research to illustrate the importance of increased funding for the NIH.
   nih discoveries fight infectious diseases and advance biomedical 
                               discovery
    Infectious diseases remain among the leading causes of mortality 
and morbidity in the United States and worldwide. No single approach or 
product alone can successfully stop infectious disease, but NIH funded 
research enlarges our arsenals against menacing pathogens. The National 
Institute of Allergy and Infectious Diseases (NIAID) maintains a wide 
spectrum research portfolio on numerous infectious diseases and their 
prevention, diagnosis and treatment. The National Institute of General 
Medical Sciences (NIGMS) contributes insights into basic pathogen 
biology and more, as well as new products and technologies directly 
applicable to microbiology, immunology, and healthcare. Other NIH 
institutes also conduct studies in these areas important to the 
Nation's health.
    The intensifying mobilization against the Zika virus is just the 
latest example of NIH potential to find R&D solutions that target 
specific threats and boost interagency public health initiatives. 
Previous examples include innovative NIH responses to Ebola, HIV/AIDS, 
and influenza. The recent Administration request for emergency 
supplemental funding to prepare for and respond to the Zika outbreak 
underscores the challenges ahead for biomedical research. At present, 
there are no vaccines, no rapid diagnostics and no cures for Zika 
infection. Much of the responsibility for identifying candidate Zika 
related products will rest on both NIAID's own intramural scientists 
and the many more supported by NIAID extramural grants to scientists 
working in universities and the private sector. Any successful 
multiagency fight against Zika virus and public policies must be 
grounded in solid scientific information about the pathogen, its 
transmission, and how it causes disease (pathogenesis) in infected 
humans.
    When NIH unveiled its fiscal year 2016-2020 Strategic Plan 
recently, the agency rightly argued that it is positioned to capitalize 
on today's promising biomedical trends and discoveries. The NIH plan 
cited 21st century R&D opportunities like mobile health technologies 
and wearable biosensors, interdisciplinary initiatives like precision 
medicine and microbiome research, cutting edge structural biology for 
drug discovery, bioinformatics and massive datasets, and 
pharmacogenomics to optimize therapeutics.
    NIAID HIV/AIDS focused programs have generated life extending 
drugs, improved diagnostics, and candidate vaccines, the rewards of 
sustained R&D strategies and long term funding. Not only have HIV 
treatments transformed life expectancies, but many study results have 
added to our general scientific knowledge. In 2015, NIAID funded 
researchers reported evidence supporting early antiretroviral therapy 
in all those infected with HIV, tested a potential HIV infection 
preventing drug in an animal model that utilized gene therapy and 
conducted encouraging studies using or eliciting neutralizing 
antibodies against HIV. In the decades since HIV/AIDS was first 
identified, NIH has compiled the world's leading HIV/AIDS research 
portfolio with remarkable success, but continuing its efforts is 
essential. There are an estimated 40,000 Americans still infected each 
year and more than one million living with the infection.
    In its 5 year strategic plan, NIH outlines ambitious expectations 
that include reaching clinical trials with an influenza vaccine that 
induces host immunity against multiple viral strains. A universal flu 
vaccine is one of the ``golden rings'' sought by biomedical 
researchers. Influenza costs the U.S. economy an estimated $87.1 
billion annually in medical costs, loss of lives and lost productivity. 
Other hoped for clinical trials would evaluate NIH vaccines for 
respiratory syncytial virus, a leading cause of childhood pneumonia.
    Stakeholders in U.S. and global public health have voiced rising 
concern in recent years over the shrinking industry pipeline of 
upcoming novel products against infectious diseases, particularly 
worrisome in the face of expanding drug resistance among pathogens. 
NIAID funded research is central in the national effort to accelerate 
R&D for new antimicrobial drugs and vaccines. In 2015, scientists with 
NIH funding reported various advances in vaccines that would target 
drug resistant tuberculosis, West Nile virus, Middle East Respiratory 
Syndrome (MERS), Epstein-Barr virus, influenza, malaria and Ebola. 
Others reported a clinical study of antibiotic treatment for skin 
infections of methicillin resistant Staphylococcus aureus (MRSA). NIGMS 
supported investigators described antibiotic effects on gut microbiomes 
and host susceptibility to Clostridium difficile infection, use of high 
throughput screening to identify candidate tuberculosis drugs and 
intracellular mechanisms employed by pathogens to resist antimicrobial 
compounds.
    Advances in microbiology and immunology also come from other NIH 
institutes and programs. Much of the National Cancer Institute's 
research focuses on the body's immune systems. The National Institute 
of Child Health and Human Development devotes much of its portfolio to 
infectious diseases like malaria and HIV infection in children and 
pregnant women. The National Eye Institute's experimental immunology 
research investigates the pathogenesis of inflammatory eye diseases, 
while the National Institute of Dental and Craniofacial Research 
includes biofilms, microbial genomics, and microbial virulence among 
its research areas. At the National Institute of Neurological Disorders 
and Stroke, scientists study microbial pathogens like those causing 
shingles, meningitis, and encephalitis.
nih expertise supports u.s. r&d enterprise, national health initiatives
    Over 80 percent of NIH's annual budget underwrites extramural 
research in all 50 States and the District of Columbia. Distributed 
through more than 57,000 research and training grants, NIH funding 
directly supports more than 400,000 jobs in the Nation's biomedical R&D 
enterprise. It also underwrites the training of current and future 
scientists and other technical workforces. NIH funding in fiscal year 
2017 will further boost research at U.S. universities and other 
institutions by enabling access to breakthrough research tools like 
high throughput screening of candidate drug compounds and the CRISPR 
gene editing technique. Agency funding also indirectly benefits 
millions of Americans employed in industries that have utilized NIH 
discoveries, such as biotechnology, pharmaceuticals and suppliers of 
R&D technologies for research purposes.
    The ASM is disappointed that the proposed fiscal year 2017 budget 
signals a near record low in the success rate for new and competing 
research grants (estimated 17.5 percent of reviewed grants would 
receive funding). NIH remains the world's largest source of biomedical 
funding, but this failure to fully encourage innovation within newly 
proposed research seems shortsighted. NIH provides the majority of 
Federal support for all university R&D, an additional indication of its 
importance. Arguments for increasing research funding can point to the 
estimated U.S. healthcare expenditures (>$2.5 trillion/year) or the 
slowing growth in U.S. biomedical R&D spending in relation to other key 
nations, as well as our declining global biomedical market share.
    NIH institutes and centers routinely find innovative ways to 
fulfill the agency's mission, to discover basic knowledge about living 
systems and apply that knowledge to enhance human health. As a result, 
NIH funded expertise provides unique contributions to national and 
global public health initiatives. Examples are the National Action Plan 
for Combating Antibiotic Resistant Bacteria announced last March and 
the national call to action from the White House's Fast Track Action 
Committee on Mapping the Microbiome released in November, and most 
recently the National Action Plan for Multidrug Resistant TB. They 
stress interdisciplinary approaches and partnerships among institutions 
with relevant capabilities, both traditional strengths of NIH programs.
    The ASM urges Congress to steadily, predictably and consistently 
increase the NIH budget to ensure adequate funding for research and 
training programs allowing appropriate planning and optimization of 
resources. We appreciate the opportunity to submit a statement in 
support of biomedical research funding and stand ready to assist 
Congress during the budget process.
                                 ______
                                 
        Prepared Statement of the American Society for Nutrition
    Dear Chairman Blunt and Ranking Member Murray: Thank you for the 
opportunity to provide testimony regarding fiscal year 2017 
appropriations. The American Society for Nutrition (ASN) respectfully 
requests $35 billion dollars for the National Institutes of Health 
(NIH) and $170 million dollars for the Centers for Disease Control and 
Prevention/National Center for Health Statistics (CDC/NCHS) in fiscal 
year 2017. ASN is dedicated to bringing together the world's top 
researchers to advance our knowledge and application of nutrition, and 
has more than 5,000 members working throughout academia, clinical 
practice, government, and industry.
                     national institutes of health
    The NIH (National Institutes of Health) is the Nation's premier 
sponsor of biomedical research and is the agency responsible for 
conducting and supporting 86 percent of federally-funded basic and 
clinical nutrition research. Although nutrition and obesity research 
makes up less than 8 percent of the NIH budget, some of the most 
promising nutrition-related research discoveries have been made 
possible by NIH support. NIH nutrition-related discoveries have 
impacted the way clinicians prevent and treat heart disease, cancer, 
diabetes and other chronic diseases. For example, U.S. death rates from 
heart disease and stroke have decreased by more than 60 percent, and 
the proportion of older adults with chronic disabilities has dropped by 
one-third. With additional support for NIH, additional breakthroughs 
and discoveries to improve the health of all Americans will be made 
possible.
    Investment in biomedical research generates new knowledge, improved 
health, and leads to innovation and long-term economic growth. A decade 
of flat-funding, followed by sequestration cuts, has taken a 
significant toll on NIH's ability to support research. Such economic 
stagnation is disruptive to training, careers, long-range projects and 
ultimately to progress. Increasing the NIH budget to $35 billion 
dollars would help to restore the funding that was lost to 
sequestration and support additional competing research project grants. 
ASN recommends $35 billion dollars for NIH in fiscal year 2017, an 
additional $3 billion up from the President's budget request to enable 
NIH to fund more R01 grants while still providing much needed increases 
to other parts of the portfolio. NIH needs sustainable and predictable 
budget growth in order to fulfill the full potential of biomedical 
research, including nutrition research, and to improve the health of 
all Americans.
 centers for disease control and prevention national center for health 
                               statistics
    The National Center for Health Statistics (NCHS), housed within the 
Centers for Disease Control and Prevention (CDC), is the Nation's 
principal health statistics agency. ASN recommends a fiscal year 2017 
funding level of $170 million dollars for NCHS, $10 million more than 
in fiscal year 2016 and the President's budget request, to help ensure 
uninterrupted collection of vital health and nutrition statistics, and 
help cover the costs needed for technology and information security 
maintenance and upgrades that are necessary to replace aging survey 
infrastructure.
    The NCHS provides critical data on all aspects of our healthcare 
system, and it is responsible for monitoring the Nation's health and 
nutrition status through surveys such as the National Health and 
Nutrition Examination Survey (NHANES), that serve as a gold standard 
for data collection around the world. Nutrition and health data, 
largely collected through NHANES, are essential for tracking the 
nutrition, health and well-being of the American population, and are 
especially important for observing nutritional and health trends in our 
Nation's children.
    Nutrition monitoring conducted by the Department of Health and 
Human Services in partnership with the U.S. Department of Agriculture/
Agricultural Research Service is a unique and critically important 
surveillance function in which dietary intake, nutritional status, and 
health status are evaluated in a rigorous and standardized manner. 
Nutrition monitoring is an inherently governmental function and 
findings are essential for multiple government agencies, as well as the 
public and private sector. Nutrition monitoring is essential to track 
what Americans are eating, inform nutrition and dietary guidance 
policy, evaluate the effectiveness and efficiency of nutrition 
assistance programs, and study nutrition-related disease outcomes. 
Funds are needed to ensure the continuation of this critical 
surveillance of the Nation's nutritional status and the many benefits 
it provides.
    Through learning both what Americans eat and how their diets 
directly affect their health, the NCHS is able to monitor the 
prevalence of obesity and other chronic diseases in the U.S. and track 
the performance of preventive interventions, as well as assess 
`nutrients of concern' such as calcium, which are consumed in 
inadequate amounts by many subsets of our population. Data such as 
these are critical to guide policy development in the area of health 
and nutrition, including food safety, food labeling, food assistance, 
military rations and dietary guidance. For example, NHANES data are 
used to determine funding levels for programs such as the Supplemental 
Nutrition Assistance Program (SNAP) and the Women, Infants, and 
Children (WIC) clinics, which provide nourishment to low-income women 
and children.
    To continue support for the agency and its important mission, ASN 
recommends an fiscal year 2017 funding level of $170 million for NCHS. 
Sustained funding for NCHS can help to ensure uninterrupted collection 
of vital health and nutrition statistics, and will help to cover the 
costs needed for technology and information security upgrades that are 
necessary to replace aging survey infrastructure.
    Thank you for the opportunity to submit testimony regarding fiscal 
year 2017 appropriations for the National Institutes of Health and the 
CDC/National Center for Health Statistics. Please contact John E. 
Courtney, Ph.D., Executive Officer, if ASN may provide further 
assistance.
    Sincerely.

    [This statement was submitted by Patrick J. Stover, Ph.D., 
President, American Society for Nutrition.]
                                 ______
                                 
        Prepared Statement of the American Society of Hematology
    The American Society of Hematology (ASH) thanks the Subcommittee 
for the opportunity to submit written testimony on the fiscal year (FY) 
2017 Departments of Labor, Health and Human Services, and Education 
Appropriations bill.
    ASH represents more than 15,000 clinicians and scientists committed 
to the study and treatment of blood and blood-related diseases. These 
diseases encompass malignant disorders such as leukemia, lymphoma, and 
myeloma; life-threatening conditions, including thrombosis and bleeding 
disorders; and congenital diseases such as sickle cell anemia, 
thalassemia, and hemophilia. In addition, hematologists have been 
pioneers in the fields of bone marrow transplantation, stem cell 
biology and regenerative medicine, gene- and immunotherapy, and the 
development of many drugs for the prevention and treatment of heart 
attacks and strokes.
 funding for hematology research: an investment in the nation's health
    Over the past 60 years, American biomedical research has led the 
world in probing the nature of human disease. This research has led to 
new medical treatments, saved innumerable lives, reduced human 
suffering, and spawned entire new industries. This research would not 
have been possible without support from the National Institutes of 
Health (NIH).
    Funding for hematology research has been an important component of 
this investment in the nation's health. Much of the research that 
produced cures and treatments for hematologic diseases has been funded 
by the NIH. The study of blood and its disorders is a trans-NIH issue 
involving many institutes at the NIH, including the National Heart, 
Lung and Blood Institute (NHLBI), the National Cancer Institute (NCI), 
the National Institute of Diabetes, Digestive and Kidney Diseases 
(NIDDK), and the National Institute on Aging (NIA).
    With the advances gained through an increasingly sophisticated 
understanding of how the blood system functions, hematologists have 
changed the face of medicine through their dedication to improving the 
lives of patients. As a result, children are routinely cured of acute 
lymphoblastic leukemia (ALL); more than 90 percent of patients with 
acute promyelocytic leukemia (APL) are cured with a drug derived from 
vitamin A; older patients suffering from previously lethal chronic 
myeloid leukemia (CML) are now effectively treated with well-tolerated 
pills; and patients with multiple myeloma are treated with new classes 
of drugs.
    Hematology advances also help patients with other types of cancers, 
heart disease, and stroke. Even modest investments in hematology 
research have yielded large dividends for other disciplines. Basic 
research on blood has aided physicians who treat patients with heart 
disease, strokes, end-stage renal disease, cancer, and AIDS. Blood 
thinners effectively treat or prevent blood clots, pulmonary embolism, 
and strokes. Death rates from heart attacks are reduced by new forms of 
anticoagulation drugs.
Future Promise
    The era of precision medicine has arrived. The field of hematology 
has experienced a recent surge in progress thanks to novel 
technologies, mechanistic insights, and cutting-edge therapeutic 
strategies that have driven significant and meaningful advances in the 
quality of care. Insights into new genetic and biologic markers can be 
used to understand what causes a disease, the risk factors that 
predispose to disease, and how patients will respond to a particular 
treatment. These foundational insights are reframing modern research 
with the continued goal of improving outcomes and discovering cures for 
the most challenging hematologic diseases.
    Translating these new discoveries and technologies into 
personalized patient care offers the possibility of better survival, 
less toxicity, disease prevention, improved quality of life, and lower 
health-care costs. Yet today, a number of specific and critically 
important research questions must be answered to gain the insights that 
will launch the field into the next generation of care for hematologic 
conditions. A wide variety of blood-related diseases--from malignancies 
such as lymphoma and leukemia, to non-malignant diseases including 
hemoglobinopathies such as sickle cell disease and thalassemia--
continue to be associated with significant morbidity and mortality and 
demand attention to reduce their burden and improve the quality of care 
worldwide.
                       fiscal year 2017 requests
NIH Funding
    ASH thanks Congress for the robust bipartisan support that resulted 
in the welcome and much needed funding increase for the NIH that 
Congress provided in the fiscal year 2016 Consolidated Appropriations 
Act. ASH supports the Ad Hoc Group for Medical Research recommendation 
that NIH receive at least $34.5 billion in fiscal year 2017 as the next 
step toward a multi-year increase in our nation's investment in medical 
research. If the nation is to continue to accelerate the development of 
life-changing cures, pioneering treatments, and innovative prevention 
strategies, it is essential to sustain predictable increases in the NIH 
budget. Trials to find new therapies and cures for millions of 
Americans with blood cancers, bleeding disorders, clotting problems, 
and genetic diseases are just a few of the important projects that 
could be delayed unless NIH continues to receive predictable and 
sustained funding. This requested $2.4 billion increase represents 5 
percent real growth above the projected rate of biomedical inflation, 
and will help ensure that NIH-funded research can continue to improve 
our nation's health and enhance our competitiveness in today's global 
information and innovation-based economy.
    Additionally, the Society strongly supports the Administration's 
proposed Moonshot Initiative, which seeks to accelerate progress across 
all cancers by supporting research in cancer prevention and vaccine 
development, early detection, immunotherapy and combination therapy, 
genomic analysis, data sharing, and pediatric cancer.
Centers for Disease Control and Prevention (CDC) Public Health Response 
        for Blood Disorders
    The Society also recognizes the important role of the Centers for 
Disease Control and Prevention (CDC) in preventing and controlling 
clotting, bleeding, and other hematologic disorders. Blood disorders--
such as sickle cell disease, anemia, blood clots, and hemophilia--are a 
serious public health problem and affect millions of people each year 
in the United States, cutting across the boundaries of age, race, sex, 
and socioeconomic status. Men, women, and children of all backgrounds 
live with the complications associated with these conditions, many of 
which are painful and potentially life-threatening.
    CDC is uniquely positioned to reduce the public health burden 
resulting from blood disorders by contributing to a better 
understanding of these conditions and their complications; ensuring 
that prevention programs are developed, implemented, and evaluated; 
ensuring that information is accessible to consumers and healthcare 
providers; and encouraging action to improve the quality of life for 
people living with or affected by these conditions. The Society is 
concerned that the Division of Blood Disorders was cut by over $4 
million in the Consolidated Appropriations Act of 2014. ASH 
respectfully requests that the Committee restore funding for the 
Division of Blood Disorders, by including increased funding to the 
public health approach to blood disorders account to enable CDC to meet 
growing needs for programs to address sickle cell disease and deep vein 
thrombosis/pulmonary embolism (DVT/PE). This funding will allow CDC to 
improve health outcomes and limit complications to those who are risk 
or currently have bleeding and clotting disorders, by promoting a 
comprehensive care model; identifying and evaluating effective 
prevention strategies; and increasing public and healthcare provider 
awareness.
Additional Activities
    In fiscal year 2017, ASH also urges the Subcommittee to recognize 
the following activities impacting hematology:
  --Centers for Disease Control and Prevention, National Center on 
        Birth Defects and Developmental Disabilities
    --Report Language:
      Sickle Cell Disease.--The Committee believes more can be done to 
            educate patients and medical providers about sickle cell 
            disease (SCD) and sickle cell trait (SCT). It is especially 
            important that individuals know their sickle cell status, 
            the potential for medical complications, and the 
            implications when making reproductive choices and that 
            providers be informed of the current recommendations (best 
            practices) for providing medical care to individuals with 
            SCD/SCT. The Committee asks that the Center's Blood 
            Disorders Division provide a plan on how to carry out a 
            public health awareness and education campaign to meet 
            these goals.
    --Background:
      Sickle cell disease is the most common inherited red blood cell 
            disorder in the United States, affecting approximately 
            100,000 Americans (mostly but not exclusively of African 
            ancestry). SCD causes the production of abnormal 
            hemoglobin, which can get stuck and block blood flow, 
            causing pain and infections. Complications of sickle cell 
            anemia include stroke, acute chest syndrome, organ damage, 
            other disabilities, and in some cases premature death. Most 
            SCD patients can expect to live into adulthood, but the 
            cost of care and the burden of pain, end-organ injury, and 
            premature death remain high.
  --Centers for Medicare and Medicaid Services, Program Management
    --Report Language:
      Sickle Cell Disease.--The Committee encourages CMS working 
            through the Center for Medicare and Medicaid Innovation to 
            explore with the interested provider and patient 
            organizations, the development of model programs to provide 
            integrated comprehensive care for adults with sickle cell 
            disease (SCD). With an estimated 50 percent of the SCD 
            population served under Medicaid and another 25 percent on 
            Medicare, CMS has every incentive to assure that 
            individuals with SCD are able to access specialized high 
            quality services. Consideration should be given to funding 
            of care coordinators/case managers for this population with 
            incentives to reduce hospital admissions/readmissions and 
            emergency department visits.
    --Background:
      Sickle cell disease is the most common inherited red blood cell 
            disorder in the United States, affecting approximately 
            100,000 Americans (mostly but not exclusively of African 
            ancestry). SCD causes the production of abnormal 
            hemoglobin, which can get stuck and block blood flow, 
            causing pain and infections. Complications of sickle cell 
            anemia include stroke, acute chest syndrome, organ damage, 
            other disabilities, and in some cases premature death. 
            According to the Agency for Healthcare Research and Quality 
            (AHRQ) Healthcare Cost and Utilization Project--2012, 
            Sickle cell disease was the 5th most common discharge 
            diagnosis for hospital ``super users'' for Medicaid 
            patients under 64 and patients with SCD are high utilizers 
            of emergency room services. Most SCD patients can expect to 
            live into adulthood, but the cost of care and the burden of 
            pain, end-organ injury, and premature death remain high.
    Thank you again for the opportunity to submit testimony. Please 
contact Tracy Roades, ASH Legislative Advocacy Manager, at 
troades@hematology.org, if you have any questions or need further 
information concerning hematology research or ASH's fiscal year 2017 
requests.
                                 ______
                                 
        Prepared Statement of the American Society of Nephrology
    On behalf of the more than 20 million children, adolescents, and 
adults living with kidney diseases in the United States, the American 
Society of Nephrology requests $2.165 billion for the National 
Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the 
National Institutes of Health (NIH) for fiscal year 2017. The society 
also requests an additional $150 million per year over 10 years for 
NIDDK-funded kidney research above the current funding level. These are 
crucial and necessary investments for preventing illness and 
maintaining fiscal responsibility. Investing in research to slow the 
progression of kidney diseases and improve therapies for patients would 
yield significant savings to Medicare in the long run.
    Once kidney disease progresses to end-stage renal disease (ESRD), 
patients need either costly dialysis treatments or a kidney transplant. 
Because there are not enough kidney donations for every patient who 
needs one, most of the 662,000 Americans with ESRD are on dialysis at 
an annual cost of $85,000 per patient. In 1972, Congress made a 
commitment to provide Medicare coverage for every American with ESRD so 
all Americans who needed dialysis would have access to it.
    Consequently, ESRD is the only health condition Medicare 
automatically provides coverage for regardless of age and income. At an 
annual cost of $35 billion--more than NIH's entire budget of $32 
billion--the Medicare ESRD Program represents 7 percent of Medicare's 
budget even though ESRD patients represent less than 1 percent of the 
Medicare population. Despite the burden of kidney disease, NIH 
investments in kidney research are less than 1 percent of total 
Medicare costs for patients with kidney diseases (approximately $591 
million vs. $98.9 billion in 2013).
    The vast majority of Federal research leading to advances in the 
care and treatment of Americans with kidney diseases is funded by 
NIDDK, and there have been several major breakthroughs in the past 
several years thanks to NIDDK-funded research.
    For example, geneticists focused on the kidney have made advances 
in understanding the biological processes leading to the development of 
some common kidney diseases. In addition, scientists have announced a 
method for growing new kidneys in a laboratory, as well as a rapid 
method for screening new prescription medications using kidney cells 
that would spare the expense and time of conducting human clinical 
trials. NIDDK-funded research also led to the development of 
bioengineered kidneys that are currently undergoing clinical testing.
    Change is on the way because of advances made through NIDDK-funded 
kidney research. Additional, sustained funding is needed to accelerate 
these and other novel therapies that could improve the care of patients 
with kidney diseases and result in significant savings to Medicare. A 
failure to maintain and strengthen NIDDK's ability to support the 
groundbreaking work of researchers across the country carries a 
palpable human toll, denying hope to the millions of patients awaiting 
the possibility of a healthier tomorrow.
    The American Society of Nephrology urges Congress to uphold its 
longstanding legacy of bipartisan support for biomedical research. 
Should you have any questions or wish to discuss NIDDK kidney research 
in more detail, please contact Grant Olan, Senior Policy and Government 
Affairs Associate of the American Society of Nephrology, at golan@asn-
online.org.
                  about american society of nephrology
    The American Society of Nephrology is a 501(c)(3) non-profit, tax-
exempt organization that leads the fight against kidney disease by 
educating the society's nearly 16,000 nephrologists, scientists, and 
other healthcare professionals, advancing research and innovation, 
communicating new knowledge, and advocating for the highest quality 
care for patients. For more information, visit www.asn-online.org.
                                 ______
                                 
     Prepared Statement of the American Society of Plant Biologists
    On behalf of the American Society of Plant Biologists (ASPB), we 
would like to thank the Subcommittee for its support of the National 
Institutes of Health (NIH). ASPB and its members strongly believe that 
sustained investments in scientific research are a critical component 
of economic growth and job creation in our Nation. ASPB supports the 
maximum fiscal year 2017 appropriation for NIH and asks that the 
Subcommittee Members encourage increased support for plant-related 
research within the agency; 25 percent of our medicines originate from 
discoveries related to plant natural products, and such research has 
contributed in innumerable ways to improving the lives and health of 
Americans and people throughout the world.
    ASPB is an organization of professional plant biology researchers, 
educators, students, and postdoctoral scientists with members across 
the Nation and throughout the world. A strong voice for the global 
plant science community, our mission--achieved through work in the 
realms of research, education, and public policy--is to promote the 
growth and development of plant biology, to encourage and communicate 
research in plant biology, and to promote the interests and growth of 
plant scientists in general.
              plant biology research and america's future
    Among many other functions, plants form much of the base of the 
food chain upon which all life depends. Importantly, plant research is 
also helping make many fundamental contributions in the area of human 
health, including that of a sustainable supply and discovery of plant-
derived pharmaceuticals, nutriceuticals, and alternative medicines. 
Plant research also contributes to the continued, sustainable, 
development of better and more nutritious foods and the understanding 
of basic biological principles that underpin improvements in the health 
and nutrition of all Americans.
          plant biology and the national institutes of health
    Plant science and many of our ASPB member research activities have 
enormous positive impacts on the NIH mission to pursue ``fundamental 
knowledge about the nature and behavior of living systems and the 
application of that knowledge to extend healthy life and reduce the 
burdens of illness and disability.'' In general, plant research aims to 
improve the overall human condition--be it food, nutrition, medicine or 
agriculture--and the benefits of plant science research readily extend 
across disciplines. In fact, plants are often the ideal model systems 
to advance our ``fundamental knowledge about the nature and behavior of 
living systems'' as they provide the context of multi-cellularity while 
affording ease of genetic manipulation, a lesser regulatory burden, and 
maintenance requirements that are less expensive than those required 
for the use of animal systems.
    Many fundamental biological components and mechanisms (e.g., cell 
division, viral and bacterial invasion, polar growth, DNA methylation 
and repair, innate immunity signaling and circadian rhythms) are shared 
by both plants and animals. For example, a process known as RNA 
interference, which has potential application in the treatment of human 
disease, was first discovered in plants. Subsequent research eventually 
led to two American scientists, Andrew Fire and Craig Mello, earning 
the 2006 Nobel Prize in Physiology or Medicine. More recently, 
scientists engineered a class of proteins called TALENs capable of 
precisely editing genomes to potentially correct mutations that lead to 
disease. That these therapeutic proteins are derived from others 
initially discovered in a plant pathogen exemplifies the application of 
plant biology research to improving human health. These important 
discoveries again reflect the fact that some of the most important 
biological discoveries applicable to human physiology and medicine can 
find their origins in plant-related research endeavors.
    Health and Nutrition.--Plant biology research is also central to 
the application of basic knowledge to ``extend healthy life and reduce 
the burdens of illness and disability.'' Without good nutrition, there 
cannot be good health. Indeed, a World Health Organization study on 
childhood nutrition in developing countries concluded that over 50 
percent of child deaths under the age of five could be attributed to 
malnutrition's effects in weakening the immune system and exacerbating 
common illnesses such as respiratory infections and diarrhea. 
Strikingly, most of these deaths were not linked to severe 
malnutrition, but chronic nutritional deficiencies brought about by 
overreliance on single crops for primary staples. Plant researchers are 
working today to address the root cause of this problem by balancing 
the nutritional content of major crop plants to provide the full range 
of essential micronutrients in plant-based diets.
    By contrast, obesity, cardiac disease, and cancer take a striking 
toll in the developed world. Research to improve and optimize 
concentrations of plant compounds known to have, for example, anti-
carcinogenic properties, will hopefully help in reducing disease 
incidence rates. Ongoing development of crop varieties with tailored 
nutraceutical content is an important contribution that plant 
biologists can and are making toward realizing the long-awaited goal of 
personalized medicine, especially for preventative medicine.
    Drug Discovery.--Plants are also fundamentally important as sources 
of both extant drugs and drug discovery leads. In fact, 60 percent of 
anti-cancer drugs in use within the last decade are of natural product 
origin--plants being a significant source. An excellent example of the 
importance of plant-based pharmaceuticals is the anti-cancer drug 
taxol, which was discovered as an anti-carcinogenic compound from the 
bark of the Pacific yew tree through collaborative work involving 
scientists at the NIH National Cancer Institute and plant natural 
product chemists. Taxol is just one example of the many plant compounds 
that will continue to provide a fruitful source of new drug leads.
    While the pharmaceutical industry has largely neglected natural 
products-based drug discovery in recent years, research support from 
NIH offers yet another paradigm. Multidisciplinary teams of plant 
biologists, bioinformaticians, and synthetic biologists are being 
assembled to develop new tools and methods for natural products 
discovery and creation of new pharmaceuticals. We appreciate NIH's 
current investment into understanding the biosynthesis of natural 
products through transcriptomics and metabolomics of medicinal plants 
and support more funding opportunities similar to the ``Genomes to 
Natural Products'' which will hopefully pave the way for new plant-
related medicinal research.
                               conclusion
    Although NIH does recognize that plants serve many important roles, 
the boundaries of plant-related research are expansive and integrate 
seamlessly and synergistically with many different disciplines that are 
also highly relevant to NIH. As such, ASPB asks the Subcommittee to 
provide the maximum appropriation and direct NIH to support additional 
plant research in order to continue to pioneer new discoveries and new 
methods with applicability and relevance in biomedical research.
    Thank you for your consideration of ASPB's testimony. For more 
information about ASPB, please see www.aspb.org.

    [This statement was submitted by Tyrone C. Spady, Ph.D., Director 
of Legislative and Public Affairs, American Society of Plant 
Biologists.]
                                 ______
                                 
          Prepared Statement of the American Thoracic Society

                    SUMMARY: FUNDING RECOMMENDATIONS
                             (In millions $)
 
 
------------------------------------------------------------------------
National Institutes of Health..............................     34,500
    National Heart, Lung & Blood Institute.................      3,400
    National Institute of Allergy & Infectious Disease.....      4,715
    National Institute of Environmental Health Sciences....        732.2
    Fogarty International Center...........................         70.7
    National Institute of Nursing Research.................        152
Centers for Disease Control and Prevention.................      7,800
    National Institute for Occupational Safety & Health....        339.1
    Asthma Programs........................................         30.5
    Div. of Tuberculosis Elimination.......................        243
    Office on Smoking and Health...........................        220
    National Sleep Awareness Roundtable (NSART)............          1
------------------------------------------------------------------------

    The ATS's 15,000 members help prevent and fight respiratory disease 
through research, education, patient care and advocacy.
                        lung disease in america
    Respiratory diseases are the third leading cause of death in the 
U.S., responsible for one of every seven deaths. Diseases affecting the 
respiratory (breathing) system include chronic obstructive pulmonary 
disease (COPD), lung cancer, influenza, sleep disordered breathing, 
pediatric lung disorders, tuberculosis, occupational lung disease, 
asthma, and critical illness.
                     national institutes of health
    The NIH is the world's leader in groundbreaking biomedical health 
research into the prevention, treatment and cure of diseases such as 
lung cancer, COPD and tuberculosis. But sequestration, annual funding 
cuts and a lack of inflationary adjustments over the past decade have 
eroded the NIH research budget. NIH's spending power in inflation-
adjusted dollars has declined by over 20 percent since 2003. The number 
of grants supported by the NIH is now at the lowest level since 2001. 
The ATS is very concerned that due to reductions in Federal research 
funding, there is a lack of opportunities for young investigators who 
represent the future of scientific innovation. We ask the subcommittee 
to provide at least $34.5 billion in funding for the NIH in fiscal year 
2017.
    Despite the fact that lung disease is the third leading cause of 
death in the U.S., lung disease research is underfunded. The COPD death 
rate has doubled within the last 30 years and is still increasing, 
while the rates for the other top causes of death (heart disease, 
cancer and stroke) have decreased by over 50 percent. In fiscal year 
2014, lung disease, critical illness and sleep research represented 
27.3 percent of the National Heart Lung and Blood Institute's (NHLBI) 
budget. Despite the growing lung disease burden, research funding for 
the disease is a small fraction of the money invested for the other 
three leading causes of death. In order to stem the devastating effects 
of lung disease, research funding must continue to grow.
               centers for disease control and prevention
    In order to ensure that health promotion and chronic disease 
prevention are given top priority in Federal funding, the ATS supports 
a funding level for the Centers for Disease Control and Prevention 
(CDC) that enables it to carry out its prevention mission, and ensure a 
translation of new research into effective state and local public 
health programs. We ask that the CDC budget be adjusted to reflect 
increased needs in chronic disease prevention, infectious disease 
control, including TB control and occupational safety and health 
research and training. The ATS recommends a funding level of $7.8 
billion for the CDC in fiscal year 2017.
                         antibiotic resistance
    According to the Centers for Disease Control and Prevention's (CDC) 
2013 report, Antibiotic Resistance Threats in the United States, as 
many as 23,000 deaths occur in the U.S. annually due to antibiotic 
resistant bacterial and fungal pathogens including drug resistant 
pneumonia and sepsis infections. The rise of antibiotic resistance 
demonstrates the need to increase efforts through the CDC, NIH and 
other Federal agencies to monitor and prevent antibiotic resistance and 
develop rapid new diagnostics and treatments. This includes the 
following recommendations for CDC programs:
  --$200 million for the Antibiotic Resistance Solutions Initiative
  --$21 million for the National Healthcare Safety Network (NHSN)
  --$30 million for the Advanced Molecular Detection (AMD) Initiative
    To address antibiotic resistance research needs, we urge the 
committee to provide $4,715 billion for the National Institutes of 
Allergy and Infectious Disease (NIAID) to spur research into rapid new 
diagnostics, new treatments and other activities and $512 million for 
the Biomedical Advanced Research and Development Authority (BARDA) to 
support antimicrobial research and development.
                                  copd
    Chronic Obstructive Pulmonary Disease (COPD) is the third leading 
cause of death in the United States and the third leading cause of 
death worldwide, yet the disease remains relatively unknown to most 
Americans. CDC estimates that 12 million patients have COPD; an 
additional 12 million Americans are unaware that they have this life 
threatening disease. In 2010, the estimated economic cost of lung 
disease in the U.S. was $186 billion, including $117 billion in direct 
health expenditures and $69 billion in indirect morbidity and mortality 
costs.
    The NHLBI is developing a national action plan on COPD, in 
coordination with the CDC to expand COPD surveillance, development of 
public health interventions and research on the disease and increase 
public awareness of the disease and we urge Congress to support it. We 
also urge CDC to include COPD-based questions to future CDC health 
surveys, including the National Health and Nutrition Evaluation Survey 
(NHANES) and the National Health Information Survey (NHIS).
                            tobacco control
    Tobacco use is the leading preventable cause of death in the U.S., 
responsible for one in five deaths annually. The ATS is pleased that 
the Department of Health and Human Services has made tobacco use 
prevention a top priority. Tobacco cessation and prevention activities 
are among the most effective and cost-effective investments in disease 
prevention. The CDC's Office on Smoking and Health (OSH) is the lead 
Federal program for tobacco prevention and control and created the 
``Tips from Former Smokers'' Campaign, which has prompted hundreds of 
thousands of smokers to call 1-800-QUIT-NOW or visit smokefree.gov for 
assistance in quitting--with even more smokers making quit attempts on 
their own or with the assistance of their physicians. In order to 
significantly reduce tobacco use within 5 years, as recommended by the 
subcommittee in fiscal year 2010, the ATS recommends a total funding 
level of $220 million for the Office of Smoking and Health in fiscal 
year 2017.
                                 asthma
    Asthma is a significant public health problem in the United States. 
Approximately 25 million Americans currently have asthma. In 2013, 
3,388 Americans died as a result of asthma exacerbations. Asthma is the 
third leading cause of hospitalization among children under the age of 
15 and is a leading cause of school absences from chronic disease. The 
disease costs our healthcare system over $50.1 billion per year. 
African Americans have the highest asthma prevalence of any racial/
ethnic group and the age-adjusted death rate for asthma in this 
population is three times the rate in whites. A study published in the 
American Journal of Respiratory Critical Care in 2012 found that for 
every dollar invested in asthma interventions, there was a $36 benefit. 
We ask that the subcommittee's appropriations request for fiscal year 
2017 that funding for CDC's National Asthma Control Program be 
maintained at a funding level of at least $30.596 million.
                                 sleep
    Several research studies demonstrate that sleep-disordered 
breathing and sleep-related illnesses affect an estimated 50-70 million 
Americans. The public health impact of sleep illnesses and sleep 
disordered breathing is still being determined, but is known to include 
increased mortality, traffic accidents, cardiovascular disease, 
obesity, mental health disorders, and other sleep-related 
comorbidities. The ATS recommends a funding level of $1 million in 
fiscal year 2017 to support activities related to sleep and sleep 
disorders at the CDC, including surveillance activities and public 
educational activities. The ATS also recommends an increase in funding 
for research on sleep disorders at the Nation Center for Sleep 
Disordered Research (NCSDR) at the NHLBI.
                              tuberculosis
    Tuberculosis (TB) is the leading global infectious disease killer, 
ahead of HIV/AIDS, claiming 1.5 million lives each year. In the U.S., 
every State reports cases of TB annually and in 2015, the CDC reported 
the first national increase in TB cases in over 20 years. Drug 
resistant tuberculosis was identified as a serious public health threat 
to the U.S. in the CDC's 2013 report on antimicrobial resistance. Drug-
resistant TB strains poses a particular challenge to domestic TB 
control due to the high costs of treatment, intensive healthcare 
resources and burden on patients. Treatment costs for multidrug-
resistant (MDR) TB, which is up to 2 years in length, range from 
$100,000 to $300,000. The continued global pandemic of this airborne 
infectious disease and spread of drug resistant TB demand that the U.S. 
strengthen our investment in global and domestic TB control and 
research to develop new TB diagnostic, treatment and prevention tools.
    The Comprehensive Tuberculosis Elimination Act (CTEA, Public Law 
110-392), enacted in 2008, reauthorized programs at CDC with the goal 
of putting the U.S. back on the path to eliminating TB. The ATS 
recommends a funding level of $243 million in fiscal year 2017 for 
CDC's Division of TB Elimination, as authorized under the CTEA, and 
urges the NIH to expand efforts to develop new tools to address TB. 
Additionally, in recognition of the unique public health threat posed 
by drug resistant TB, we urge BARDA to support research and development 
into new drug resistant TB diagnostic, treatment and prevention tools.
                         pediatric lung disease
    The ATS is pleased to report that infant death rates for various 
lung diseases have declined for the past 10 years. In 2010, of the 10 
leading causes of infant mortality, 4 were lung diseases or had a lung 
disease component. Many of the precursors of adult respiratory disease 
start in childhood. For instance, many children with respiratory 
illness grow into adults with COPD. It is estimated that 7.1 million 
children suffer from asthma. While some children appear to outgrow 
their asthma when they reach adulthood, 75 percent will require life-
long treatment and monitoring of their condition. The ATS encourages 
the NHLBI and NICHD to sustain and expand research efforts to study 
lung development and pediatric lung diseases.
                            critical illness
    The burden associated with the provision of care to critically ill 
patients is enormous, and is anticipated to increase significantly as 
the population ages. Approximately 200,000 people in the United States 
require hospitalization in an intensive care unit because they develop 
a form of pulmonary disease called Acute Lung Injury. Despite the best 
available treatments, 75,000 of these individuals die each year from 
this disease. This is the approximately the same number of deaths each 
year due to breast cancer, colon cancer, and prostate cancer combined. 
Investigation into diagnosis, treatment and outcomes in critically ill 
patients should be a priority, and the NIH should be funded and 
encouraged to coordinate investigation in this area in order to meet 
this growing national imperative.
                      fogarty international center
    The Fogarty International Center (FIC) provides training grants to 
U.S. universities to teach AIDS treatment and research techniques to 
international physicians and researchers. Because of the link between 
AIDS and TB infection, FIC has created supplemental TB training grants 
for these institutions to train international health professionals in 
TB treatment and research. The ATS recommends Congress provide $70.7 
million for FIC in fiscal year 2017, to allow expansion of the TB 
training grant program from a supplemental grant to an open competition 
grant.
          researching and preventing occupational lung disease
    As Congress considers funding priorities for fiscal year 2017, the 
ATS urges the subcommittee to provide at least $339.1 million in 
funding for the National Institute for Occupational Safety and Health 
(NIOSH). NIOSH, within the Centers for Disease Control and Prevention 
(CDC), is the primary Federal agency responsible for conducting 
research and making recommendations for the prevention of work-related 
illness and injury.
    The ATS appreciates the opportunity to submit this statement to the 
subcommittee.

    [This statement was submitted by Atul Malhotra, MD, President, 
American Thoracic Society.]
                                 ______
                                 
             Prepared Statement of the Arthritis Foundation
    On behalf of the more than 50 million adults and 300,000 children 
living with doctor-diagnosed arthritis in the U.S., the Arthritis 
Foundation thanks Chairman Blunt and Ranking Member Murray for the 
opportunity to provide written testimony to the Appropriation 
Subcommittee on Labor, Health and Human Services (HHS), and Education 
and Related Agencies for fiscal year 2017. We respectfully request $16 
million for the Centers for Disease Control and Prevention (CDC) 
Arthritis Program and sufficient funding for the National Institutes of 
Health (NIH) for fiscal year 2017.
    Arthritis affects 1 in 5 Americans and is the leading cause of 
disability in the U.S., according to CDC. It limits the daily 
activities of nearly 23 million Americans and causes work limitations 
for 40 percent of the people with the disease. This translates to $156 
billion a year in direct and indirect costs from two forms of arthritis 
alone--osteoarthritis (OA) and rheumatoid arthritis (RA). There is no 
cure for arthritis, and for some forms of arthritis like OA, there is 
no effective pharmaceutical treatment. Research is critical to build 
towards a cure, to develop better treatments with fewer severe side 
effects, and to identify biomarkers and therapies for types of 
arthritis for which none exist. A strong investment in public health 
research and programs is essential to making breakthroughs in 
treatments finding a cure for arthritis, and for delivering those 
breakthroughs to the people who suffer from this debilitating disease.
   centers for disease control and prevention (cdc) arthritis program
    The CDC Arthritis Program is the only Federal program dedicated 
solely to arthritis. It provides grants to 12 States to support public 
health programs, provide education services, perform public health 
research, and support data collection. Its goal is to connect all 
Americans with arthritis to resources to help them manage their 
disease. Evidence-based programs like Enhance Fitness help keep older 
adults active, and have shown a 35 percent improvement in physical 
function, resulting in fewer hospitalizations and lower health costs 
compared to non-participants. Further, 1 in 3 veterans has doctor-
diagnosed arthritis, and these evidence-based exercise programs are 
recommended by the CDC to help our veterans reduce the impact of 
arthritis on their lives.
    Missouri is one of the 12 CDC-funded States, and with this Federal 
support, the State Arthritis and Osteoporosis Program and its partners 
have been able to develop and disseminate specific marketing material 
for arthritis programs, offer more programs in more communities and in 
more sites, involve more agencies and partners, and involve more 
referrals from doctor's offices. The impact to-date is a 50 percent 
increase in the number of self-management programs offered across the 
State in 2 years, a doubling of the offering of the Walk with Ease 
program, and an increase of 18 active partners in the Health Delivery 
System partnership.
    Not only does the Arthritis Program provide resources to people 
with arthritis, it also supports data collection on the prevalence and 
severity of arthritis. Because of this support, we know that 1 in 5 
Americans has doctor-diagnosed arthritis, including 27 percent of 
people in Oklahoma and 24 percent of people in Connecticut, and 415,000 
of those people in Oklahoma and 267,000 of those people in Connecticut 
are limited by their arthritis. Without the Arthritis Program, the 
robust level of data collection we have now would not exist. As you 
know, this data is critical for determining where to direct public 
health programs and how to set research priorities. For example, 
because of the data on the high number of people with arthritis who 
also have at least one other chronic disease like heart disease (24 
percent) or diabetes (16 percent), we know that research on co-
morbidities and coordinated chronic disease programs are important to 
reducing the overall impact of chronic disease on people with 
arthritis.
    Given the high prevalence and severity of this disease, the 
Arthritis Program is woefully under-funded compared to the investment 
in other chronic diseases. Funding for the program was cut by 25 
percent in fiscal year 2015, bringing the fiscal year 2015 total down 
from $13 million to $9.5 million. As a result, program staff had to cut 
program activities between 10-50 percent, with some eliminations, and 
were unable to make new investments in arthritis programs. While $1.5 
million was restored in fiscal year 2016, the Arthritis Program is 
still not operating at its full funding level of $13 million, and 
combined with previous flat funding, has lost millions of dollars in 
purchasing power over the last 6 fiscal years.
    In 2013 for the first time, data showed that arthritis affects at 
least 20 percent of the population in every State. All 50 States need 
funding from the Arthritis Program. While this is a long-term goal, a 
critical first step is to increase funding in fiscal year 2017 by $5 
million so it can continue its current level of operations in the 12 
States it supports and begin to expand into additional States. With 
this increase, the Arthritis Program could operate in an additional 2 
States, support more national grants and increase its investment in 
public health research. Therefore, we urge you to fund the CDC 
Arthritis Program at $16 million in fiscal year 2017.
                  national institutes of health (nih)
    As previously stated, there is no cure for arthritis, and for some 
forms of the disease, no effective pharmaceutical treatments. Even for 
auto-immune forms of the disease like RA, biologic medications--which 
have revolutionized treatment by halting the progress of disease in 
many patients--have severe side effects. There is also no ``gold 
standard'' diagnostic for many forms of arthritis like RA and juvenile 
arthritis, and therefore it can take a long time to diagnose these 
diseases. It is not uncommon for children to go months without an 
official diagnosis, which can delay the start of critical treatment. 
Research is the key to identifying better diagnostics and better 
treatments, so that people have access to treatments early in their 
disease, ensuring a higher quality of life and better health outcomes.
    The National Institute of Arthritis and Musculoskeletal and Skin 
Diseases (NIAMS) is one of the primary NIH Institutes that supports 
arthritis research. There are a number of initiatives supported by 
NIAMS to better understand arthritis. The Osteoarthritis Initiative is 
a public-private, multi-center, longitudinal study of knee OA that was 
launched in 2002 with the goal of identifying biomarkers for OA as 
potential surrogate endpoints for onset and progression. The recently 
launched Accelerating Medicines Partnership is a public-private 
partnership that includes RA/lupus as one of three disease topics with 
the goal of accelerating drug development.
    Research currently supported by NIAMS is addressing major questions 
necessary to unlocking the unknowns of arthritis, such as: how gene-
environment interactions can help determine the relationship between RA 
and environmental and genetic factors that trigger onset; which 
biological pathways are affected in people with RA and how drug 
development can target those pathways to expand the pool of drugs 
available to people with RA; and how existing successful anti-rheumatic 
drugs may be used for other arthritis-related diseases.
    Most recently, researchers have found the gene that confirms the 
existence of psoriatic arthritis. This is a breakthrough that has the 
potential to lead to targeted therapies for psoriatic arthritis, and 
even treatments that can prevent its onset. These research 
breakthroughs can have an enormous impact on the quality of life for 
people with arthritis, in addition to generating a strong return on 
investment in reduced healthcare costs and better quality of life for 
patients.
    Future research efforts can explore how changes to DNA regions can 
lead to disease, with the goal of uncovering additional targeted 
treatments. A strong overall NIH funding level is critical to 
maintaining the investment in research on arthritis in all its forms. 
Therefore, we urge you to provide sufficient funding for NIH in fiscal 
year 2017 to keep pace with the growing research needs in the arthritis 
community.
    We thank the subcommittee for its commitment to public health. As 
you write the fiscal year 2017 Labor-HHS-Education appropriations bill, 
we urge you to fund the CDC Arthritis Program at $16 million and 
provide sufficient funds to the NIH in order to continue the investment 
in improving the lives of people with arthritis. Please contact Sandie 
Preiss, the Arthritis Foundation National VP of Advocacy and Access at 
spreiss@arthritis.org or the Arthritis Foundation Senior Director of 
Advocacy and Access Anna Hyde at ahyde@arthritis.org with any 
questions.

    [This statement was submitted by Sandie Preiss, National Vice 
President of Advocacy and Access.]
                                 ______
                                 
    Prepared Statement of the Association for Career and Technical 
                               Education
    Chairman Blunt, Ranking Member Murray and members of the 
subcommittee, on behalf of the Association for Career and Technical 
Education (ACTE), the Nation's largest not-for-profit association 
committed to the advancement of education that prepares youth and 
adults for successful careers, I would like to urge you to help support 
career and technical education (CTE) through a strong Federal 
investment in the Carl D. Perkins Career and Technical Education Act 
(Perkins) for fiscal year 2017. To ensure that students are equipped 
with the academic, technical and employability skills they need for 
success in the jobs that are available today, and the careers of 
tomorrow, I respectfully request that the subcommittee increase the 
Perkins Basic State Grant program (Title I), administered by U.S. 
Department of Education, Office of Career, Technical, and Adult 
Education, to $1.3 billion in the fiscal year 2017 Labor, Health and 
Human Services, and Education appropriations bill.
    Perkins is the principal source of dedicated Federal funding for 
CTE programs in secondary and postsecondary institutions across the 
county. This Federal investment is crucial to ensuring that students 
are prepared for careers in expanding fields like engineering, 
information technology, advanced manufacturing and healthcare. In a 
rapidly changing job market, CTE provides students with transferable 
skills that ensure they are college-and career-ready, while offering 
retraining opportunities to many working adults.
    Despite the importance of Perkins funding in advancing high-quality 
CTE programs for more than 11 million students nationwide, 
congressional appropriations have not kept pace with the growing need. 
Funding for the Perkins Basic State Grant program is still $5.4 million 
below its pre-sequestration level. From fiscal year 2007 through fiscal 
year 2016, total Perkins grant funding to States declined by 13 
percent--nearly $170 million less in funding to support CTE, and an 
even greater loss if you take into account the effects of inflation.
    The erosion of Perkins funds comes at a time when CTE programs are 
experiencing new attention and growth. States are using Perkins funding 
to strengthen student performance results in areas such as attainment 
of academic and technical skills, and transitioning to further 
education or employment. In the most recent data available, the average 
high school graduation rate for students concentrating in CTE programs 
is 93 percent. Students involved in CTE programs are engaged in their 
education, perform well academically, gain critical employability 
skills and earn industry-recognized credentials. Perkins provides a 
strong return on our Federal investment by fostering an educated and 
highly skilled workforce that delivers direct benefits to American 
employers, and further strengthens the economy through productivity and 
innovation.
    The Obama administration's fiscal year 2017 budget request includes 
an increase of $75 million for the proposed American Technical Training 
Fund, which would provide competitive grants to support the development 
job training programs in high-demand fields. The additional request of 
a $2 million increase for CTE National Programs would provide technical 
assistance and evaluation support for projects under the American 
Technical Training Fund proposal. While these resources would help meet 
the needs of a few programs, the administration's budget, once again, 
fails to provide any additional funding for the formula Perkins Basic 
State Grant program. It is the position of ACTE that limited resources 
for education and job training are better directed to proven, formula-
driven programs that serve students in communities across the country, 
and we remain committed to expanding equitable access to high-quality 
CTE.
    Increasing the Perkins Basic State Grant to $1.3 billion, a 15 
percent increase over the current level, would restore funding for 
States to the fiscal year 2007 level and could support an additional 
1.7 million students by expanding access to CTE programs of study that 
create a seamless educational pathway by strengthening the integration 
of academics and CTE content in the classroom, providing career 
guidance and academic counseling services, ensuring that CTE classrooms 
have the latest technology and equipment, and providing professional 
development and technical assistance for CTE educators. Thank you for 
your continued leadership and for your thoughtful consideration of our 
request. We look forward to working in a bipartisan fashion with the 
subcommittee throughout the fiscal year 2017 appropriations process.

    [This statement was submitted by Stephen DeWitt, Deputy Executive 
Director.]
                                 ______
                                 
   Prepared Statement of the Association for Research in Vision and 
                              Opthalmology
                           executive summary
    ARVO requests fiscal year 2017 appropriated National Institutes of 
Health (NIH) and the National Eye Institute (NEI) funding of at least 
$34.5 billion and $770 million, respectively, a 7.5 percent increase 
reflecting 5 percent real growth above projected 2.5 percent biomedical 
inflation.
  --ARVO thanks Congress for its bipartisan action in fiscal year 2016 
        to increase NIH funding by $2 billion over fiscal year 2015, 
        which is the largest actual dollar and percent increase since 
        fiscal year 2003.
  --We request a second year of budget increases to rebuild NIH's 
        discretionary funding base--especially as it has lost 22 
        percent of purchasing power since fiscal year 2003, in terms of 
        constant dollars--and to create a trend of predictable and 
        sustained funding.
  --ARVO also thanks Congress for the $31 million National Eye 
        Institute (NEI) increase over fiscal year 2015, especially 
        since it reflects the first time in 4 years that NEI's 
        operating budget exceeds that of the pre-sequester fiscal year 
        2012 level, albeit by a modest 0.8 percent. Further increases 
        this year will continue to rebuild NEI's discretionary funding 
        base--especially as it has lost 25 percent of purchasing power 
        since fiscal year 2003, in terms of constant dollars--and go 
        far to ensure predictable and sustained funding.
    ARVO shares the concerns expressed by bipartisan Leaders and 
Members of the Appropriations Committee and the LHHS Appropriations 
Subcommittee regarding the President's proposal to replace $1 billion 
of the NIH discretionary base funding with mandatory funding. ARVO is 
especially concerned that the President proposes to not only flat-fund 
most of the Institutes and Centers (I/Cs), but achieve this through the 
use of mandatory funding. In the case of the NEI, its discretionary 
base would be reduced to $687 million, with the difference reflecting 
mandatory funding that would raise it to the flat-funded level of $708 
million.
    ARVO looks forward to working with the appropriators to secure an 
increase of 5 percent real growth above inflation in fiscal year 2017 
NIH and NEI funding as the next step in ensuring the security and 
momentum of the Nation's biomedical research enterprise. We also stand 
ready to work with the authorizers on potential mechanisms to provide 
short-term ``surge'' funding to take advantage of the exceptional 
scientific opportunities now available to address current and emerging 
health challenges.
   nei's budget is not keeping pace as the burden of eye disease and 
                        vision impairment grows
    NEI's fiscal year 2016 enacted funding of $715.9 million--reduced 
to a $708 million operating budget due to pass-throughs--reflects the 
first time in four fiscal years that NEI's operating budget exceeds 
that of the pre-sequester fiscal year 2012 funding level of $702 
million. In the 4 years it has taken the NEI budget to grow a modest 
0.8 percent, it has experienced the compounded loss of purchasing power 
due to biomedical inflation rates ranging from 2 to 2.5 percent. During 
that timeframe, NEI's operating budget was also reduced as a result of 
a transfer back to the NIH Office of AIDS Research (OAR) for funding of 
the successfully completed NEI-sponsored Studies of the Ocular 
Complications of AIDS (SOCA). Although OAR's funding to NEI was not 
committed indefinitely, its return to NIH Central in the amounts of 
$5.6 million (fiscal year 2013), $6.9 million (fiscal year 2014), and 
$7.4 million (fiscal year 2015) had essentially cut NEI's budget 
further, resulting in a new baseline upon which future funding 
increases were calculated.
    In June 2014, Prevent Blindness (PB) released a report entitled 
``The Future of Vision: Forecasting the Prevalence and Costs of Vision 
Problems,'' which it commissioned from the University of Chicago's 
National Opinion Research Center (NORC). This report estimates the 
current annual cost (inclusive of direct and indirect costs) of vision 
disorders at $145 billion, an increase of $6 billion from the $139 
billion estimate in PB's 2013 study entitled ``Cost of Vision Problems: 
The Economic Burden of Vision Loss and Eye Disorders in the United 
States,'' which also concluded that direct medical costs associated 
with vision disorders are the fifth highest--only less than heart 
disease, cancers, emotional disorders, and pulmonary conditions. PB's 
2014 study projects that the total annual cost of vision disorders, 
which includes government, insurance, and patient costs, will grow to 
$373.2 billion in 2050 when expressed in 2014 dollars--which is $717 
billion when adjusted for inflation. Of the $373.2 billion estimated 
2050 costs, $154 billion or 41 percent will be borne by the Federal 
Government as the Baby-Boom generation ages into the Medicare program.
    Current NEI funding of $708 million is still less than 0.5 percent 
of the $145 billion annual cost of vision disorders. The U.S. is 
spending only $2.20 per-person, per-year for vision research at the 
NEI, while the 2013 PB report estimates that the cost of treating low 
vision and blindness is at least $6,690 per-person, per-year.
    The very health of the vision research community is also at stake. 
The convergence of past factors which have reduced NEI funding has 
affected both young and seasoned investigators and threatened the 
continuity of research and the retention of trained staff, while making 
institutions more reliant on private bridge and philanthropic funding. 
Tahreem Mir, MD, a postdoctoral research at Wilmer Eye Institute, 
summed up the situation facing young investigators:

        ``I have witnessed several of my colleagues, all brilliant 
        scientists, struggle to fund their research. Many spend more 
        time writing grants than conducting actual science.''
    $770 million fiscal year 2017 funding enables nei to pursue its 
                   audacious goal of restoring vision
    Among NEI's most exciting pursuits is the ``Audacious Goals 
Initiative (AGI),'' which aims to restore vision within the next decade 
through regeneration of the retina by replacing cells that have been 
damaged by disease and injury and restoring their visual connections to 
the brain. The AGI builds upon discoveries from past investment in 
biomedical research, such as gene sequencing, gene therapy, and stem 
cell therapies, and combines these with new discoveries--such as 
imaging technologies that enable researchers to non-invasively view in 
real-time biological processes occurring in the retina at a cellular 
level--to develop new therapies for degenerative retinal disorders.
    NEI has awarded the first set of grants associated with novel 
imaging technologies to help clinicians observe the function of 
individual neurons in human patients and follow them over time as they 
test new therapies. It is proceeding with a second round of awards 
associated with identifying new factors that control regeneration and 
comparing the regenerative process among model organisms, rodents, and 
non-human primates.
    As NEI Director Paul Sieving, M.D., Ph.D. noted in his February 
2013 comments at the first AGI meeting:

        ``Success would transform life for millions of people with eye 
        and vision diseases. It would have major implications for 
        medicine of the future, for vision diseases, and even beyond 
        this, for neurological diseases.''

    These are ambitious goals that require sustained and predictable 
funding increases. Our Nation's investment in vision health is an 
investment in its overall health. NEI's breakthrough research is a 
cost-effective investment, since it is leading to treatments and 
therapies that can ultimately delay, save, and prevent health 
expenditures, especially those associated with the Medicare and 
Medicaid programs. It can also increase productivity, help individuals 
to maintain their independence, and generally improve the quality of 
life--especially since vision loss is associated with increased 
depression and accelerated mortality.
  americans fear vision loss, which is a growing public health problem
    The 2012 study entitled ``Vision Problems in the United States,'' 
released by Prevent Blindness and funded in part by the NEI reported 
that, of the nearly 143 million Americans age 40-plus (per the 2010 
U.S. Census), 4 million were blind or had significant vision impairment 
and 37 million had an age-related eye disease, such as AMD, glaucoma, 
diabetic retinopathy, or cataracts. An additional 48 million Americans 
have a refractive error. This prevalence of vision impairment and eye 
disease will only grow, driven by:
  --The aging of the population--the ``Silver Tsunami'' of the 78 
        million baby boomers who will turn age 65 this decade and 
        experience increased risk for eye disease.
  --The disproportionate risk/incidence of eye disease in Hispanic and 
        African American communities, which increasingly account for a 
        larger share of the U.S. population.
  --Vision loss as a co-morbid condition of chronic disease, such as 
        diabetes, which is at epidemic levels due to the increased 
        incidence of obesity.
    In September 2014, the Alliance for Eye and Vision Research (AEVR) 
released results of a new poll entitled ``The Public's Attitudes about 
the Health and Economic Impact of Vision Loss and Eye Disease.'' It was 
commissioned by Research!America and conducted by Zogby Analytics with 
a grant from Research to Prevent Blindness (RPB), a private vision 
funding foundation which conducted the first-ever poll of the public's 
attitudes about vision loss in 1965. The 2014 poll--the most rigorous 
conducted to-date of attitudes about vision and vision loss among 
ethnic and racial groups including non-Hispanic Whites, African 
Americans, Hispanics, and Asian Americans--found that:
  --A significant number of Americans across all racial lines rate 
        losing their eyesight as having the greatest impact on their 
        daily life, affecting independence, productivity, and quality 
        of life.
  --African Americans, when asked what disease or ailment is the worst 
        that could happen, ranked blindness first, followed by HIV/
        AIDS. Hispanics and Asians ranked cancer first and blindness 
        second, while non-Hispanic Whites ranked Alzheimer's disease 
        first, followed by blindness.
  --America's minority populations are united in the view that not only 
        is eye and vision research very important and needs to be a 
        national priority, but many feel that the current annual 
        Federal funding is not enough and should be increased.
    In summary, ARVO requests fiscal year 2017 NIH funding of at least 
$34.5 billion and NEI funding of $770 million--the latter to better 
understand the scientific bases upon which to save sight and restore 
vision.
                               about arvo
    ARVO is a community of 12,000 vision researchers from 80 countries; 
we are the largest, most respected vision research organization in the 
world. Our aim to advance research worldwide into understanding the 
visual system and into preventing, treating and curing its disorders.
                                 ______
                                 
  Prepared Statement of the Association of American Cancer Institutes
    The Association of American Cancer Institutes (AACI), representing 
95 premier academic and free-standing cancer centers, appreciates the 
opportunity to submit this statement for consideration by the 
subcommittee. Barbara Duffy Stewart, Executive Director of AACI submits 
this request for the Department of Health and Human Services budget for 
the National Institutes of Health (NIH) in the amount of at least $34.5 
billion for fiscal year 2017. In light of President Obama and Vice 
President Biden's National Cancer Moonshot initiative, we request that 
funding for the National Cancer Institute (NCI) be prioritized and that 
NCI receive at least $5.9 billion, in order to begin the initiative.
    AACI appreciated Congress' fiscal year 2016 bipartisan spending 
bill, which provided the NIH with the largest boost in annual 
appropriations since fiscal year 2003. AACI cancer centers believe the 
partnership between the Federal Government and academic cancer centers 
is cooperative, and cancer centers continue to make strides in 
biomedical research thanks to the support of the Federal Government. 
Without such support, research projects with the potential to discover 
breakthrough therapies would not be possible.
           the president's fiscal year 2017 budget blueprint
    The President's fiscal year 2017 budget request for the NIH is 
$33.136 billion, $825 million above the enacted fiscal year 2016 level. 
This includes $5.893 billion for the NCI. In his budget blueprint, the 
President outlined the National Cancer Moonshot initiative, which 
includes an investment of $680 million, as well as $100 million for the 
Precision Medicine Initiative.
    AACI cancer centers are at the forefront of the national effort to 
eradicate cancer. The cancer centers that AACI represents house more 
than 20,000 scientific, clinical and public health investigators who 
work collaboratively to translate promising research findings into new 
approaches to prevent and treat cancer. Making progress against cancer 
is complex and time-intensive. However, the pace of discovery and 
translation of novel basic research to new therapies could be 
accelerated if researchers could count on an appropriate and 
predictable investment in Federal cancer funding.
    While the President's proposed budget would allow for 36,440 
competing Research Project Grants (RPG's) in 2017, an increase from the 
35,840 RPG's in 2016, academic cancer centers nationwide continue to 
grapple with budget constraints and the issue of investigator 
retention. Uncertainty surrounding RPG's and cancer center resources 
often drives promising scientists to explore opportunities abroad or 
outside of the biomedical research community. For most academic cancer 
centers, the majority of NCI grant funds are used to sustain shared 
resources that are essential to basic, translational, clinical and 
population cancer research, or to provide matching dollars which allow 
departments to recruit new cancer researchers to a university and 
support them until they receive their first grants. It is imperative 
that we enable America's scientists to master their craft.
    Therefore, AACI requests that Congress surpass the President's 
budget request and provide the NIH with at least $34.5 billion for 
fiscal year 2017. AACI is encouraged by the National Cancer Moonshot 
initiative and requests that the NCI receive at least $5.9 billion in 
fiscal year 2017.
                  national cancer moonshot initiative
    AACI cancer centers are invigorated by the National Cancer Moonshot 
initiative and their potential to contribute to the elimination of 
cancer. A goal of the ``moonshot'' initiative is collaboration among 
academic institutions and revolutionizing the sharing of medical and 
research data. AACI cancer centers are a primary source for the 
generation, collection and use of molecular, clinical and outcomes 
data. Steady, predictable funding for the NIH and NCI is vital as 
cancer centers work to share data and improve information systems and 
communication across the cancer continuum.
    The ``moonshot'' initiative also aims to accomplish a decade's 
worth of advances in 5 years, making new therapies available to 
patients, while also improving our ability to prevent and detect cancer 
at an early stage. Prevention and early detection are highly important 
to AACI cancer centers, as they offer patients the latest advances in 
cancer prevention, detection, diagnosis, and treatment.
    AACI member centers value the renewed investment in biomedical 
research supported by the NIH and the NCI, but robust funding for these 
important agencies will be necessary in order to accept the call for a 
``moonshot'' and accelerate scientific progress. Peaks and valleys in 
the NIH and NCI budget merely slow advances in biomedical research and 
also undermine cancer centers' ability to: conduct and support 
multidisciplinary cancer research; train cancer physicians and 
scientists; provide state-of-the-art care; and, disseminate information 
about cancer detection, diagnosis, treatment, prevention, control, 
palliative care, and survivorship across our communities.
    With excitement mounting about the scientific opportunities ahead 
and our potential to leverage the resulting advances to benefit cancer 
patients nationwide, it is imperative that Congress fully fund the 
agencies responsible for advancing cancer research. The broad portfolio 
of science supported by the NIH and NCI is essential for improving our 
basic understanding of cancer and has contributed to the health and 
well-being of Americans.
                          cancer: then and now
    Progress in cancer research has reached unprecedented levels since 
the enactment of the National Cancer Act in 1971, yet cancer remains 
one of the leading causes of death and disability in the United States. 
This year, nearly 1.7 million Americans will receive a cancer diagnosis 
and more than 595,000 Americans will lose their lives to cancer.\1\ As 
the population ages, cancer incidence is expected to grow 
significantly, reaching 2.3 million diagnoses per year by 2030.\2\
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    \1\ American Cancer Society. Facts and Figures, 2016. http://
www.cancer.org/acs/groups/content/@research/documents/document/acspc-
047079.pdf.
    \2\ Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. 
Future of cancer incidence in the United States: burdens upon an aging, 
changing nation. J Clin Oncol. 2009 Jun 10;27(17):2758-65.
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    Despite these alarming statistics, progress continues to be made in 
cancer research, discovery, and the delivery of care. The 5-year 
survival rate for all types of cancer was greater than 65 percent in 
2011, improving between 1981 and 2011, and more than 14.5 million 
cancer survivors were living in the U.S. in 2015.\3\ The improvement in 
survival reflects the advances being made by diagnosing cancers at an 
earlier stage and providing better treatments to cancer patients.
---------------------------------------------------------------------------
    \3\ American Cancer Society. Facts and Figures.
---------------------------------------------------------------------------
    The Agency for Healthcare Research and Quality estimates that the 
direct medical costs (total of all healthcare expenditures) for cancer 
in the U.S. were $74.8 billion in 2013.\4\ Even as the cost of cancer 
continues to rise, investment in cancer research could one day 
significantly reduce or even eliminate the health and economic burden 
that cancer imposes on all Americans. Ensuring stable, predictable 
funds are provided to the NIH and NCI will aid our Nation's cancer 
center researchers in discoveries which ultimately improve cancer 
treatment outcomes.
---------------------------------------------------------------------------
    \4\ American Cancer Society. Facts and Figures.
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                               conclusion
    Our country has contributed to a steady decrease in the mortality 
rate for cancer, but America can do better. Now is the time for 
Congress to invest in biomedical research in general and cancer 
research in particular. AACI joins our colleagues in the biomedical 
research community in recommending that the subcommittee recognize the 
NIH as a critical national priority by providing at least $34.5 billion 
in funding in the fiscal year 2017 Labor-HHS-Education appropriations 
bill. Additionally, we ask that the subcommittee funds the NCI with at 
least $5.9 billion in funding for fiscal year 2017.
    A robust Federal investment in our Nation's NCI-designated cancer 
centers and emerging academic cancer centers will allow the cancer 
community to heed the call for a ``moonshot to cure cancer.'' This is 
an important moment in our Nation's history and we ask the subcommittee 
to invest in academic cancer centers as they work to accomplish the 
goal to end cancer for the good of our country.

    [This statement was submitted by Barbara Duffy Stewart, Executive 
Director, Association of American Cancer Institutes.]
                                 ______
                                 
   Prepared Statement of the Association of American Medical Colleges
    The Association of American Medical Colleges is a not-for-profit 
association dedicated to transforming healthcare through innovative 
medical education, cutting-edge patient care, and groundbreaking 
medical research. Its members comprise all 145 accredited U.S. and 17 
accredited Canadian medical schools; nearly 400 major teaching 
hospitals and health systems, including 51 Department of Veterans 
Affairs medical centers; and more than 80 academic societies. Through 
these institutions and organizations, the AAMC serves the leaders of 
America's medical schools and teaching hospitals and their 148,000 
faculty members, 83,000 medical students, and 115,000 resident 
physicians.
    The AAMC requests the following for Federal priorities essential in 
assisting medical schools and teaching hospitals to fulfill their 
missions of education, research, and patient care: at least $34.5 
billion for the National Institutes of Health (NIH); $364 million in 
budget authority for the Agency for Healthcare Research and Quality 
(AHRQ); $524 million for the Title VII health professions and Title 
VIII nursing workforce development programs at the Health Resources and 
Services Administration (HRSA)'s Bureau of Health Workforce; and 
continued support for student aid through the Department of Education 
and HRSA's National Health Service Corps. The AAMC appreciates the 
subcommittee's longstanding, bipartisan efforts to strengthen these 
programs.
    National Institutes of Health.--Congress's long-standing bipartisan 
support for medical research through the NIH has created a scientific 
enterprise that is the envy of the world and has contributed greatly to 
improving the health and well-being of all Americans. The foundation of 
scientific knowledge built through NIH-funded research drives medical 
innovation that improves health through new and better diagnostics, 
improved prevention strategies, and more effective treatments.
    Nearly 84 percent of the NIH's budget is competitively awarded 
through almost 50,000 research and training grants to more than 300,000 
researchers at over 2,500 universities and research institutions 
located in every State. At least half of this funding supports life-
saving research at America's medical schools and teaching hospitals, 
where scientists, clinicians, fellows, residents, medical students, and 
trainees work side-by-side to improve the lives of Americans through 
research.
    The partnership between NIH and America's scientists, medical 
schools, teaching hospitals, universities, and research institutions is 
a unique and highly-productive relationship, leveraging the full 
strength of our Nation's research enterprise to foster discovery, 
improve our understanding of the underlying cause of disease, and 
translate this knowledge into the next generation of diagnostics, 
therapeutics, and other clinical innovations. This partnership not only 
lays the foundation for improved health and quality of life, but also 
strengthens the Nation's long-term economy.
    The AAMC thanks Congress for the bipartisan support that resulted 
in the inclusion of $32.1 billion in the fiscal year 2016 omnibus 
spending bill for medical research conducted and supported by the NIH.
    If this Nation is to continue to meet current and emerging health 
challenges, improve our Nation's health, sustain our leadership in 
medical research, and remain competitive, it is essential to sustain 
predictable increases in the NIH budget.
    The AAMC supports the Ad Hoc Group for Medical Research 
recommendation that Congress appropriates at least $34.5 billion 
through the Labor-HHS-Education spending bill for fiscal year 2017. 
This $2.4 billion increase represents 5 percent real growth above the 
projected rate of biomedical inflation, and will help ensure that NIH-
funded research can continue to improve our Nation's health and enhance 
our competitiveness in today's global information and innovation-based 
economy.
    The AAMC continues to be concerned about the long-lasting impact of 
the decline in the NIH budget on the next generation of scientists, who 
see training funds threatened and the possibility of sustaining a 
career in research diminished. The continued success of the biomedical 
research enterprise relies heavily on the imagination and dedication of 
a diverse and talented scientific workforce. Of particular concern is 
the challenge of maintaining a cadre of clinician-scientists to 
facilitate translation of basic research to human medicine. NIH 
supports many innovative training programs and funding mechanisms that 
foster scientific creativity and exploration.
    Additional funding is needed if we are to strengthen our Nation's 
research capacity, ensure a biomedical research workforce that reflects 
the racial and gender diversity of our citizenry, and inspire a passion 
for science in current and future generations of researchers.
    The AAMC thanks the subcommittee for its efforts to retain the 
limit on salaries that can be drawn from NIH extramural awards at 
Executive Level II of the Federal Executive Pay Scale. Medical schools' 
and teaching hospitals' discretionary funds from clinical revenues and 
other sources have become increasingly constrained and less available 
to invest in research. If institutions and departments divert funds to 
compensate for a reduction in the salary limit, they have less funding 
for critical activities such as bridge funding to investigators between 
grants and start-up packages to young investigators to launch their 
research programs. A lower salary cap also will disproportionately 
affect physician investigators, who will be forced to make up salaries 
from clinical revenues, thus leaving less time for research. This may 
serve as a deterrent to their recruitment into research careers. The 
AAMC urges the subcommittee to continue its efforts to retain the limit 
at Executive Level II.
    Agency for Healthcare Research and Quality.--Complementing the 
medical research supported by NIH, AHRQ sponsors health services 
research designed to improve the quality of healthcare, decrease 
healthcare costs, and provide access to essential healthcare services 
by translating research into measurable improvements in the healthcare 
system. The AAMC firmly believes in the value of health services 
research as the Nation continues to strive to provide high-quality, 
evidence-based, efficient, and cost-effective healthcare to all of its 
citizens. The AAMC joins the Friends of AHRQ in recommending $364 
million in budget authority for the agency in fiscal year 2017.
    As the only Federal agency with the sole purpose of generating 
evidence to make healthcare safer; higher quality; and more accessible, 
equitable, and affordable, AHRQ also works to ensure such evidence is 
available across the continuum of healthcare stakeholders, from 
patients to payers to providers. These research findings will better 
guide and enhance consumer and clinical decisionmaking, provide 
improved healthcare services, and promote efficiency in the 
organization of public and private systems of healthcare delivery.
    Health Professions Funding.--HRSA's Title VII health professions 
and Title VIII nursing workforce development programs are the only 
Federal programs designed to improve the supply, distribution, and 
diversity of the Nation's primary care workforce. Through loans, loan 
guarantees, and scholarships to students, and grants and contracts to 
academic institutions and non-profit organizations, the Title VII and 
Title VIII programs fill the gaps in the supply of health professionals 
not met by traditional market forces.
    Titles VII and VIII are structured to allow grantees to test 
educational innovations, respond to changing delivery systems and 
models of care, and address timely topics in their communities. By 
assessing the needs of the communities they serve and emphasizing 
interprofessional education and training, Title VII and VIII programs 
bring together knowledge and skills across disciplines to provide 
effective, efficient and coordinated care. Further, studies demonstrate 
that the programs graduate more minority and disadvantaged students and 
prepare providers that are more likely to serve in Community Health 
Centers (CHC) and the National Health Service Corps (NHSC).
    In addition to promoting educational innovations and preparing the 
workforce for changing delivery systems, the programs also support 
faculty development, curriculum development, and continuing education 
opportunities. These are all important components to ensure faculty and 
providers are equipped to meet the Nation's changing needs and train 
the next generation of health professionals.
    The AAMC joins the Health Professions and Nursing Education 
Coalition (HPNEC) in recommending $524 million for these important 
workforce programs in fiscal year 2017. This funding level is necessary 
to ensure continuation of all existing Title VII and Title VIII 
programs while also supporting promising initiatives such as the 
Pediatric Subspecialty Loan Repayment program, the Clinical Training in 
Interprofessional Practice program, the Rural Physician Training 
Grants, and other efforts to bolster the workforce. Additionally, 
because HRSA has been administering the Behavioral Health Workforce 
Education and Training (BHWET) Program, we also support the President's 
fiscal year 2017 budget proposal of shifting funds previously 
appropriated to the Substance Abuse and Mental Health Services 
Administration to HRSA.
    The AAMC objects to the administration's proposal to eliminate the 
Title VII Area Health Education Centers (AHEC) program, which, in 
academic year 2014-2015 alone, trained health professions students in 
over 11,000 sites across the country, including community-based and 
ambulatory care settings and CHCs. We appreciate the administration's 
proposal to enhance the focus on academic support and pre-professional 
engagement for students from disadvantaged backgrounds through 
supporting the Health Careers Opportunity Program (HCOP). Research 
shows that HCOP has helped students from disadvantaged backgrounds 
throughout the educational pipeline achieve higher grade point averages 
and matriculate into health professions programs. Continued support for 
these and the full spectrum of Title VII programs is essential to 
prepare our next generation of medical professionals to adapt to the 
changing healthcare needs of the Nation's aging and increasingly 
diverse population.
    In addition to funding for Title VII and Title VIII, HRSA's Bureau 
of Health Workface also supports the Children's Hospitals Graduate 
Medical Education (CHGME) program. This program provides critical 
Federal graduate medical education support for children's hospitals to 
prepare the future primary care and specialty care workforce for our 
Nation's children. We strongly support full funding for the Children's 
Hospitals Graduate Medical Education program at $300 million in fiscal 
year 2017.
    Student Aid and the National Health Service Corps (NHSC).--The AAMC 
urges the subcommittee to sustain student loan and repayment programs 
for graduate and professional students at the Department of Education. 
The average graduating debt of medical students is currently $183,000, 
and typical repayment can range from $329,000 to $480,000.
    Along with more than 50 stakeholder organizations, the AAMC urges 
the subcommittee to provide a discretionary appropriation for the 
National Health Service Corps (NHSC) in fiscal year 2017. As the Nation 
faces multiple health professional shortages, sustained investments in 
workforce programs are necessary to help care for our Nation's most 
vulnerable populations.
    Recognizing that mandatory funding may be provided through other 
mechanisms, the appropriations committees retain primary responsibility 
for funding the administrative functions of the NHSC and for avoiding 
budgetary lapses in future years. We look forward to working with 
Congress to help ensure a long-term investment in the NHSC without 
sacrificing other Federal health professions training support.
    Once again, the AAMC appreciates the opportunity to submit this 
statement for the record and looks forward to working with the 
subcommittee as it prepares its fiscal year 2017 spending bill.
                                 ______
                                 
     Prepared Statement of the Association of Independent Research 
                               Institutes
    The Association of Independent Research Institutes (AIRI) thanks 
the subcommittee for its long-standing and bipartisan leadership in 
support of the National Institutes of Health (NIH). We continue to 
believe that science and innovation are essential if we are to continue 
to improve our Nation's health, sustain our leadership in medical 
research, and remain competitive in today's global information and 
innovation-based economy.
    The $2 billion increase in the final fiscal year 2016 omnibus 
appropriations bill was a much needed increase for NIH. This increase 
is essential to addressing current and emerging health challenges and 
building a healthier nation. However, this increase did not make up for 
funds cut by sequestration in fiscal year 2013 nor did it restore the 
purchasing power NIH has lost over the past decade. In fact, despite 
budget increases in each of the past two fiscal years, the NIH budget 
remains lower than it was in fiscal year 2012 in actual dollars, and 
since 2003, NIH funding has declined by 22 percent after adjusting for 
biomedical inflation.
    While the President's fiscal year 2017 budget request for NIH would 
provide a much needed next step by increasing NIH funding above 
biomedical inflation, AIRI believes that the ongoing and emerging 
health challenges confronting the United States and the world, and the 
unparalleled scientific opportunities to address these burdens demand a 
funding level of at least $34.5 billion in fiscal year 2017. AIRI also 
urges Congress and the administration to work in a bipartisan manner to 
end sequestration and the continued cuts to medical research that 
squander invaluable scientific opportunities, discourage young 
scientists, threaten medical progress and continued improvements in our 
Nation's health, and jeopardize our economic future.
    AIRI is a national organization of more than 80 independent, non-
profit research institutes that perform basic and clinical research in 
the biological and behavioral sciences. AIRI institutes vary in size, 
with budgets ranging from a few million to hundreds of millions of 
dollars. In addition, each AIRI member institution is governed by its 
own independent Board of Directors, which allows our members to focus 
on discovery-based research while remaining structurally nimble and 
capable of adjusting their research programs to emerging areas of 
inquiry. Researchers at independent research institutes consistently 
exceed the success rates of the overall NIH grantee pool, and they 
receive about 10 percent of NIH's peer-reviewed, competitively-awarded 
extramural grants.
    The partnership between NIH and America's scientists, research 
institutions, universities, and medical schools is a unique and highly-
productive relationship, leveraging the full strength of our Nation's 
research enterprise to foster discovery, improve our understanding of 
the underlying cause of disease, and develop the next generation of 
medical advancements that deliver more treatments and cures to 
patients. Not only is NIH research essential to advancing health, it 
also plays a key economic role in communities nationwide. Approximately 
84 percent of the NIH's budget goes to more than 300,000 research 
positions at over 2,500 universities and research institutions located 
in every State.
    The Federal Government has an irreplaceable role in supporting 
medical research. No other public, corporate, or charitable entity is 
willing or able to provide the broad and sustained funding for the 
cutting edge research necessary to yield new innovations and 
technologies of the future. NIH supports long-term competitiveness for 
American workers, forming one of the key foundations for U.S. 
industries like biotechnology, medical device and pharmaceutical 
development, and more. Unfortunately, continued erosion of the national 
commitment to medical research threatens our ability to support a 
medical research enterprise that is capable of taking full advantage of 
existing and emerging scientific opportunities.
    The NIH model for conducting biomedical research, which involves 
supporting scientists at universities, medical centers, and independent 
research institutes, provides an effective approach to making 
fundamental discoveries in the laboratory that can be translated into 
medical advances that save lives. AIRI member institutions are private, 
stand-alone research centers that set their sights on the vast 
frontiers of medical science. AIRI institutes are specifically focused 
on pursuing knowledge around the biology and behavior of living systems 
and applying that knowledge to improve human health and reduce the 
burdens of illness and disability.
    Additionally, AIRI member institutes have championed (and very 
frequently are called upon to lead) technologies and research centers 
to collaborate on biological research for all diseases. Using shared 
resources--specifically, advanced technology platforms or ``cores,''--
as well as genomics, next-generation sequencing, electron and light 
microscopy, high-throughput compound screening, bioinformatics, 
imaging, and other technologies, AIRI researchers advance therapeutics 
development and drug discovery.
    AIRI member institutes are especially vulnerable to reductions in 
the NIH budget, as they do not have other reliable sources of revenue 
to make up the shortfall. In addition to concerns over funding, AIRI 
member institutes oppose legislative provisions--such as directives to 
reduce the salary limit for extramural researchers--which would harm 
the integrity of the research enterprise and disproportionately affect 
independent research institutes. Such policies hinder AIRI members' 
research missions and their ability to recruit and retain talented 
researchers. AIRI also does not support legislative language limiting 
the flexibility of NIH to determine how to most effectively manage its 
resources while funding the best scientific ideas.
    AIRI member institutes' flexibility and research-only missions 
provide an environment particularly conducive to creativity and 
innovation. Independent research institutes possess a unique 
versatility and culture that encourages them to share expertise, 
information, and equipment across research institutions, as well as 
neighboring universities. These collaborative activities help minimize 
bureaucracy and increase efficiency, allowing for fruitful partnerships 
in a variety of disciplines and industries. Also, unlike institutes of 
higher education, AIRI member institutes focus primarily on scientific 
inquiry and discovery, allowing them to respond quickly to the research 
needs of the country.
    AIRI members are located in 26 States, including many smaller or 
less-populated States that do not have major academic research 
institutions. In many of these regions, independent research institutes 
are major employers and local economic engines, and they exemplify the 
positive impact of investing in research and science.
    The biomedical research community depends upon a knowledgeable, 
skilled, and diverse workforce to address current and future critical 
health research questions. While the primary function of AIRI member 
institutions is research, most are highly involved in training the next 
generation of biomedical researchers, ensuring that a pipeline of 
promising scientists is prepared to make significant and potentially 
transformative discoveries in a variety of areas. AIRI supports 
policies that promote the ability of the United States to maintain a 
competitive edge in biomedical science.
    The NIH initiatives focusing on career development and recruitment 
of a diverse scientific workforce are important to innovation in 
biomedical research and public health. However, one of the most 
destructive and long-lasting impacts of the decline in the NIH budget 
is on the next generation of scientists, who see training funds slashed 
and the possibility of sustaining a career in research diminished. The 
continued success of the biomedical research enterprise relies heavily 
on the imagination and dedication of a diverse and talented scientific 
workforce.
    In addition, strong support for NIH is critical to the Nation's 
competitiveness. This country still has the most robust medical 
research capacity in the world, but that capacity simply cannot weather 
repeated blows such as persistent below-inflation funding levels and 
the cuts of sequestration, which jeopardize our competitive edge in an 
increasingly innovation-based global marketplace. Other countries have 
recognized the critical role that biomedical science plays in 
innovation and economic growth and have significantly increased their 
investment in biomedical science.
    This shift in funding raises the concern that talented medical 
researchers from all over the world, who once flocked to the U.S. for 
training and stayed to contribute to our innovation-driven economy, are 
now returning to better opportunities in their home countries. We 
cannot afford to lose that intellectual capacity, much less the jobs 
and industries fueled by medical research. The U.S. has been the global 
leader in medical research because of Congress's bipartisan recognition 
of NIH's critical role. To maintain our dominance, we must reaffirm 
this commitment to provide NIH the funds needed to maintain our 
competitive edge.
    AIRI thanks the subcommittee for its important work dedicated to 
ensuring the health of the Nation, and we appreciate this opportunity 
to urge the subcommittee to provide at least $34.5 billion for NIH in 
the fiscal year 2017 appropriations bill. AIRI also urges Congress and 
the administration to work in a bipartisan manner to end sequestration 
and the continued cuts to medical research that squander valuable 
scientific opportunities, discourage young scientists, threaten medical 
progress and continued improvements in our Nation's health, and 
jeopardize our economic future.
                                 ______
                                 
   Prepared Statement of the Association of Maternal & Child Health 
                                Programs
    Chairman Blunt, Ranking Member Murray and distinguished 
subcommittee members--I am grateful for this opportunity to submit 
written testimony on behalf of the Association of Maternal & Child 
Health Programs (AMCHP), our members, and the millions of women, 
children and families that are served by the Title V Maternal and Child 
Health (MCH) Services Block Grant. I am asking the subcommittee to 
support an increase of $12 million in funding for the Title V MCH 
Services Block Grant for a total of $650 million in fiscal year 2017.
    At this time, two of the most critical emerging public health 
issues facing the United States today--the Zika virus and the opioid 
use epidemic--have explicit consequences for maternal and child health. 
The Title V program stands ready to play an important role in our 
Nation's response by employing evidence-based services and strategies 
that further the program's statutory purpose to improve the health of 
all mothers and children.
    As you may know, the Title V MCH Block Grant already works to (1) 
ensure access to quality maternal and child health services, (2) reduce 
infant mortality and preventable diseases and conditions, and (3) 
provide and promote family centered, community-based, coordinated care 
for children with special healthcare needs and facilitate the 
development of community-based systems of services for such children 
and their families.
    Thank you for recognizing the value provided by the MCH Block Grant 
and providing small increases in funding over the past few years. I 
know you and your colleagues understand that the current level of 
funding does not allow us to address all the health needs of our 
Nation's women, children, fathers and families. We are proud of the 
recent progress in lowering our Nation's infant mortality rate, 
reducing teen pregnancy and decreasing the incidence of childhood 
injury. However, despite recent strides, close to 24,000 babies 
tragically die each year. Many others are born too soon and cost our 
society upwards of $26 billion per year. Gaps in both private and 
public insurance create barriers for families needing services. Many 
pregnant women still smoke. The obesity epidemic continues to plague 
our country and the list goes on and on. In the face of these 
challenges, public health programs have already borne more than their 
fair share of deficit reduction with years of cuts and a budget cap 
that could cut funding even further.
    We strongly urge you to reward programs that work and are showing 
results by providing a $12 million increase in funding for the Federal 
investment in the Title V MCH Services Block Grant. States and 
jurisdictions use the Title V MCH Block Grant formula funds to design 
and implement a wide range of maternal and child health programs that 
respond to locally defined needs. For example, the ``Every Week 
Counts'' initiative in Oklahoma, funded in part by Title V, 
demonstrated a 96 percent decrease in early elective deliveries between 
2011-2014. In Mississippi, the Title V program is a partner in the 
Healthy Teens for a Better Mississippi initiative, which recently 
reported a 15 percent decrease in the State teen birth rate between 
2012-2015.
    One of the primary focus areas for State Title V programs is 
supporting systems of services for children and youth with special 
healthcare needs (CYSHCN). These systems serve a diverse group of 
children ranging from children with chronic conditions such as asthma 
or diabetes, to children with autism, to those with more medically 
complex health issues such as spina bifida or other congenital 
disorders and include children with behavioral or emotional conditions. 
Overall, CYSHCN are defined as children birth to age 21 who have or are 
at increased risk for a chronic physical, developmental, behavioral, or 
emotional condition and require health and related services of a type 
or amount beyond that required by children generally. In a recent 
national survey, children with a chronic condition represented 
approximately 15 percent of the entire child population in the United 
States.
    Care coordination is an essential component of delivering services 
to children and youth with special healthcare needs. State Title V 
programs improve care coordination by working collaboratively with 
parents, providers and payers. In Colorado, the Title V CYSHCN program 
spearheaded an effort to streamline coordination of care by working to 
reduce duplication of services and unnecessary costs in collaboration 
with Medicaid and other programs that serve these children.
    Another key component of the Title V MCH Block Grant is the Special 
Projects of Regional and National Significance (SPRANS). SPRANS funding 
complements and helps ensure the success of State Title V, Medicaid and 
the Children's Health Insurance Program (CHIP) by driving innovation, 
training young professionals and building capacity to create integrated 
systems of care for mothers and children. Examples of innovative 
projects funded through SPRANS include guidelines for child health 
supervision from infancy through adolescence (i.e. Bright Futures); 
nutrition care during pregnancy and lactation; recommended standards 
for prenatal care; successful strategies for the prevention of 
childhood injuries; and health safety standards for out of home child 
care facilities.
    SPRANS grants are awarded to training programs at universities 
across the country including University of Alabama at Birmingham, 
University of Illinois, University of Oklahoma, University of 
Tennessee, University of Washington, Tulane University, Medical 
University of South Carolina and Johns Hopkins University. These 
institutions utilize SPRANS funding to prepare the next generation of 
maternal and child health leaders who will go on to serve in 
communities throughout the United States.
    One of the most exciting developments with the Title V MCH Block 
Grant is a transformation that is happening right now under the 
leadership of Dr. Michael Lu, Associate Administrator of the Health 
Resources and Services Administration Maternal and Child Health Bureau. 
This transformation is focused on three main goals--to reduce burden, 
maintain flexibility and improve accountability. At its center is an 
effort to improve our performance measurement framework with a 
sharpened focus on national outcome measures, national performance 
measures and evidence-based strategy measures.
    This transformation ensures that investments made by the programs 
support evidence-based or informed strategies. Title V focuses on 
accountability and delivering results, and we are confident this 
transformation will build and strengthen that important focus so you 
can be assured that we are getting the best value for the taxpayer 
dollar while making real and measurable differences in the lives of our 
mothers and children. For more information on this effort, my staff 
will be happy to help arrange for further briefing and information on 
what this means for your State.
    In our view, one of the biggest under-celebrated success stories of 
recent times are the contributions this subcommittee makes in funding 
programs such as the Title V MCH Services Block Grant that contribute 
to substantial progress in reducing infant mortality.
    Ensuring that babies are born in optimal health is all the more 
important considering the recent scientific advances in our 
understanding about how a baby's early years are critical to building a 
strong foundation for the rest of their life course. That is the good 
news--but there also are a few caveats and contradictions. First, there 
are persistent and unacceptable disparities among racial and ethnic 
groups that have existed since the data collection began. The black and 
Native American infant mortality rates are twice the rates of whites, 
and in some communities it is even three times higher.
    The second caveat is that the political will to accelerate progress 
and eliminate disparities is inconsistent. Perhaps the biggest 
contradiction is that the United States spends more money on maternity 
care than any other nation on earth, yet still lags behind 26 other 
industrialized nations on the key outcome of infant mortality.
    Part of the problem is that too often we spend more on high tech 
treatments--think elective C-sections and neonatal intensive care 
units--than on basic prevention programs to address risk factors that 
can lead to poor birth outcomes. For example, we know that 
breastfeeding, family planning, immunization, smoking cessation and 
safe sleep are effective in reducing infant mortality. However, funding 
levels for these key public health programs have never matched actual 
need, have slowly eroded over time, and are suffering further threats 
from budget caps and looming sequestration.
    The Collaborative Improvement and Innovation Network (CoIIN) to 
Reduce Infant Mortality, funded in part by Title V SPRANS dollars, is a 
public-private partnership to reduce infant mortality and improve birth 
outcomes. Participants learn from one another and national experts, 
share best practices and lessons learned, and track progress toward 
shared benchmarks. Declines in infant mortality, non-medically 
indicated early term deliveries, the number of women smoking during 
pregnancy and preterm birth have already been observed in the 13 
Southern States where the CoIIN began. These successes illustrate the 
return on investment in low-tech prevention efforts that can be 
realized through greater support for Title V.
    Congress, of course, has the power of the purse, but has not 
consistently delivered on its obligation to annually review 
programmatic funding levels for public health programs and match 
resources to national needs. Currently funded at $638.2 million, 1 year 
of spending on the Title V MCH Block Grant preventive program 
represents just a half day's spending on the Medicaid program, which at 
$1.3 billion a day reached a total of $475 billion in 2014. This 
demonstrates once again that our health system spends plenty on 
healthcare but invests precious little in prevention and public health 
efforts. In terms of total potential cost savings to our health system, 
far too little attention is consistently given to health economics and 
the measurable financial impact of public health and the prevention of 
disease, illness and early death.
    Finally, I would like to briefly mention the work being done by 
State Title V programs to respond to emerging public health issues such 
as Zika and the opioid use epidemic, both of which have direct 
implications for maternal and child health. You may be interested to 
know that Title V is already stepping in to conduct outreach and 
surveillance on Zika. In Puerto Rico, for example, the Title V Children 
with Special Health Care Needs program is providing clinical training 
and outreach to pediatric providers to ensure they are familiar with 
CDC guidelines and are able to evaluate infants with possible 
congenital Zika virus infection in accordance with those guidelines. 
Regarding opioid use, many State Title V programs are particularly 
involved with efforts to address neonatal abstinence syndrome (NAS). In 
Kentucky, the Title V agency has invested significant time working with 
other public health agencies to identify best practices for treatment 
options for women with substance use disorders, especially during 
pregnancy.
    Unfortunately, both of these issues represent major threats to the 
health and wellbeing of our Nation's women, children and their 
families. Therefore, I also urge the Appropriations Subcommittee to act 
quickly on emergency supplemental funding packages in order to meet the 
full demands required to tackle both Zika and the opioid use epidemic.
    Thank you again for your support in recent years to increase 
funding for the Title V MCH Block Grant. We hope to continue to build 
on recent successes and that you can support the $12 million increase 
in funding for the Federal investment in the cost effective and 
accountable Title V MCH Block Grant.
    About AMCHP: The Association of Maternal & Child Health Programs is 
a national resource, partner and advocate for State public health 
leaders and others working to improve the health of women, children, 
youth and families, including those with special healthcare needs.

    [This statement was submitted by Lori Tremmel Freeman, Chief 
Executive Officer, Association of Maternal & Child Health Programs.]
                                 ______
                                 
  Prepared Statement of the Association of Science-Technology Centers
                              introduction
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee, thank you for the opportunity to submit written testimony 
for the record. My name is Anthony (Bud) Rock, and I serve as the 
President and Chief Executive Officer of the Association of Science-
Technology Centers (ASTC). My testimony today addresses the importance 
of science, technology, engineering, mathematics (STEM), and health 
education, and will focus specifically on the fiscal year 2017 budgets 
for offerings at three Federal agencies over which your subcommittee 
has jurisdiction, including: (1) the 21st Century Community Learning 
Centers (21st CCLC) program at the Department of Education (ED), which 
would receive $1 billion under the President's fiscal year 2017 
request; the Office of Museum Services (OMS) at the Institute of Museum 
and Library Services (IMLS), which would receive $31.6 million under 
the President's fiscal year 2017 request; and the Science Education 
Partnership Award (SEPA) program at the National Institutes of Health 
(NIH), which would receive $18.5 million under the President's fiscal 
year 2017 request.
                              our request
    On behalf of ASTC and the nearly 400 science centers and museums we 
represent here in the United States, I urge the subcommittee to 
continue its strong support for critical STEM and health education 
programs within ED, IMLS, and NIH as the Labor, Health and Human 
Services, Education, and Related Agencies appropriations bill for 
fiscal year 2017 moves forward. Specifically, I ask you to:
  --Provide $1.3 billion for the 21st CCLC program (fiscal year 2017 
        request is $1 billion) at ED;
  --Provide $38.6 million for the OMS at IMLS (fiscal year 2017 request 
        is $31.6 million);
  --Provide $20 million for the SEPA program at NIH (fiscal year 2017 
        request is $18.5 million); and
  --Continue to thoroughly examine any proposals that would seek to 
        consolidate, reorganize, or eliminate Federal STEM, health, and 
        environmental education programs in an effort to ensure that 
        stakeholder input has been sought and that proven, successful 
        programs are maintained.
    Before providing more detail about ASTC and the science center and 
museum field, I want to first offer a brief snapshot of these Federal 
programs and why they are so vital to communities across the country.
                        department of education
    For years, the 21st Century Community Learning Centers program has 
supported the creation of community learning centers that provide 
academic enrichment opportunities during non-school hours for 
children--particularly those students who attend high-poverty and low-
performing schools. The 21st CCLC program helps students meet State and 
local student standards in core academic subjects, such as reading and 
math; offers students a broad array of enrichment activities that can 
complement their regular academic programs; and offers literacy and 
other educational services to the families of participating children. 
ASTC members across the country have utilized 21st CCLC funding to 
partner with local school districts in an effort to highlight STEM in 
afterschool.
    The President's fiscal year 2017 budget request for the Department 
of Education includes $1 billion for the 21st Century Community 
Learning Centers program--$167 million less than the amount available 
for fiscal year 2016. I encourage the subcommittee to continue to 
support the program by providing $1.3 billion for fiscal year 2017.
                institute of museum and library services
    IMLS is driven by its mission to inspire libraries and museums to 
advance innovation, lifelong learning, and cultural and civic 
engagement by providing leadership through research, policy 
development, and grant making. The agency's Office of Museum Services 
offers and administers competitive grant programs that undergo a 
rigorous peer review process in an effort to identify well-designed 
projects. Just last fall, IMLS announced new grants for 217 museum 
projects through the Museums for America and National Leadership Grants 
for Museums programs. Recipients included Exploration Place (Wichita, 
Kansas), which will use the funding to create a new 400-square-foot 
aquifer exhibit and ten on-site and outreach STEM educational programs 
that will incorporate Next Generation Science Standards and 21st 
Century Skills to elevate the level of water awareness and encourage 
individual conservation, community policy discussion, creative problem 
solving, and technological intervention; the Discovery Center at 
Murfree Spring (Murfreesboro, Tennessee), which will use the funding to 
expand its STEAM Bus program's outreach visits to two underserved, 
rural elementary schools and deliver hands-on, discovery-based science 
lessons to grades 3-5 to address the need for substantive, informal 
science education in rural elementary schools and to encourage lifelong 
learning of STEM subjects while supporting Tennessee State curriculum 
standards; the Oregon Museum of Science and Industry (Portland, 
Oregon), which will use the funding to help to develop, design, and 
fabricate two new innovative exhibits in the museum's MOVE thematic 
area, which will be transformed into a maker-inspired space and present 
visitors with large-scale design challenges around how things move; and 
the Madison Children's Museum (Madison, Wisconsin), which will use the 
funding to model a creative approach to behavioral change encouraging 
increased physical activity by redesigning stairwells in its historic 
building and by producing related programming to counteract decreased 
activity and a rise in obesity among Wisconsin children.
    The President's fiscal year 2017 budget request includes $31.6 
million for the Office of Museum Services at the Institute of Museum 
and Library Services. ASTC asks the subcommittee to provide $38.6 
million--the congressionally authorized level of funding--for OMS 
programs for fiscal year 2017.
                     national institutes of health
    According to NIH, the goal of the Science Education Partnership 
Award program is to invest in educational activities that assist in 
workforce development to meet the Nation's biomedical, behavioral and 
clinical research needs. By supporting partnerships between researchers 
and teachers, schools, and institutions like science centers and 
museums, the SEPA program provides opportunities for students from 
underserved communities to consider careers in research, provides 
teachers with professional development in science- and health-related 
content and teaching skills, and improves community health literacy 
through exhibits and programming at science centers and museums.
    To highlight one recent example from the last round of SEPA grants, 
the John A. Burns School of Medicine at the University of Hawaii at 
Manoa received an award to support the Hawaii Science Career 
Inspiration (HiSCI) program, the goal of which is ``to enhance science 
education resources and training available to teachers and students in 
disadvantaged communities of Hawaii in order to ensure a maximally 
large and diverse workforce to meet the Nation's biomedical, behavioral 
and clinical research needs.'' The program will provide a number of 
benefits to teachers, including professional development in molecular 
biology techniques, the opportunity to attend focus group meetings, and 
the chance to apply for classroom resources. K-12 students who are 
interested in healthcareers will benefit from offerings like a Teen 
Health Camp, interactions with expert speakers, and mentoring by 
medical students.
    The President's fiscal year 2017 budget request includes $18.5 
million--the same amount available for fiscal year 2016--for SEPA. 
Given the program's impact and importance, I ask the subcommittee to 
continue its strong support by providing $20 million for SEPA for 
fiscal year 2017.
            stem education consolidation and reorganization
    With regard to the Federal STEM education consolidation plan first 
released by the administration for fiscal year 2014 and amended in each 
of the last three budget requests, I recognize the importance of 
creating efficiencies within the Federal Government whenever possible. 
Nevertheless, I continue to have serious concerns about a proposal that 
would eliminate effective programs that support informal STEM, health, 
and environmental learning. Integral Federal investments, including the 
SEPA program itself, have been slated for termination in previous 
fiscal years. While SEPA now enjoys the support of the administration, 
programs at the National Aeronautics and Space Administration and the 
National Oceanic and Atmospheric Administration were not as fortunate 
and are, once again, on the chopping block. I sincerely appreciate the 
subcommittee's thoughtful consideration of the harmful effect of the 
proposed terminations, and ask you to remain steadfast in your support 
of these programs.
                     about astc and science centers
    The Association of Science-Technology Centers is a global 
organization providing collective voice, professional support, and 
programming opportunities for science centers, museums, and related 
institutions, whose innovative approaches to science learning inspire 
people of all ages about the wonders and the meaning of science in 
their lives. Science centers are sites for informal learning, and are 
places to discover, explore, and test ideas about science, technology, 
engineering, mathematics, health, and the environment. They feature 
interactive exhibits, hands-on science experiences for children, 
professional development opportunities for teachers, and educational 
programs for adults. In science centers, visitors become adventurous 
explorers who together discover answers to the myriad questions of how 
the world works--and why. As members of this subcommittee know, it is 
imperative that we spark an interest in STEM fields at an early age--a 
key role for community-based science centers and museums, who often 
undertake this effort with the aforementioned support from ED, IMLS, 
and NIH, in addition to other Federal agencies.
    ASTC works with science centers and museums to address critical 
societal issues, locally and globally, where understanding of and 
engagement with science are essential. As liaisons between the science 
community and the public, science centers are ideally positioned to 
heighten awareness of critical issues like agriculture, energy, the 
environment, infectious diseases, and space; increase understanding 
of--and exposure to--important and exciting new technologies; and 
promote meaningful exchange and debate between scientists and local 
communities. ASTC now counts 651 members, including 486 operating or 
developing science centers and museums in 42 countries. Collectively, 
our institutions garner 100 million visits worldwide each year. Here in 
the United States alone, your constituents pass through science center 
doors 69 million times to participate in intriguing educational science 
activities and explorations of scientific phenomena.
    Our centers reach a wide audience, a significant portion of which 
are school groups. Here in the U.S., 94 percent of our members offer 
school field trips, and we estimate that more than 13 million children 
attend science centers and museums as part of those groups each year. 
Field trips, however, are truly just the beginning of what science 
centers and museums contribute to our country's educational 
infrastructure, as: 92 percent offer classes and demonstrations; 90 
percent offer school outreach programs; 76 percent offer workshops or 
institutes for teachers; 74 percent offer programs for home-schoolers; 
67 percent offer programs that target adult audiences; 65 percent offer 
curriculum materials; 50 percent offer after-school programs; 34 
percent offer youth employment programs; and 22 percent offer citizen 
science projects.
                               conclusion
    With this in mind, and while I am fully aware of the significant 
budget challenges that face this subcommittee, Congress, and the 
Nation, I hope you will continue to recognize the important educational 
offerings science centers and museums make available to students, 
families, and teachers, along with the essential Federal support they 
receive from ED, IMLS, and NIH.
    Again, I respectfully request that you provide $1.3 billion for the 
21st Century Community Learning Centers program at the Department of 
Education; $38.6 million for the Office of Museum Services at the 
Institute of Museum and Library Services, and $20 million for the 
Science Education Partnership Awards program at the National Institutes 
of Health. In addition, please continue to closely examine any 
proposals that would seek to consolidate, reorganize, or eliminate 
Federal STEM, health, and environmental education programs in an effort 
to ensure that stakeholder input has been sought and that proven, 
successful programs are maintained.
    Thank you once again for your strong support for America's science 
centers and museums--and for the opportunity to present these views. My 
staff and I would be happy to respond to any questions or provide 
additional information as needed by the subcommittee.
                                 ______
                                 
    Prepared Statement of the Association of University Programs in 
                     Occupational Health and Safety
    On behalf of the Association of University Programs in Occupational 
Health and Safety (AUPOHS), an organization representing the 18 
multidisciplinary, university-based Education and Research Centers 
(ERCs) and the 10 Agricultural Centers for Disease and Injury Research, 
Education, and Prevention (Agricultural Centers) funded by the National 
Institute for Occupational Safety and Health (NIOSH), we respectfully 
request that the fiscal year 2017 Labor, Health and Human Services 
appropriations bill include no less than $339.121 million for NIOSH, 
including $28.5 million for the Education and Research Centers and $25 
million for the Agriculture, Forestry and Fishing (AFF) Program from 
which the Agricultural Centers receive their funding.
    Occupational injury and illness represent a striking burden on 
America's health and well-being. Despite significant improvements in 
workplace safety and health over the last several decades, each day 
more than 8,000 workers are seriously injured on the job, 12 die from 
an injury suffered at work, and 145 die from work-related diseases. 
This huge health burden costs industry and citizens an estimated $4.8 
billion per week. This is an especially tragic situation because work-
related fatalities, injuries and illnesses most often affect the most 
productive individuals in our society and are preventable with 
effective, professionally directed, health and safety programs.
    In addition to its extensive research mission, NIOSH is the Federal 
agency responsible for supporting education and training to prevent 
work-related injuries and illnesses in the United States. The most 
significant NIOSH education program aims to provide training to current 
health professionals while educating the next generation of 
professionals in university settings. These Education and Research 
Centers (ERCs) are regional and national resources for parties involved 
with occupational health and safety--industry, labor, government, 
academia, and the public. Collectively, the ERCs provide training and 
research resources to every Federal Region in the United States. ERCs 
contribute to national efforts to reduce losses associated with work-
related illnesses and injuries by offering:
  --Prevention Research: Developing the basic knowledge and associated 
        technologies to prevent work-related illnesses and injuries.
  --Professional Training: ERCs support graduate degree programs in 
        Occupational Medicine, Occupational Health Nursing, Safety 
        Engineering, Industrial Hygiene, and other related fields to 
        provide qualified professionals in essential disciplines.
  --Research Training: Preparing doctoral-trained scientists who will 
        respond to future research challenges and who will prepare the 
        next generation of occupational health and safety 
        professionals.
  --Continuing Education: Short courses designed to enhance 
        professional skills and maintain professional certification for 
        those who are currently practicing in occupational health and 
        safety disciplines. These courses are delivered throughout the 
        regions of the 18 ERCs, as well as through distance learning 
        technologies.
  --Regional Outreach: Responding to specific requests from employers, 
        healthcare professionals, and workers on issues related to 
        occupational health and safety.
    The rapidly changing workplace continues to present new health 
risks to American workers that need to be addressed through 
occupational safety and health research. For example, work related 
injury and fatality rates increase as workers get older, with rates for 
workers 65 years and older nearly three times greater than younger 
workers. For example, between 2002 and 2022, the number of workers 55 
years and older will increase over 100 percent to over 41 million (BLS 
2016). In addition to changing demographics, the rapid development of 
new technologies (e.g., nanotechnology) poses many unanswered questions 
with regard to workplace health and safety that require urgent 
attention. Newly emerging risks, such as Ebola and other infectious 
disease outbreaks, require swift responses to the need for worker 
protection.
    The heightened awareness of terrorist threats, and the increased 
responsibilities of first responders and other homeland security 
professionals, illustrates the need for strengthened workplace health 
and safety in the ongoing war on terror. The NIOSH ERCs play a crucial 
role in preparing occupational safety and health professionals to 
identify and mitigate vulnerabilities to terrorist attacks and to 
increase readiness to respond to biological, chemical, or radiological 
attacks. In addition, occupational health and safety professionals have 
worked for several years with emergency response teams to minimize 
disaster losses. For example, NIOSH took a lead role in protecting the 
safety of 9/11 emergency responders in New York City and Virginia, with 
ERC-trained professionals applying their technical expertise to meet 
immediate protective needs and to implement evidence-based programs to 
safeguard the health of clean-up workers.
    In response to risks posed by potential Ebola exposure, ERCs have 
delivered educational programs and provided expertise in developing 
protocols and policies to prevent worker exposure. In one case, a 
single webinar developed for this purpose reached more than 320 
company, academic, and government organizations. Additionally, NIOSH is 
the Federal agency that is charged with certifying and approving the 
respirators that are required to protect U.S. workers.
    We need manpower to address these challenges and it is the NIOSH 
ERCs that train the professionals who fill key positions in health and 
safety programs, regionally and around the Nation. And because ERCs 
provide multi-disciplinary training, ERC graduates protect workers in 
virtually every walk of life.
    NIOSH also focuses research and outreach efforts on the Nation's 
most dangerous workplaces. People who work in agriculture, forestry and 
fishing experience occupational fatality rates that are 6 times to more 
than 32 times higher than the average for American workers. The 
Agricultural Centers program was established by Congress in 1990 
(Public Law 101-517) in response to evidence that agricultural workers 
were suffering substantially higher rates of occupational injury and 
illness than other U.S. workers.
    Today the NIOSH Agriculture, Forestry, and Fishing (AFF) Initiative 
includes nine regional Agricultural Centers and one national center to 
address children's farm safety and health. The AFF program is the only 
substantive Federal effort to meet the obligation to ensure safe 
working conditions in this most vital production sector. While 
agriculture, forestry, and fishing constitute one of the largest 
industry sectors in the U.S. (DOL 2011), most AFF operations are 
themselves small: nearly 78 percent employ fewer than 10 workers, and 
most rely on family members, immigrants, part-time, contract and/or 
seasonal labor. Many of these agricultural workers are excluded from 
labor protections, including OSHA oversight, on the vast majority of 
American farms.
    The AFF sector averages 540 fatalities per year resulting in the 
highest fatality rate of any sector in the Nation. More than 1 in 100 
AFF workers incur nonfatal injuries resulting in lost work days each 
year. These reported figures do not even include men, women, and youths 
on the most dangerous farms--those with fewer than 11 full-time 
employees. In addition to the harm to individual men, women, and 
families, these deaths and injuries inflict serious economic losses 
including medical costs and lost capital, productivity, and earnings. 
The life-saving, cost-effective work of the NIOSH AFF program is not 
replicated by any other agency:
  --State and Federal OSHA personnel rely on NIOSH research in the 
        development of evidence-based standards for protecting 
        agricultural workers and would not be able to fulfill their 
        mission without the NIOSH AFF program.
  --While committed to the well-being of farmers, the USDA has little 
        expertise in the medical or public health sciences. USDA no 
        longer funds, as it did historically, land grant university-
        based farm safety specialists.
  --Staff members of USDA's National Institute of Food and Agriculture 
        interact with NIOSH occupational safety and health research 
        experts in order to learn about the cutting-edge research and 
        new directions in this area.
    NIOSH Agricultural Center activities include:
  --AFF research has shown that the use of rollover protective 
        structures (ROPS or rollbars) and seatbelts on tractors can 
        prevent 99 percent of overturn-related deaths. A New York 
        program has increased the installation of ROPS by 10-fold and 
        recorded over 140 close calls with no injuries among farmers 
        who had installed ROPS. 99 percent of program participants said 
        they would recommend the program to other farmers. Similar 
        programs are now offered to prevent serious injuries due to 
        entanglement in other farm machinery.
  --Working in partnership with producers and farm owners, the 
        Agricultural Centers have teamed to develop evidence-based 
        solutions for reducing exposure to pesticides and other farm 
        chemicals among farmers, farm workers and their children.
  --Commercial Fishing has an annual fatality rate nearly 60 times 
        higher than the rate for all U.S. workers. Research has shown 
        that knowledge of maritime navigation rules and emergency 
        preparedness means survival. An Agricultural Center team 
        produced an interactive navigation training CD in three 
        languages, demonstrated the effectiveness of refresher survival 
        drill instruction, and assisted the US Coast Guard's revision 
        of regulations requiring commercial fishing vessel captains 
        complete navigation training.
  --The NIOSH Agricultural Centers have partnered with producers, 
        employers, the Federal migrant health program, physicians, 
        nurses, and Internet Technology specialists to educate farmers, 
        employers, and healthcare providers about the best way to treat 
        and prevent agricultural injury and illness.
  --New tools and work processes developed by Agricultural Center 
        researchers have been introduced and widely adopted by 
        agricultural producers because they reduce musculoskeletal 
        injury and pain and at the same time improve productivity.
  --The logging industry has a fatality rate more than 25 times higher 
        than that of all U.S. workers. NIOSH Agricultural Centers, 
        including those in the Southeast and the Northwest, have 
        ongoing studies and outreach efforts to ensure the safety of 
        our Nation's 86,000 workers in forestry & logging.
    Thank you for the opportunity to present testimony on behalf of the 
many individuals committed to working to improve the safety and 
wellbeing of others in our communities.
                                 ______
                                 
      Prepared Statement of the Association of Zoos and Aquariums
    Thank you Chairman Blunt and Ranking Member Murray for allowing me 
to submit testimony on behalf of the Nation's 216 AZA-accredited zoos 
and aquariums. Specifically, I want to express my support for the 
inclusion of $38.6 million for the Institute of Museum and Library 
Services' (IMLS) Office of Museum Services in the fiscal year 2017 
Labor, Health and Human Services, Education, and Related Agencies 
appropriations bill.
    Founded in 1924, the Association of Zoos and Aquariums (AZA) is a 
nonprofit 501c(3) organization dedicated to the advancement of zoos and 
aquariums in the areas of conservation, education, science, and 
recreation. Accredited zoos and aquariums annually see more than 183 
million visitors, collectively generate more than $17 billion in annual 
economic activity, and support more than 166,000 jobs across the 
country. Over the last 5 years, AZA-accredited institutions supported 
more than 4,000 field conservation and research projects with 
$160,000,000 annually in more than 100 countries. In the last 10 years, 
accredited zoos and aquariums formally trained more than 400,000 
teachers, supporting science curricula with effective teaching 
materials and hands-on opportunities. School field trips annually 
connect more than 12,000,000 students with the natural world.
    Aquariums and zoological parks are defined by the ``Museum and 
Library Services Act of 2003'' (Public Law 108-81) as museums. The 
Office of Museum Services awards grants to museums to support them as 
institutions of learning and exploration, and keepers of cultural, 
historical, and scientific heritages. Grants are awarded in several 
areas including educational programming, professional development, and 
collections management, among others.
    As valued members of local communities, AZA-accredited zoos and 
aquariums offer a variety of programs ranging from unique educational 
opportunities for schoolchildren to conservation initiatives that 
benefit both local and global species. The competitive grants offered 
by the IMLS Office of Museum Services ensure that many of these 
programs, which otherwise may not exist because of insufficient funds, 
positively impact local communities and many varieties of species.
    Unfortunately, current funding has allowed IMLS to fund only a 
small fraction of all highly-rated grant applications. Meanwhile, zoo 
and aquarium attendance has increased and the educational services zoos 
and aquariums provide to schools and communities are in greater demand 
than ever, as is the need for greater funding to develop these 
programs. AZA-accredited zoos and aquariums are essential partners at 
the Federal, State, and local levels in providing education and 
cultural opportunities that adults and children may otherwise never 
enjoy.
    As museums, zoos and aquariums share the same mission of preserving 
the world's great treasures, educating the public about them, and 
contributing to the Nation's economic and cultural vitality. Therefore, 
I strongly encourage you to include $38.6 million for the Institute of 
Museum and Library Services' Office of Museum Services in the fiscal 
year 2017 Labor, Health and Human Services, Education, and Related 
Agencies appropriations bill.
    Thank you for your consideration of our comments.

    [This statement was submitted by Kristin L. Vehrs, Executive 
Director, Association of Zoos and Aquariums.]
                                 ______
                                 
     Prepared Statement of the Brain Injury Association of America
    Chairman Blunt and Ranking Member Murray, thank you for the 
opportunity to submit this written testimony with regard to the fiscal 
year 2017 Labor-HHS-Education appropriations bill. This testimony is on 
behalf of the Brain Injury Association of America (BIAA), our network 
of State affiliates, and hundreds of local chapters and support groups 
from across the country.
    In the civilian population alone every year, more than 2.5 million 
people sustain brain injuries from falls, car crashes, assaults, and 
contact sports. Males are more likely than females to sustain brain 
injuries. Children, teens, and seniors are at greatest risk. Currently, 
more than 5 million Americans live with a TBI-related disability.
    Increasing numbers of servicemembers returning from the conflicts 
in Iraq and Afghanistan with TBI and their families are seeking 
resources for information to better understand TBI and to obtain vital 
support services to facilitate successful reintegration into their 
communities.
    Administration for Community Living.--The TBI Act authorizes the 
Administration for Community Living (ACL) in the Department of Health 
and Human Services (HHS) to award grants to (1) States, American Indian 
Consortia and territories to improve access to service delivery and to 
(2) State Protection and Advocacy (P&A) Systems to expand advocacy 
services to include individuals with traumatic brain injury. For the 
past 17 years the Federal TBI State Grant Program has supported State 
efforts to address the needs of persons with brain injury and their 
families and to expand and improve services to underserved and unserved 
populations including children and youth; veterans and returning 
troops; and individuals with co-occurring conditions.
    In fiscal year 2009, the number of State grant awards was reduced 
to 15, later adding three more States, in order to increase each 
monetary award from $118,000 to $250,000. This means that many States 
that had participated in the program in past years have now been forced 
to close down their operations, leaving many unable to access brain 
injury care.
    Increased funding of the program will provide resources necessary 
to sustain the grants for the 20 States currently receiving funding and 
to ensure funding for additional States. Steady increases over 5 years 
for this program will provide for each State including the District of 
Columbia and the American Indian Consortium and territories to sustain 
and expand State service delivery; and to expand the use of the grant 
funds to pay for such services as Information & Referral (I&R), systems 
coordination and other necessary services and supports identified by 
the State. This year we ask for an additional $1,000,000 to allow for 
the funding of four more State programs, bringing the total State grant 
allocation to just over $7,000,000.
    Similarly, the TBI P&A Program currently provides funding to all 
State P&A systems for purposes of protecting the legal and human rights 
of individuals with TBI. State P&As provide a wide range of activities 
including training in self-advocacy, outreach, information & referral 
and legal assistance to people residing in nursing homes, to returning 
military seeking veterans benefits, and students who need educational 
services. We request $5,000,000 be allocated to the TBI P&A program to 
allow them to serve more individuals in each State.
    Effective Protection and Advocacy services for people with 
traumatic brain injury is needed to help reduce government expenditures 
and increase productivity, independence, and community integration. 
However, advocates must possess specialized skills, and their work is 
often time-intensive. An increased appropriation in this area would 
ensure that each P&A can move towards providing a significant PATBI 
program with appropriate staff time and expertise.
    CDC--National Injury Center.--$10 million (+ $5 million) for the 
Centers for Disease Control and Prevention TBI Registries and 
Surveillance, Brain Injury Acute Care Guidelines, Prevention and 
National Public Education/Awareness.
    The Centers for Disease Control and Prevention's National Injury 
Center is responsible for assessing the incidence and prevalence of TBI 
in the United States. The CDC estimates that 2.5 million TBIs occur 
each year and 5.3 million Americans live with a life-long disability as 
a result of TBI. The TBI Act as amended in 2014 requires the CDC to 
coordinate with the Departments of Defense and Veterans Affairs to 
include the number of TBIs occurring in the military. This coordination 
will likely increase CDC's estimate of the number of Americans 
sustaining TBI and living with the consequences.
    CDC also funds States for TBI registries, creates and disseminates 
public and professional educational materials, for families, caregivers 
and medical personnel, and has recently collaborated with the National 
Football League and National Hockey League to improve awareness of the 
incidence of concussion in sports. CDC plays a leading role in helping 
standardize evidence based guidelines for the management of TBI and $1 
million of this request would go to fund CDC's work in this area.
    In 2013, the National Academies of Sciences, Engineering, and 
Medicine (formerly known as the Institute of Medicine, or the IOM) 
issued a report calling on the CDC to establish a surveillance system 
that would capture a rich set of data on sports- and recreation-related 
concussions among 5-21 year olds that otherwise would not be available. 
To meet this goal, we request an increase of $5 million in the CDC 
budget to establish and oversee a national surveillance system to 
accurately determine the incidence of concussions, particularly among 
the most vulnerable of Americans--our children and youth. In the 
President's fiscal year 2017 budget, a $5 million increase was included 
for the Centers for Disease Control and Prevention (CDC) Injury 
Prevention and Control Center to develop sports concussion surveillance 
to accurately determine the incidence of sports related concussions 
among youth ages 5-21.
    NIDILRR TBI Model Systems of Care.--Funding for the TBI Model 
Systems in the Administration on Community Living is urgently needed to 
ensure that the Nation's valuable TBI research capacity is not 
diminished, and to maintain and build upon the 16 TBI Model Systems 
research centers around the country.
    The TBI Model Systems of Care program represents an already 
existing vital national network of expertise and research in the field 
of TBI, and weakening this program would have resounding effects on 
both military and civilian populations. The TBI Model Systems are the 
only source of non-proprietary longitudinal data on what happens to 
people with brain injury. They are a key source of evidence-based 
medicine, and serve as a ``proving ground'' for future researchers.
    In order to make this program more comprehensive, Congress should 
increase funding in fiscal year 2017 for NIDILRR's TBI Model Systems of 
Care program, in order to add one new Collaborative Research Project. 
In addition, given the national importance of this research program, 
the TBI Model Systems of Care should receive ``line-item'' status 
within the broader NIDILRR budget. Specifically, the Congressional 
Brain Injury Task Force requests increased funding by $13 million over 
the next 6 years to support the TBI Model Systems program:
  --Increase funding for the National Data and Statistical Center by 
        $100,000 annually to allow all participants to be followed; 
        when re-competed, increase from $625,000 to $1 million 
        annually;
  --Increase funding for centers by $150,000 annually from the current 
        average of $437,500;
  --Increase the number of competitively funded centers from 16 to 18; 
        and
  --Increase the number of multicenter TBI Model Systems Collaborative 
        Research projects from one to five, each with an annual budget 
        of $1.5 million (current funding is $600,000 each).
    We ask that you consider favorably these requests for the 
Administration for Community Living, the CDC, and the NIDILRR's TBI 
Model Systems Program to further data collection, increase public 
awareness, improve medical care, assist States in coordinating 
services, protect the rights of persons with TBI, and bolster vital 
research.
                                 ______
                                 
        Prepared Statement of the Campaign for Tobacco-Free Kids
    I am Matthew Myers, President of the Campaign for Tobacco-Free 
Kids. I am submitting this written testimony for the record in support 
of funding for the Office on Smoking and Health (OSH) at the Centers 
for Disease Control and Prevention (CDC). We urge the subcommittee to 
include at least $210 million for CDC's OSH in the Labor-HHS-Ed 
appropriations bill for fiscal year 2017.
    Tobacco use remains the leading cause of preventable disease and 
death in the United States. More than 480,000 Americans die from 
tobacco use each year, and 16 million Americans are currently living 
with a tobacco-caused disease.\1\ Tobacco use is responsible for 32 
percent of heart disease deaths, 30 percent of all cancer deaths, 87 
percent of lung cancer deaths, and 61 percent of all pulmonary disease 
deaths.\2\ Smoking shortens the life of a smoker by more than a decade 
and increases the risk of early death much more than other risk 
factors.\3\
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services (HHS), The Health 
Consequences of Smoking--50 Years of Progress: A Report of the Surgeon 
General, 2014, http://www.surgeongeneral.gov/library/reports/50-years-
ofprogress/.
    \2\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
    \3\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
---------------------------------------------------------------------------
    Tobacco use almost always begins during adolescence. Ninety percent 
of adult smokers begin as teenagers, or earlier.\4\ As youth become 
adults, they typically continue to use tobacco because they have become 
addicted to nicotine. Given the addictiveness of nicotine, smoking is 
not simply a matter of choice. Most adult smokers want to quit (nearly 
70 percent) and wish they never started (about 90 percent).\5\ But 
overcoming an addiction to nicotine is difficult, and tobacco users 
often must make multiple quit attempts before they succeed.
---------------------------------------------------------------------------
    \4\ Substance Abuse and Mental Health Services Administration 
(SAMHSA), Calculated based on data in 2013 National Survey on Drug Use 
and Health.
    \5\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014; and Fong, G., et al., ``The 
Near-Universal Experience of Regret Among Smokers in Four Countries: 
Findings from the International Tobacco Control Policy Evaluation 
Survey,'' Nicotine & Tobacco Research, Vol. 6, Supplement 3, December 
2004.
---------------------------------------------------------------------------
    Fortunately, we know how to reduce tobacco use. Smoking rates have 
been cut by more than half since the first Surgeon General's report on 
the harms from smoking in 1964.\6\ According to recent surveys, the 
smoking rate among adults declined nearly 20 percent from 2005 to 2014, 
and the smoking rate among 12th graders declined nearly 70 percent 
between 1997 and 2015.\7\ This progress has been driven by the 
implementation of policies and programs that have proven to be highly 
effective in preventing youth from starting to use tobacco products and 
helping adult tobacco users to quit.
---------------------------------------------------------------------------
    \6\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
    \7\ Ahmed, J., et al., ``Current Cigarette Smoking Among Adults--
United States, 2005-2014;'' Morbidity and Mortality Weekly Report, 
November 13, 2015: 64(44) http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6444a2.htm?s_cid=mm6444a2_w; and Monitoring the Future, University of 
Michigan, December 2015.
---------------------------------------------------------------------------
    These successful efforts to reduce tobacco use have generated 
enormous gains for public health. People are living longer, healthier 
lives. Over the past 50 years, tobacco control measures have prevented 
about eight million people from dying prematurely.\8\ About 30 percent 
of the gain in life expectancy between 1964 and 2012 is due to efforts 
to reduce tobacco use, an especially remarkable achievement when one 
considers the enormous medical innovations that occurred during this 
time.\9\
---------------------------------------------------------------------------
    \8\ Holford, T., et al., ``Tobacco Control and the Reduction in 
Smoking-Related Premature Deaths in the United States, 1964-2012,'' 
Journal of the American Medical Association, January 8, 2014: 311(2).
    \9\ Holford, T., et al, JAMA, January 8, 2014: 311(2).
---------------------------------------------------------------------------
    The CDC's Office on Smoking and Health plays a critical role in 
continuing our Nation's successful efforts to reduce the toll that 
tobacco takes on our health. OSH translates science into best practices 
for reducing tobacco use, provides funding and technical support to 
implement them, and monitors progress in reducing tobacco use rates.
    Since 2012, OSH has funded a national media campaign, Tips from 
Former Smokers (Tips), to encourage smokers to quit. It features real 
people discussing the harsh reality of living with a disease caused by 
smoking, and it has proven to be highly successful and cost-effective. 
A recent evaluation found that over a 9-week period in 2014 the Tips 
media campaign motivated 1.8 million smokers to make a quit attempt and 
helped 104,000 people to quit.\10\ CDC estimates that over the past 3 
years this media campaign has motivated about 5 million smokers to make 
a quit attempt, helped 300,000 smokers to quit for good, and saved at 
least 50,000 people from premature death.\11\ It cost just $393 for 
each year of life saved, which is considered a ``best buy'' in public 
health.\12\
---------------------------------------------------------------------------
    \10\ Neff, L., et al, ``Evaluation of the National Tips From Former 
Smokers Campaign:the 2014 Longitudinal Cohort,'' Prev Chronic Dis 2016; 
13: 150556.
    \11\ Centers for Disease Control and Prevention (CDC), Fiscal Year 
2017 Justification of Estimates for Appropriations Committees http://
www.cdc.gov/budget/documents/fy2017/fy-2017-cdc-congressional-
justification.pdf.
    \12\ Xu, Xin, et al., ``Cost-Effectiveness Analysis of the First 
federally Funded Antismoking Campaign,'' American Journal of Preventive 
Medicine, 2014.
---------------------------------------------------------------------------
    CDC also provides funding to States for quitlines, which provide 
telephone-based counseling services to help tobacco users to quit and, 
in some States, provide tobacco cessation medications. Smokers who use 
quitlines are at least two to three times more likely to succeed than 
those who try to quit on their own.\13\
---------------------------------------------------------------------------
    \13\ Fiore, MC, et al., Treating Tobacco Use and Dependence: 2008 
Update--Clinical Practice Guideline, U.S. Public Health Service, May 
2008, http://www.surgeongeneral.gov/tobacco/
treating_tobacco_use08.pdf.
---------------------------------------------------------------------------
    In addition, CDC provides grants to all 50 States and the 
territories to help establish and maintain tobacco prevention and 
cessation programs at the State and local level. Comprehensive State 
tobacco programs like the ones CDC helps to maintain have been found to 
be cost effective. A study of Washington State's tobacco prevention and 
cessation program found that for every dollar spent by the State on 
tobacco prevention, the State saved more than $5 in reduced 
hospitalization costs.\14\
---------------------------------------------------------------------------
    \14\ Dilley, Julia A., et al., ``Program, Policy and Price 
Interventions for Tobacco Control: Quantifying the Return on Investment 
of a State Tobacco Control Program,'' American Journal of Public 
Health, Published online ahead of print December 15, 2011. See also, 
Washington State Department of Health, Tobacco Prevention and Control 
Program, Progress Report, March 2011, http://www.doh.wa.gov/tobacco/
program/reports/2011ProgReport.pdf. Washington State Department of 
Health, Tobacco Prevention and Control Program, News Release, 
``Thousands of lives saved due to tobacco prevention and control 
program,'' November 17, 2010, http://www.doh.wa.gov/Publicat/2010_news/
10-183.htm.
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    CDC also conducts important surveillance and other research on 
tobacco use and its impact on health. For example, the National Youth 
Tobacco Survey, which CDC conducts with FDA, found that e-cigarette use 
among youth tripled between 2013 and 2014.\15\
---------------------------------------------------------------------------
    \15\ U.S. Centers for Disease Control and Prevention (CDC), 
``Tobacco Use Among Middle and High School Students--United States, 
2011-2014,'' Morbidity and Mortality Weekly Report (MMWR) 64(14):381-
385, April 2015, http://www.cdc.gov/mmwr/preview/mmwrhtml/
mm6414a3.htm?s_cid=mm6414a3_e.
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    Last year, the House Labor-HHS-Ed appropriations bill for fiscal 
year 2016 would have reduced funding for OSH by 50 percent, from $216.5 
million to $105.5 million. This substantial reduction would have 
undermined CDC's efforts to prevent youth from starting to use tobacco 
and to help adults to quit. Programs we know are working would have 
been curtailed and possibly eliminated. CDC would have had to end its 
successful and cost-effective media campaign. It would also likely have 
had to reduce funding for State quitlines and State and local tobacco 
prevention and cessation programs.
    We were pleased that the Senate Labor-HHS-Ed appropriations bill 
for fiscal year 2016 would have provided level funding for OSH and were 
relieved that the Consolidated Appropriations Act for fiscal year 2016 
included a much smaller cut than what the House had proposed.
    We urge the subcommittee to provide at least $210 million for OSH 
for fiscal year 2017, which is the funding level enacted for fiscal 
year 2016. Without continued attention and resources, we risk 
undermining the progress that has been made in reducing the disease and 
death caused by tobacco use. We risk more cancers, heart disease, 
respiratory disease, and other tobacco-caused diseases and more people 
dying years earlier than if they did not smoke. Without urgent action, 
5.6 million children alive today will die prematurely from a smoking-
related disease.\16\
---------------------------------------------------------------------------
    \16\ HHS, The Health Consequences of Smoking--50 Years of Progress: 
A Report of the Surgeon General, 2014.
---------------------------------------------------------------------------
    The Federal Government cannot afford to take a hands-off approach 
to tobacco use. Tobacco use not only harms the health of tobacco users 
but also burdens families, the healthcare system, and government 
budgets. It is responsible for approximately $170 billion in healthcare 
costs each year. Nearly 60 percent of these healthcare costs are paid 
by government programs such as Medicare and Medicaid.\17\
---------------------------------------------------------------------------
    \17\ Xu, X et al., ``Annual Healthcare Spending Attributable to 
Cigarette Smoking: An Update,'' American Journal of Preventive 
Medicine, 2014.
---------------------------------------------------------------------------
    At a time when Congress is working on a bipartisan basis to 
facilitate the development of new cures and treatments for devastating 
diseases, the subcommittee should, at a minimum, maintain existing 
funding for programs that have proven effective at preventing cancers, 
heart disease, chronic obstructive pulmonary disease (COPD) and other 
diseases caused by tobacco. At a time of concern about high healthcare 
costs, the subcommittee should, at a minimum, maintain existing 
investments to address risk factors like tobacco use that, if left 
unaddressed, will lead to higher medical costs for treating preventable 
diseases in the future.
    We appreciate the opportunity to share our views on the importance 
of OSH's work and the need to maintain, at a minimum, its current 
funding level.
                                 
                                 ______
                                 
               Prepared Statement of Carmical Donna deg.
                  Prepared Statement of Donna Carmical
    Thank you for the opportunity to submit testimony regarding the 
National Institute of Health (NIH) 2017 budget request. My name is 
Donna Carmical, I am the grandmother of a child who died from pediatric 
cancer. We lived in blissful ignorance about childhood cancer before 
Declan was diagnosed. We assumed, like most Americans, that our country 
was doing everything imaginable to ensure that children would have the 
most advanced cures and treatments possible. We were wrong, horribly 
wrong. The National Institute of Health (NIH) is unfairly 
discriminating against children--the children who have battled cancer, 
who are battling cancer as well as the children yet to be diagnosed--
and doing children a grave injustice. NIH has called childhood cancer 
``rare'' not really a problem and said they could do more if Congress 
provided more funding. Childhood cancer research is not a priority for 
NIH.
    Despite the fact that Senate report language has urged NIH to 
increase funding for childhood cancer research in a variety of 
statements over the past decade, NIH has barely acknowledged this 
problem. It is hard to understand their rationale. Some compelling 
facts:
  --Childhood cancer is the #1 disease related killer of kids in the 
        U.S., killing thousands of children each and every year.
  --The incidence of childhood cancer has been increasing steadily over 
        the past decades. Today 1 in 285 children will be diagnosed 
        with cancer before they reach the age of 20.
  --20 percent of children diagnosed are terminal on diagnosis.
  --60 percent of children diagnosed suffer life altering impacts of 
        treatments, largely due to the lack of pediatric protocols, 
        treatments are often a guess game of experiments and use of 
        downsized adult protocols.
  --95 percent of the survivors of childhood cancer will suffer serious 
        health impacts before they reach the age of 45.
  --Adult cancers and childhood cancers are different, while childhood 
        cancer research often benefits adults with cancer the opposite 
        is less common.
    Childhood cancer is not one disease, there are 16 major types of 
cancer and over 100 subtypes. Many of these childhood cancers, like 
DIPG, AT/RT, receive little to no funding for research. The National 
Cancer Institute indicates that survival rates for a few childhood 
cancers like acute lymphoblastic leukemia (ALL) have improved 
dramatically over the past decades, ironically this is due to the 
investment in research. NIH makes little mention of statistics 
regarding the deadly childhood cancers where there has been little to 
no research for decades.
    There are many urgent reasons to invest in childhood cancer 
research yet NIH persists in ignoring this issue at great peril to our 
children and their children. At last year's Senate hearing, I listened 
to Dr. Fauci state that NIH spends more than $3 billion a year trying 
to cure AIDs. As one Senator said, if you take your medicine, AIDS is 
not killing anyone in this country. Dr. Fauci stated that $6 billion a 
year would be saved by curing AIDS. Thousands of children are dying 
each year as a result of childhood cancer, and tens of thousands of 
survivors are irreparably harmed largely because we have done so little 
to develop pediatric cancer treatments and protocols. A cost analysis 
about the realities of childhood cancer should be done by NIH. 
Considering that 16,000 children under the age of 19 are diagnosed each 
year, one could speculate that curing childhood cancer could save more 
than $8 billion a year.
    The average age of a child diagnosed with cancer is 8 years old, 
the long term costs of 380 thousand survivors who have been treated 
with less than the best treatments has a long term cost to society that 
hasn't been calculated. If survivors pass the 5 year survival rate--
they are statistically considered cured; yet, many children suffer long 
term impacts, secondary cancers, heart problems, infertility, learning 
disabilities, stunted growth, hearing problems and more. The increase 
in survivors, burden of disease, growing number of survivors, as well 
as number of deaths each year are a great cost to society. An 
investment in childhood cancer research could deliver big results--
pediatric protocols that might result in cures, less invasive 
treatments, reduction in life altering impacts, etc.
    Congress required the Government Accounting Office to review how 
NIH sets priorities and review the strategic planning process a few 
years ago, GAO Report 14-246. The Senate required NIH to submit an 
overarching strategic plan by December 2015. The manner in which NIH 
sets priorities, how they make decisions that will result in the best 
outcomes for the American people is difficult to understand and like 
their budget process less than transparent. The strategic planning 
process requires that NIH consult internally and externally, that they 
consult with Congress, stakeholders and the public. Despite stakeholder 
requests to be part of the strategic planning effort, there was no real 
outreach to make this happen. The Strategic Plan recently completed 
does not really comport with the intent of the legislation. The NIH 
Strategic Plan does not give the public a sense of its 4 year long 
range strategic goals, short range agency priorities and in fact mostly 
expands the mission statement. There is no real sense in terms of what 
kind of results and outcomes the public should expect in terms of a 
$120 billion investment. However, NIH strategic plan objectives could 
all benefit by significant investment in childhood cancer research 
(advance opportunities in biomedical research, foster innovation by 
setting NIH priorities, enhance scientific stewardship, excel as a 
Federal science agency by managing for results).
    NIH has a less than transparent budget process, the RCDC indicates 
that approximately $6 billion is dedicated to research in the following 
areas: AIDS, Drug Abuse, Obesity, Tobacco and Alcoholism (recognizing 
that it is difficult to understand the RCDC portfolio as there is lots 
of double counting). As a taxpayer and investor in the NIH portfolio 
the childhood cancer community would like to see NIH re-prioritize 
their research and find significant investment in childhood cancer 
research as well as a childhood cancer research line item in their 
budget. This means investment in research, not more studies but 
research grants that will result in real research towards finding less 
invasive treatments for kids and specific childhood cancer drugs, 
treatments and cures. This is not a matter of more money for NIH, it's 
a matter of priorities and childhood cancer research should be a 
national priority. Our kids deserve no less. We need specific childhood 
cancer research, not more studies and administrative costs.
    As reported by The Atlantic in a January 2013 article, ``there is 
not enough funding for childhood cancer, specifically. The National 
Cancer Institute, a Government organization, provides funding for 
researchers, but only 10 percent of them can move forward with their 
findings due to budget cuts. Most of the financial support researchers 
receive is from philanthropists. In the meantime, research that could 
benefit children on an individual level stays in the lab, and doctors 
prescribe the same regimens that can be successful, but can also hurt 
the patient in several ways. Researchers say they are working hard to 
discover new theories and treatments, but they feel they are being held 
back.'' The article goes on to quote, Dr. William Carroll, researcher 
and director of the cancer institute at New York University saying, 
``Ninety-six percent of grants (sic childhood cancer) don't get funded 
. . . There's no doubt there's less funding available, and it's driving 
people out of the field.''
    Ironically many pediatric cancer organizations raising funds for 
childhood cancer research have been started by families who have lost a 
child to pediatric cancer. These families are trying to fund research 
because their eyes have been opened to the lack of childhood cancer 
research funding, they have seen their children suffer and die and they 
want to create awareness and change this picture for kids. Families 
desperately want other kids to have cures denied to their own children. 
The thing is that all the money we can raise by shaving heads, selling 
lemonade, golf tournaments, car washes, races, bake sales--all of this 
will not make a dent in this problem. Even the largest organizations 
that are raising tens of millions of dollars means that cures for 
children are probably 100 years into the future. Our children need 
significant Federal investment in childhood cancer research now. 
Childhood cancer research needs a huge investment, an investment of 
billions--the kind of investment we have made in AIDS research, EBOLA, 
etc, the kind of research that will ensure results.
    Dr. Collins says we should envision the first AIDS free generation 
since the virus emerged more than 30 years ago. This success would not 
have been possible without the substantial investment of dollars in 
AIDS research, an investment of tens of billions of taxpayer dollars 
over the last two decades. NIH is seeking a cure, a vaccine and that is 
great but only around 20 percent of that $3 billion annually is being 
used to develop a cure for AIDS. It is time to re-prioritize those 
programs and as required by law determine where dollars will achieve 
the most in terms of results and ``manage for results'' as stated in 
the NIH strategic plan.
    Congress has urged NIH to deal with the issue, the Children's 
Health Act (CHA) of 2000 required NIH to study risk factors for 
childhood cancer and improve outcomes for children with cancer; it 
required NIH to conduct and support research directly related to 
disease in children; to insure investment in tomorrow's pediatric 
research. It's hard to understand how these requirements have been 
carried out--where are the results of this requirement. The National 
Children's Study was passed in 2002, Congress appropriated over $1 
billion to this debacle with little to show for these funds, where is 
the accountability. It is also mind-boggling that this 15 year journey 
to put together a cohort of 1000,000 children failed at great cost to 
the taxpayer and it appears not even the remnants of this study will 
factor into the newly funded Precision Medicine Initiative. As 
taxpayers and investors in the country's largest research organization, 
the public deserves accountability, transparency and answers in how NIH 
sets priorities and why childhood cancer research is continually 
ignored in the funding process. It seems the statistical answer is that 
annually 1.6 million adults are diagnosed with cancer and only around 
16,000 children; but, numbers can be used to tell the story you want. 
If you consider that 77 percent of those 1.6 million adults are over 
the age of 55, grandparents like me, most of us would tell you that we 
think childhood cancer research should be a priority in funding 
decisions! Our grandchildren deserve the best that we can give them, 
not what's left over.
    What we learned during Declan's battle has left us forever changed. 
What we saw and learned during those many months in the hospital is 
life altering. What we see every single day, what these brave kids, 
these babies endure--you have to see the horror to understand where the 
childhood cancer community is coming from. Watching our kids being 
treated with experimental protocols--knowing there are no cures that 
the poison, cut and burn techniques are used because this is all our 
medical community has--it is wrong. The medical community trying to 
save our kids deserves better treatment options and drugs that will 
only come through research.
    I'm nobody special, just a mother and grandmother. I understand 
that I don't know much compared to the wonderful scientists at NIH. I 
understand that the budget process is hard work for the committees, and 
resources are limited. But my experience over the past 5 years compels 
me to fight for kids. I can't do anything to change what happened to 
our sweet Declan, but I believe research will result in more funding 
for those deadly childhood cancers. Much like the prognosis has changed 
for AIDS over the past decades, I believe research could provide 
pediatric treatments and protocols that will offer cures to children 
like Declan in the future. We can't keep condemning these kids to death 
year after year and do nothing because of money.
    I hope you will investigate and legislate more about the childhood 
cancer issue. Making childhood cancer research a priority in the 
Federal budget process would be a tremendous legacy for Congress and 
has great potential to give children the cures and hope they deserve. 
Thank you.

THE ASKS FOR NIH BUDGET

    1.  Transparency--meet the requirement of GPRA by providing a 
strategic plan, annual plan, annual performance report on 
performance.gov. Eliminate double counting in the RCDC information.
    2.  Burden of Disease Study--require NIH to contract out a burden 
of disease study that considers all aspects of childhood cancer costs 
to society, annually and over time.
    3.  Childhood Cancer Research--legislate an appropriation floor for 
funding that should go directly into childhood cancer research grants 
in keeping with the Children's Health Act of 2000.
    4.  Line Item--Require that NIH develop a funding line item for 
childhood cancer research. This creates transparency and accountability 
in the budget process.
                                 ______
                                 
 Prepared Statement of the Centers for Disease Control and Prevention 
                               Coalition
    The CDC Coalition is a nonpartisan coalition of more than 140 
organizations committed to strengthening our Nation's prevention 
programs. We represent millions of public health workers, clinicians, 
researchers, educators and citizens served by CDC programs.
    We believe Congress should support CDC as an agency, not just its 
individual programs and urge a funding level of $7.8 billion for CDC's 
programs in fiscal year 2017. We are disappointed President Obama's 
budget request would cut CDC's program level by $194 million below 
fiscal year 2016. We acknowledge that the President's budget provides 
increased funding for several important programs and initiatives such 
as combating antibiotic resistance and preventing prescription drug 
overdose. We are also pleased that the President's budget would fully 
allocate the Prevention and Public Health Fund for public health 
activities. Unfortunately, the President's budget cuts or completely 
eliminates other important programs including the REACH program, the 
Preventive Health and Health Services Block Grant, cancer prevention 
and control, immunizations and environmental health tracking and we 
urge you to restore the funding.
    CDC is a key source of funding and technical assistance for State 
and local programs that aim to improve the health of communities. CDC 
funding provides the foundation for State and local public health 
departments, supporting a trained workforce, laboratory capacity and 
public health education communications systems.
    CDC serves as the command center for the Nation's public health 
defense system against emerging and reemerging infectious diseases. 
From aiding in the surveillance, detection and prevention of the Zika 
virus to playing a lead role in the control of Ebola in West Africa and 
detecting and responding to cases in the U.S., to monitoring and 
investigating last year's multi-state measles outbreak to pandemic flu 
preparedness, CDC is the Nation's--and the world's--expert resource and 
response center, coordinating communications and action and serving as 
the laboratory reference center for identifying, testing and 
characterizing potential agents of biological, chemical and 
radiological terrorism, emerging infectious diseases and other public 
health emergencies. CDC serves as the lead agency for bioterrorism and 
public health emergency preparedness and must receive sustained support 
for its preparedness programs to meet future challenges. We urge you to 
provide adequate funding for CDC's infectious disease, laboratory and 
emergency preparedness and response activities.
    Heart disease is the Nation's No. 1 cause of death. In 2014, over 
614,000 people in the U.S. died from heart disease, accounting for 
nearly 23 percent of all U.S. deaths. More males than females died of 
heart disease in 2014, while more females than males died of stroke 
that year. Stroke is the fifth leading cause of death and is a leading 
cause of disability. In 2014, nearly 133,000 people died of stroke, 
accounting for about one of every 20 deaths. CDC's Heart Disease and 
Stroke Prevention Program, WISEWOMAN, and Million Hearts work to 
improve cardiovascular health.
    Cancer is the second most common cause of death in the U.S. More 
than 1.6 million new cancer cases and 595,690 deaths from cancer are 
expected in 2016. In 2013 the direct medical costs of cancer were $74.8 
billion. The National Breast and Cervical Cancer Early Detection 
Program helps millions of low-income, uninsured and medically 
underserved women gain access to lifesaving breast and cervical cancer 
screenings and provides a gateway to treatment upon diagnosis. CDC also 
funds grants to all 50 States to develop comprehensive cancer control 
plans, bringing together a broad partnership of public and private 
stakeholders to set joint priorities and implement specific cancer 
prevention and control activities customized to address each State's 
particular needs.
    Cigarette smoking causes more than 480,000 deaths each year. CDC's 
Office of Smoking and Health funds important programs and education 
campaigns such as the Tips From Former Smokers campaign that help to 
prevent tobacco addiction and provide resources to encourage smokers to 
quit. We must continue to support these vital programs to reduce the 
enormous health and economic costs of tobacco use in the United States.
    Of the 29.1 million Americans who have diabetes, more than 8 
million cases are undiagnosed. Each year, about 1.4 million people are 
newly diagnosed with diabetes. Diabetes is the leading cause of kidney 
failure, nontraumatic lower-limb amputations, and new cases of 
blindness among adults in the United States. The total direct and 
indirect costs associated with diabetes were $245 billion in 2012. We 
urge you to provide adequate resources for the Division of Diabetes 
Translation which funds critical diabetes prevention, surveillance and 
control programs.
    Obesity prevalence in the U.S. remains high. While the obesity 
rates among children between the ages of 2-5 have significantly 
decreased over the past decade, more than one-third of adults are obese 
and 17 percent of children are obese. Obesity, diet and inactivity are 
cross-cutting risk factors that contribute significantly to heart 
disease, cancer, stroke and diabetes. CDC funds programs to encourage 
the consumption of fruits and vegetables, encourage sufficient exercise 
and develop other habits of healthy nutrition and physical activity.
    Arthritis is the most common cause of disability in the U.S., 
striking more than 53 million Americans of all ages, races and 
ethnicities. CDC's Arthritis Program plays a critical role in 
addressing this growing public health crisis and working to improve the 
quality of life for individuals affected by arthritis and we urge you 
to support adequate funding for the program.
    CDC provides national leadership in helping control the HIV 
epidemic by working with community, State, national, and international 
partners in surveillance, research, prevention and evaluation 
activities. CDC estimates that about 1.2 million Americans are living 
with HIV with 12.8 percent undiagnosed. The number of people living 
with HIV is increasing as new drug therapies are keeping HIV-infected 
persons healthy longer and dramatically reducing the death rate. 
Prevention of HIV transmission is the best defense against the AIDS 
epidemic.
    Sexually transmitted diseases continue to be a significant public 
health problem in the U.S. Nearly 20 million new infections occur each 
year. CDC estimates that STDs, including HIV, cost the U.S. healthcare 
system almost $16 billion annually.
    The National Center for Health Statistics collects data on chronic 
disease prevalence, health disparities, emergency room use, teen 
pregnancy, infant mortality and causes of death. The health data 
collected through the Behavioral Risk Factor Surveillance System, Youth 
Risk Behavior Survey, Youth Tobacco Survey, National Vital Statistics 
System, and National Health and Nutrition Examination Survey must be 
adequately funded.
    CDC oversees immunization programs for children, adolescents and 
adults and is a global partner in the ongoing effort to eradicate polio 
worldwide. Influenza vaccination levels remain low for adults. Levels 
are substantially lower for pneumococcal vaccination among adults as 
well, with significant racial and ethnic disparities in vaccination 
levels persisting among the elderly. Childhood immunizations provide 
one of the best returns on investment of any public health program. For 
every dollar spent on childhood vaccines to prevent thirteen diseases, 
more than $10 is saved in direct and indirect costs. Over the past 20 
years, CDC estimates childhood immunizations have prevented 732,000 
deaths and 322 million illnesses. We urge you to restore the 
President's proposed cuts to the Section 317 Immunization program.
    Injuries are the leading causes of death for people ages 1-44. 
Unintentional and violence-related injuries, such as older adult falls, 
prescription drug overdose, child maltreatment and sexual violence, 
account for approximately 27 million emergency department visits each 
year. In 2013, injury and violence cost the U.S. approximately $671 
billion in direct and indirect medical costs. The National Center for 
Injury Prevention and Control must be adequately funded to prevent 
injuries and minimize their consequences.
    Birth defects affect one in 33 babies and are a leading cause of 
infant death in the U.S. Children with birth defects who survive often 
experience lifelong physical and mental disabilities. Over 500,000 
children are diagnosed with a developmental disability and it is 
estimated that up to 57 million people in the U.S currently live with a 
disability. The National Center on Birth Defects and Developmental 
Disabilities conducts important programs to prevent birth defects and 
developmental disabilities and promote the health of people living with 
disabilities and blood disorders and must be adequately funded.
    The National Center for Environmental Health works to protect 
public health by helping to control asthma, protect from threats 
associated with natural disasters and climate change, reduce, monitor 
and track exposure to lead and other hazards and ensure access to safe 
and clean water. We urge you to support the President's request for the 
Climate and Health and Safe Water programs, increase funding for the 
Childhood Lead Poisoning Prevention, Environmental Health Laboratory 
and Asthma programs, restore proposed cuts to the National 
Environmental and Public Health Tracking Network and restore funding 
for the Built Environment and Health program which was eliminated in 
2016.
    In order to meet the many ongoing public health challenges outlined 
above, we urge you to support our fiscal year 2017 request of $7.8 
billion for CDC's programs.

    [This statement was submitted by Donald Hoppert, Director of 
Government Relations, American Public Health Association.]
                                 ______
                                 
          Prepared Statement of Centers for Independent Living
    I am writing to support the National Council on Independent 
Living's request for Congress to reaffirm your commitment to the more 
than 57 million Americans disabilities by increasing funding in the HHS 
appropriations for Centers for Independent Living (CILs). I am asking 
that you increase funding by $200 million, for a total of $301 million 
for the Independent Living line item in fiscal year 2017.
    CILs are cross-disability, non-residential, community-based, 
nonprofit organizations that are designed and operated by individuals 
with disabilities. CILs are unique in that they are directly governed 
and staffed by people with all types of disabilities, including people 
with mental, physical, sensory, cognitive, and developmental 
disabilities. Each of the 365 federally funded centers provides five 
core services: information and referral, individual and systems 
advocacy, peer support, independent living skills training, and 
transition services, which were added with the passage of the Workforce 
Innovation and Opportunity Act (WIOA). From 2012-2014, CILs provided 
the core services to nearly 5 million people with disabilities, and 
provided additional services such as housing assistance, 
transportation, personal care attendants, and employment services to 
hundreds of thousands of individuals. During this same period, prior to 
transition being added as a core service, CILs transitioned 13,030 
people with disabilities from nursing homes and other institutions into 
the community.
    Transition services were added as a fifth core service with the 
2014 reauthorization of the Rehabilitation Act within the Workforce 
Innovation and Opportunity Act. Transition services include the 
transition of individuals with significant disabilities from nursing 
homes and other institutions to home and community-based residences 
with appropriate supports and services, assistance to individuals with 
significant disabilities at risk of entering institutions to remain in 
the community, and the transition of youth with significant 
disabilities to postsecondary life. This core service is vital to 
achieving full participation for people with disabilities.
    Every day, CILs are fighting to ensure that people with 
disabilities gain and maintain control over our own lives. We know that 
this cannot occur when people reside in institutional settings. 
Opponents of deinstitutionalization say that allowing people with 
disabilities to live in the community will result in harm. We know that 
the 13,030 people with disabilities who CILs successfully transitioned 
out of nursing homes and institutions from 2012-2014 prove otherwise. 
Additionally, when services are delivered in an individual's home, the 
result is a tremendous cost savings to Medicaid, Medicare, and States. 
Community-based services enable people with disabilities to become less 
reliant on long-term government supports, and they are significantly 
less expensive than nursing home placements. We are grateful that 
Congress demonstrated their understanding and support for community-
based services when WIOA was passed and transition was added as a fifth 
core service.
    Since transition services were added as a core service, the need 
for funding is critical. Moreover, CILs need additional funding to 
restore the devastating cuts to the Independent Living program, make up 
for inflation costs, and address the increased demand for independent 
living services.
    In 2016, the Independent Living Program is receiving $2.5 million 
less in funding than it was in 2010. It is simply not possible to meet 
the increasing demand for services and effectively provide transition 
services without additional funding. Increased funding should be 
reinvested from the billions currently spent to keep people with 
disabilities in costly Medicaid nursing homes and institutions and out 
of mainstream society.
    Centers for Independent Living play a crucial role in the lives of 
people with disabilities, and work tirelessly to ensure that people 
with disabilities have a real choice in where and how they live, work, 
and participate in the community. Additionally, CILs are an excellent 
service and a bargain for America, keeping people engaged with their 
communities and saving taxpayer money. NCIL is dedicated to increasing 
the availability of the invaluable and extremely cost-effective 
services CILs provide, and they have submitted written testimony with a 
similar request.
    I strongly support NCIL's testimony.
                                 ______
                                 
   Prepared Statement of the Children's Environmental Health Network
    The Children's Environmental Health Network (CEHN or the Network) 
is pleased to have this opportunity to submit testimony on fiscal year 
2017 appropriations for the following programs and activities that 
safeguard the health and future of all of our children:
  --Centers for Disease Control and Prevention ($7.8 billion), 
        especially the National Center for Environmental Health 
        ($236.899 million) and its programs, including: Healthy Homes 
        and Lead Poisoning Prevention Program ($35 million); National 
        Asthma Control Program ($30.596 million); and the National 
        Environmental Public Health Tracking Program ($50 million)
  --National Institute of Environmental Health Sciences (NIEHS) ($717.7 
        million), to continue support of efforts and research focused 
        on children's health
  --Pediatric Environmental Health Specialty Units (PEHSUs) ($2 
        million)
    The CEHN was created more than 20 years ago by concerned 
pediatricians and researchers with a goal of protecting the developing 
child from environmental health hazards and to promote a healthy 
environment. Today's children are facing the distressing possibility 
that they may be the first generation to see a shorter life expectancy 
than their parents due to poor health. Key contributors to this trend 
are obesity, asthma, learning disabilities, and autism. For all of 
these conditions, the child's environment plays a role in causing, 
contributing to or mitigating these chronic conditions. The estimated 
costs of environmental disease in children (such as lead poisoning, 
childhood cancer, and asthma) were $76.6 billion in 2008.\1\ 
Additionally, protecting our children--those born as well as those yet 
to be born--from environmental hazards is a national security issue. 
When we protect children from harmful chemicals in their environment, 
we help to assure that they will reach their full potential. American 
competiveness depends on having healthy, educated children who grow up 
to be healthy productive adults. We strongly urge the subcommittee to 
support and expand children's environmental health programs.
---------------------------------------------------------------------------
    \1\ Trasande, Liu Y. ``Reducing The Staggering Costs Of 
Environmental Disease In Children, Estimated At $76.6 Billion In 2008, 
Health Affairs. No. (2011): doi: 10.1377/hlthaff.2010.1239.
---------------------------------------------------------------------------
            centers for disease control and prevention (cdc)
    As the Nation's leader in public health promotion and disease 
prevention, the CDC should receive top priority in Federal funding. CDC 
continues to be faced with unprecedented challenges and 
responsibilities. CEHN applauds your support for CDC in past years and 
urges you to support a funding level of $7.8 billion for CDC's core 
programs in fiscal year 2017.
                national center for environmental health
    The National Center for Environmental Health (NCEH) is particularly 
important in protecting the environmental health of young children. 
This is especially evident as seen by the recent crisis in Flint, 
Michigan, were the critical role that core environmental health 
services must play in protecting our families and communities is front 
and center. Current research is uncovering the extensive role that 
environment plays in human health and development. As a result, NCEH 
partners with public health agencies and a wide range of other 
organizations to bring their expertise and support to an expanding 
scope of environmental-human health challenges. We urge the 
subcommittee to provide $236.899 million to NCEH to support these 
critical programs.
          healthy homes and lead poisoning prevention program
    Support critically underfunded childhood lead poisoning prevention 
activities by funding the CDC Healthy Homes and Lead Poisoning 
Prevention Program at $35 million. This funding level will provide 
grants in all 50 States for surveillance to determine the extent of 
childhood lead poisoning, as well as educate the public and healthcare 
providers about lead poisoning, and ensure that lead-exposed children 
received needed medical and environmental follow-up services. There is 
no safe level of lead exposure and lead damage can be permanent and 
irreversible leading to a myriad of academic and behavioral problems in 
school, failure to graduate and a host of other health impairments 
later in life. Today over 500,000 children are exposed to unacceptably 
high levels of lead.
                    national asthma control program
    NCEH's National Asthma Control Program not only has greatly 
increased data collection about this rampant epidemic but it also 
encourages States to use evidence-based approaches to reduce costs and 
improve outcomes for people living with asthma. Asthma is an epidemic 
in the U.S., affecting 10 percent of our Nation's children. We urge the 
subcommittee to fund this vital program at $30.596 million in fiscal 
year 2017.
         national environmental public health tracking program
    Public health officials need integrated health and environmental 
data so that they can protect the public's health. The CDC's National 
Environmental Public Health Tracking Program helps to track 
environmental hazards and the diseases they may cause and to coordinate 
and integrate local, State and Federal health agencies' collection of 
critical health and environmental data. Participation in the tracking 
network development will decline under further cuts and erase the 
progress we have made across the country to better link data with 
public health action.
       national institute of environmental health science (niehs)
    NIEHS is the leading institute conducting research to understand 
how the environment influences human health. Unlike other NIH 
Institutes focused on one disease or one body system, NIEHS is charged 
with all diseases, all human health and body systems, as they are 
affected by the environment--a vital and monumental charge. NIEHS plays 
a critical role in our efforts to understand how to protect children, 
whether it is identifying and understanding the immediate impact of 
chemical substances or understanding childhood exposures that may not 
affect health until decades later. Today's pediatric health challenges 
are chronic conditions such as obesity, asthma, learning disabilities, 
and autism; and for all of these health challenges, environment plays a 
role in cause, prevention, or mitigation. Recent NIEHS funded studies 
have shown that exposure to traffic-related air pollution (nitrogen 
dioxide, PM2.5, and PM10) during pregnancy and 
the first year of life is associated with the development of autism. 
Additional research on likely biological pathways is needed to 
determine whether these associations are causal. CEHN recommends that 
$732.3 million be provided for NIEHS' fiscal year 2017 budget.
             pediatric environmental health specialty units
    Pediatric Environmental Health Specialty Units (PEHSUs) form a 
valuable resource network for parents and clinicians around the Nation 
and are funded jointly by the Agency for Toxic Substances and Disease 
Registry (ATSDR) and the EPA with a very modest budget. PEHSU 
professionals provide medical consultation to healthcare professionals, 
and information and resources to school, child care, health and 
medical, and community groups and help inform policymakers by providing 
data and background on local or regional environmental health issues 
and implications for specific populations or areas. We urge the 
subcommittee to fully fund ATSDR's portion of this program in fiscal 
year 2017.
    Again, thank you for the opportunity to submit this testimony.

    [This statement was submitted by Nsedu Obot Witherspoon, M.P.H., 
Executive Director, Children's Environmental Health Network.]
                                 ______
                                 
    Prepared Statement of the Children's Hospitals Graduate Medical 
                           Education Program
    The Children's Hospitals Graduate Medical Education (CHGME) program 
is administered by the Bureau of Health Workforce in the Health 
Resources and Services Administration at the Department of Health and 
Human Services. The statement testimony focuses on the purpose of CHGME 
and its benefit to all children. The testimony includes a request for 
the subcommittee to appropriate $300 million for CHGME in fiscal year 
2017.
    The Children's Hospital Association advances child health through 
innovation in the quality, cost and delivery of care. Representing more 
than 220 institutions, the Association is the voice of children's 
hospitals nationally. As organizations dedicated to protecting and 
advancing the health of America's children, we thank the subcommittee 
for its longstanding bipartisan support of the Children's Hospital 
Graduate Medical Education program (CHGME).
    A robust pediatric workforce is essential to ensuring that no child 
lacks access to high quality medical care. The CHGME program supports 
this goal by providing funding for the training of pediatric providers 
at independent children's teaching hospitals, much as Medicare supports 
training in teaching hospitals that serve primarily adults. CHGME 
benefits all children, supporting the training of doctors who go on to 
care for children living in every State--in cities, rural communities, 
suburbs and everywhere in between.
    For fiscal year 2016, Congress provided $295 million for CHGME, the 
program's first funding increase since fiscal year 2010. Children's 
hospitals are extremely grateful to the subcommittee for this strong 
commitment to the health of America's children. For fiscal year 2017, 
the Children's Hospitals Association urges the subcommittee to continue 
to advance children's health and fund CHGME at its authorized level of 
$300 million.
    Congress created CHGME in 1999 with bipartisan support because it 
recognized that the absence of dedicated GME funding for freestanding 
children's teaching hospitals created gaps in the training of pediatric 
providers, which potentially threatened access to care for children. 
Since then, the CHGME program has had a tremendous impact. Although the 
58 hospitals that currently receive CHGME funding comprise only 1 
percent of all hospitals, they train approximately half (49 percent) of 
all pediatric residents--more than 6,000 annually--including 45 percent 
of all general pediatricians and 51 percent of all pediatric 
specialists.
    CHGME has enabled children's hospitals to increase their overall 
training by more than 45 percent since the program began in 1999. In 
addition, the CHGME program has accounted for more than 74 percent of 
the growth in the number of new pediatric subspecialists being trained 
nationwide. Bipartisan legislation reauthorizing CHGME through fiscal 
year 2018 was enacted in 2014, demonstrating the high level of ongoing 
support among lawmakers for the program.
    However, while much has been achieved in strengthening the 
pediatric workforce, much remains to be done. Since 2000, the national 
population of children has grown 3 percent, increasing from 72.3 
million to 74.2 million today. At the same time, the healthcare needs 
of the pediatric population are increasing. The number of children with 
complex medical conditions is growing at a faster rate than the overall 
child population, requiring an increased number of specialty care 
providers.\1\
---------------------------------------------------------------------------
    \1\ 2014 report, ``Summary of Available Evidence and Methodology 
for Determining Potential Medicaid Savings from Improving Care 
Coordination for Medically Complex Children'', prepared for Children's 
Hospital Association by Dobson DaVanzo & Associates, p. vi.
---------------------------------------------------------------------------
    Unfortunately, funding to train the doctors to serve these children 
has not kept pace. While children under 18 currently comprise about 23 
percent of the U.S. population, only 9 percent of all Federal support 
for graduate medical education is targeted toward training pediatric 
providers (combining CHGME and Medicare funding for pediatric 
residents).\2\
---------------------------------------------------------------------------
    \2\ Sources: U.S. Census Bureau; 2014 report, ``Comparative 
Analysis of GME Funding for Children's Hospitals and General Acute Care 
Teaching Hospitals'', prepared for Children's Hospitals Association by 
Dobson DaVanzo & Associates.
---------------------------------------------------------------------------
    Our Nation's commitment to children's healthcare still lags behind 
our investment in adults with respect to workforce training. 
Freestanding children's hospitals, which, as noted, train approximately 
half of all pediatricians and pediatric specialists, receive almost no 
Federal GME support through Medicare. Furthermore, analysis 
commissioned by the Children's Hospital Association shows that at 
current funding levels, the average CHGME payment per full-time 
equivalent (FTE) resident represents only 45 percent of what Medicare 
GME provides to support training in adult teaching hospitals.
    Strengthening funding for CHGME will help children and their 
families, including those with rare and complex conditions. Nationwide, 
serious pediatric workforce shortages persist, most acutely among 
pediatric subspecialties. The most recent survey data available from 
children's hospitals shows the following wait times for scheduling 
appointments due to shortages:
  --Developmental pediatrics--Average wait time of 13 weeks
  --Endocrinology--Average wait time of 10 weeks
  --Neurology--Average wait time of nine weeks
  --Pulmonology--Average wait time of eight weeks
  --Gastroenterology--Average wait time of five weeks
    Localized shortages of pediatric primary care also continue, 
particularly in certain rural areas.
    CHGME has allowed children's hospitals to develop training programs 
in highly specialized disciplines that target the unique needs of 
children, including, for example, pediatric surgical oncology, 
radiation oncology, pediatric pathology and bone marrow 
transplantation. Only a small number of institutions provide training 
in some of these areas.\3\ Strong ongoing support is vital to maintain 
and expand programs focused on these subspecialties, and reductions in 
funding slow the ability to train providers in areas of need. During a 
period of reduced CHGME funding earlier in this decade, some hospitals 
reported that their resident FTE levels, which had been increasing in 
response to demand, leveled off and declined.
---------------------------------------------------------------------------
    \3\ Children's Hospital Association fact sheet, ``Percentage of 
Pediatric Specialists Trained at CHGME Hospitals'' , 2012.
---------------------------------------------------------------------------
    Even with CHGME, children's hospitals incur significant additional 
costs to subsidize their teaching mission, costs that can be as high as 
$40 million annually above what they receive from CHGME. These 
additional costs are particularly difficult to bear given that 
children's hospitals are typically large Medicaid providers, with more 
than 50 percent of the average number of days of care covered by 
Medicaid. Medicaid reimbursement levels in many States remain well 
below those of private insurance and other government programs, 
creating another significant fiscal challenge for children's hospitals, 
particularly as State Medicaid programs have been scaled back 
significantly in recent years. Without CHGME, hospitals would be at 
risk of having to cut back training experiences and patient care 
services impacting children's access to care and the future pediatric 
workforce.
    Furthermore, there are currently no adequate substitutes for CHGME 
to support training at freestanding children's hospitals. Other 
potential sources of support, such as Medicaid GME--which has been 
significantly reduced or eliminated in many States--or competitive 
grant funding, are not available to many children's hospitals and 
cannot support training on the scale necessary to meet current and 
future workforce needs.
    The White House's fiscal year 2017 budget proposes converting CHGME 
to a mandatory funding program, funded at a level of $295 million 
annually. Children's hospitals applaud the White House for recognizing 
the need to provide steady, predictable funding for pediatric training. 
We also are pleased that the President has supported a funding level 
consistent with that provided by Congress in fiscal year 2016. 
Children's hospitals look forward to working with Congress on long-term 
steps to strengthen CHGME. However, in the present term, we believe 
that it is vital that Congress continue its history of strong 
bipartisan support of the program through the annual appropriations 
process.
    The CHGME program is critical to protecting gains in pediatric 
health and ensuring access to care for children nationwide. We 
recognize that the current budget climate is extraordinarily 
challenging and that Congress has a responsibility to carefully 
consider the Nation's spending priorities. However, now is the time to 
take a step forward in pediatric medicine and ensure our children have 
access to the healthcare services they need.
    The Children's Hospital Association, and the children and families 
we serve, thank you for your past support for this critical program and 
your leadership in protecting children's health. We respectfully 
request that the subcommittee continue its history of bipartisan 
support for children's health and fund CHGME at its authorized funding 
level of $300 million in the fiscal year 2017 Labor-HHS appropriations 
bill.
    The Children's Hospital Association advances child health through 
innovation in the quality, cost and delivery of care. Representing more 
than 220 children's hospitals, the Association is the voice of 
children's hospitals nationally. The Association champions public 
policies that enable hospitals to better serve children and is the 
premier resource for pediatric data and analytics, driving improved 
clinical and operational performance of member hospitals. Formed in 
2011, Children's Hospital Association brings together the strengths and 
talents of three organizations: Child Health Corporation of America 
(CHCA), National Association of Children's Hospitals and Related 
Institutions (NACHRI) and National Association of Children's Hospitals 
(N.A.C.H.). The Children's Hospital Association has offices in 
Washington, DC, and Overland Park, Kansas.
                                 ______
                                 
  Prepared Statement of the Coalition for Clinical and Translational 
                                Science
    Chairman Blunt, Ranking Member Murray, and distinguished members of 
the subcommittee, thank you for your time and your consideration of the 
priorities of the clinical and translational research community as you 
work to craft the fiscal year 2017 L-HHS appropriations bill. The 
community would like to thank you for your past support of the full 
spectrum of medical research, including the $2.1 billion funding 
increase for NIH in fiscal year 2016. Our fiscal year 2017 
recommendations include:
  --CCTS joins the broader medical research and public health community 
        in asking Congress to provide NIH with $34.5 billion, an 
        increase of $2.4 billion over fiscal year 2016, with 
        proportional increases for various Institutes and Centers.
    --Please provide the National Center for Advancing Translational 
            Sciences (NCATS) with $736.6 million in fiscal year 2017 (a 
            proportional 7.47 percent increase).
    --Please continue to support and provide meaningful funding 
            increases for the Clinical and Translational Science Awards 
            (CTSA) program at NCATS and oppose the diversion of 
            designated CTSA funds by NCATS to non-CTSA activities at 
            CTSA institutions.
    --Please continue to support and provide meaningful funding 
            increases for the Institutional Development Awards (IDeA) 
            program at the National Institute for General Medical 
            Sciences and the Research Centers in Minority Institutions 
            (RCMI) program at the National Institute on Minority Health 
            and Health Disparities.
  --CCTS joins the broader medical research community in asking 
        Congress to restore funding for the Agency for Healthcare 
        Research and Quality (AHRQ) to the fiscal year 2015 level of 
        $363.7 million (an increase of $29.7 million).
    --Please continue to support research training and career 
            development activities at AHRQ, specifically established 
            ``K'' and ``T'' award mechanisms.
       about the coalition for clinical and translational science
    CCTS is the unified voice of the clinical and translational science 
research community. CCTS is a nationwide, grassroots network of 
dedicated individuals who work together to educate Congress and the 
administration about the value and importance of Federal clinical and 
translational research and research training and career development 
activities. The Coalition includes the Nation's leading health research 
institutions. CCTS's goals are to ensure that the full spectrum of 
medical research is adequately funded, the next generation of 
researchers is well-prepared, and the regulatory and public policy 
environment facilitates ongoing expansion and advancement of the field 
of clinical and translational science.
       association for clinical and translational science (acts)
    ACTS supports investigations that continually improve team science, 
integrating multiple disciplines across the full translational science 
spectrum: from population based and policy research, through patient 
oriented and human subject clinical research, to basic discovery. Our 
goal is to improve the efficiency with which health needs inform 
research and new therapies reach the public.
    ACTS is the academic home for the disciplines of research 
education, training, and career development for the full spectrum of 
translational scientists. Through meetings, publications, and 
collaborative efforts, ACTS will provide a forum for members to 
develop, implement, and evaluate the impact of research education 
programs.
    ACTS provides a strong voice to advocate for translational science, 
clinical research, patient oriented research, and research education 
support. We will engage at the local, State, and Federal levels and 
coordinate efforts with other professional organizations.
    ACTS will promote investigations and dissemination of effective 
models for mentoring future generations of translational scientists. 
Through collaborative efforts, ACTS will provide a forum for members to 
share studies, promote best practices, and optimize professional 
relationships among trainees and mentors.
                   the clinical research forum (crf)
    CRF was formed in 1996 to discuss unique and complex challenges to 
clinical research in academic health centers. Over the past decade, it 
has convened leaders in clinical research annually and has provided a 
forum for discussing common issues and interests in the full spectrum 
of research. Through its activities, the Forum has enabled sharing of 
best clinical practices and increasingly has played a national advocacy 
role in support of the boarder interests and needs of clinical 
research.
    Governed by a board of directors constituted of clinical 
researchers from 13 member institutions, CRF has grown to 60 members 
from academia, industry, and volunteer health organizations. CRF 
engages leaders in the clinical research enterprise including leaders 
from government, foundations, other not-for-profit organizations, and 
industry in addressing the challenges and opportunities facing the 
clinical research enterprise.
    Parallel with our widening focus upon the broad needs of the entire 
national clinical research enterprise, CRF is committed to working in 
those areas where it is uniquely positioned to have a significant 
impact. Collaboration with other organizations with similar goals and 
synergizing with their efforts strengthens all approaches to the issues 
facing clinical research.
                     national institutes of health
    This Nation has a proud history as a global leader in medical 
research and biotechnology. This leadership has provided our country 
with cutting-edge patient care, high-quality jobs, and meaningful 
economic growth. The Milliken Institute recently calculated that every 
dollar invested in NIH returns about a $1.70 in economic output in the 
short term and as much as $3.20 long-term. Crucially, through a robust 
external research program, NIH resources flow out to the States where 
the benefit of the funding infusion is felt on the local level.
    NIH's impact on public health has been profound. Conditions once 
considered a death-sentence can now be managed, survival rates for 
patients with life-threatening diseases have increased dramatically, 
and additional innovative therapies and diagnostic tools come to market 
each year. NIH has been successful, but much more can be done. Please 
provide NIH with at least $34.5 billion in fiscal year 2017 so ongoing 
research projects can be adequately supported and new research 
activities can be initiated.
                 the full spectrum of medical research
Clinical and Translational Science Awards (CTSAs)
    Thank you for providing CTSA's with $500 million in fiscal year 
2016. We hope you will provide a proportional increase of nearly 7 
percent for CTSAs in fiscal year 2017. Further, we hope funds 
appropriated by Congress for CTSAs continue to be used by NCATS for 
infrastructure and core long-term activities at CTSA sites.
    NIH's CTSA Program, which is housed within the National Center for 
Advancing Translational Sciences (NCATS), is transforming the 
efficiency and effectiveness of clinical and translational research. 
Since its establishment with a handful of centers in 2006, the CTSA 
program has expanded to 62 of the leading medical research institutions 
located across the country. These centers are linked together and work 
in concert to improve human health by energizing the research and 
training environment to innovate and enhance the quality of clinical 
and translational research.
    Recently, based on a recommendation by your subcommittee, the 
Institute of Medicine (IOM) released a review of the CTSA program. The 
report entitled, The CTSA Program at NIH: Opportunities for Advancing 
Clinical and Translational Research, spoke favorably of the CTSA effort 
and made the following recommendations to improve the program:
  --Strengthen NCATS leadership of the CTSA program;
  --Reconfigure and streamline the CTSA Consortium;
  --Build on the strengths of individual CTSAs across the spectrum of 
        clinical and translational research;
  --Formalize and standardize evaluation processes for individual CTSAs 
        and the CTSA Program;
  --Advance innovation in education and training programs;
  --Ensure community engagement in all phases of research; and
  --Strengthen clinical and translational research relevant to child 
        health.
    CCTS supports the recommendations of the IOM report and the 
organization is hopeful these changes will continue to be implemented 
quickly. Another emerging opportunity is to promote collaboration 
between CTSAs and all NIH Institutes and Centers. Further, when the 
CTSA program was authorized, Congress indicated that the consortium 
would be considered fully-funded when it received an annual 
appropriation of $750 million.
Institutional Development Awards Program (IDeA)
    Thank you for providing the IDeA program with a meaningful funding 
increase in fiscal year 2016. We hope you will continue to invest in 
this important program for fiscal year 2017.
    The IDeA program broadens the geographic distribution of NIH 
funding for biomedical research. The program fosters health-related 
research and enhances the competitiveness of investigators at 
institutions located in States in which the aggregate success rate for 
applications to NIH has historically been low. The program also serves 
unique populations--such as rural and medically underserved 
communities--in these States. The IDeA program increases the 
competitiveness of investigators by supporting faculty development and 
research infrastructure enhancement at institutions in 23 States and 
Puerto Rico. Through Centers of Biomedical Research Excellence and IDeA 
Networks for Biomedical Research Excellence, the IDeA program builds 
important infrastructure and works to advance the field of clinical and 
translational research.
            research centers in minority institutions (rcmi)
    Thank you for providing over $2 million in new funding for RCMI in 
fiscal year 2016. Please provide another important funding increase for 
this emerging program in fiscal year 2017.
    RCMI develops and strengthens the research infrastructure of 
minority institutions by expanding human and physical resources for 
conducting basic, clinical, and translational research. It provides 
grants to institutions that award doctoral degrees in the health 
professions or health-related sciences and have a significant 
enrollment of students from racial and ethnic minority groups that are 
underrepresented in biomedical sciences. The RCMI program serves the 
dual purpose of bringing more racial and ethnic minority scientists 
into mainstream research and promoting minority health research because 
many of the investigators at RCMI institutions study diseases that 
disproportionately affect minority populations.
                                 ______
                                 
     Prepared Statement of the Coalition of Northeastern Governors
    The Coalition of Northeastern Governors (CONEG) is pleased to share 
with the Subcommittee on Labor, HHS, Education, and Related Agencies 
this testimony for the hearing record regarding fiscal year 2017 
appropriations for the Low Income Home Energy Assistance Program 
(LIHEAP). The Governors recognize the challenging fiscal decisions 
facing Congress this year, and deeply appreciate the subcommittee's 
long-standing support for this vital program. They also recognize the 
struggles that millions of the Nation's low-income households face to 
safely heat and cool their homes. Therefore, they urge the subcommittee 
to provide no less than $4.7 billion in regular LIHEAP block grant 
funding in fiscal year 2017. They also urge the subcommittee to provide 
these funds in a manner consistent with the LIHEAP statutory objective 
of assisting those households with the highest energy burden; and to 
ensure that the full appropriated funds are released to the States in a 
timely manner.
    LIHEAP provides a vital lifeline to the most vulnerable 
households--the elderly, disabled and families with children under the 
age of 5. Moreover, approximately 20 percent of LIHEAP households have 
at least one member who served this country in the military. Many of 
these LIHEAP-eligible households live on fixed, very modest incomes: 
approximately $24,000 annually for a two-person household and $36,450 
for four persons. Even though the average cost of heating a home (for 
all fuel types) slightly decreased in the past year from $880 to a 
projected $779 for the just-ended heating season, many LIHEAP 
households across the country still struggle to pay their heating 
bills.
    Households in the Northeast face some of the Nation's highest home 
heating bills due to the extended winter heating season and heating 
fuel prices that typically exceed national averages regardless of the 
fuel used. Approximately 30 percent of households in the northeast 
States rely upon delivered fuels, such as home heating oil or propane. 
For these delivered-fuel households, the average cost for heating their 
home--$1,282 for home heating oil; $1,368 for propane--is much higher 
than the national average cost to heat a home. Low-income households 
that are dependent on delivered fuels face additional challenges in 
managing their home-heating costs. Compared to homes heating with 
natural gas or electricity, these delivered-fuel households are less 
likely to have the option of payment plans, access to utility 
assistance programs, and the protection of utility service shut-off 
moratoria during the heating season. LIHEAP funds are particularly 
critical for these households, as the typical LIHEAP benefit covers, on 
average, one-third of the total home heating bill for the season. If 
LIHEAP funds are not available to these households, the fuel delivery 
truck simply does not come.
    Reducing home energy costs also presents unique challenges to 
northeast States. The region has some of the country's oldest homes, 
many of which have structural issues that make them ineligible for 
weatherization assistance. Low-income families are more likely to rent 
than to own a home and therefore have less ability or incentive to make 
significant energy efficiency upgrades. In addition, the cost of 
switching to less expensive heating fuels is often prohibitive and is 
simply not possible in rural and metropolitan areas not served by 
natural gas infrastructure.
    State LIHEAP programs continue to develop innovate ways to stretch 
scarce LIHEAP dollars while providing a meaningful benefit to those 
households with the greatest need. States have negotiated with fuel 
vendors to receive discounts on delivered fuels and have worked with 
utilities to develop payment plans to reduce the possibility of service 
shut-offs once the moratoria end. Even with these cost-efficient 
changes, in recent years States have had to take actions such as 
tightening program eligibility, closing the program early, and reducing 
benefit levels.
    In summary, the CONEG Governors appreciate the subcommittee's 
continued support for LIHEAP. They urge you to fund the core block 
grant program at the level of no less than $4.7 billion in fiscal year 
2017, and to provide the funds in a manner that is consistent with the 
LIHEAP statutory objective of addressing those households with the 
highest energy burden while also ensuring that the full appropriated 
funds are released to the States in a timely manner.
                                 ______
                                 
    Prepared Statement of the College on Problems of Drug Dependence
    Mr. Chairman and members of the subcommittee, thank you for the 
opportunity to submit testimony to the subcommittee in support of the 
research funded by the National Institute on Drug Abuse. The College on 
Problems of Drug Dependence (CPDD), a membership organization with over 
1000 members, has been in existence since 1929. It is the longest 
standing group of scholars in the United States addressing problems of 
drug dependence and abuse. The organization serves as an interface 
among governmental, industrial and academic communities maintaining 
liaisons with regulatory and research agencies as well as educational, 
treatment, and prevention facilities in the drug abuse field.
    Recognizing that so many health research issues are inter-related, 
we request that the subcommittee provide at least $34.5 billion for the 
National Institutes of Health (NIH) and within that amount a 
proportionate increase for the National Institute on Drug Abuse, in 
your fiscal year 2017 Labor, Health and Human Services, Education and 
Related Agencies appropriations bill. We also respectfully request the 
inclusion of the following NIDA specific report language.
    Opioid Misuse and Addiction. The Committee is concerned about the 
escalating epidemic of prescription opioid and heroin use, addiction 
and overdose in the U.S. Nearly 130 people die each day in this country 
from opioid overdose, making it one of the most common causes of death 
for adolescents and young adults. The Committee appreciates the 
important role that research can and should play in the various Federal 
initiatives aimed at this crisis. The Committee urges NIDA to (1) 
continue funding research on medications to alleviate pain, including 
the development of those with reduced abuse liability; (2) as 
appropriate, work with private companies to fund innovative research 
into such medications; and (3) report on what we know regarding the 
transition from opioid analgesics to heroin abuse and addiction within 
affected populations.
    Adolescent Brain Development. The Committee recognizes and supports 
the Adolescent Brain and Cognitive Development (ABCD) Study. We know 
that the brain continues to develop into the mid-twenties. However, we 
do not yet know enough about the dramatic brain development that takes 
place during adolescence and how the various experiences children are 
exposed to during this time (e.g., sports injuries, lack of sleep, 
marijuana or other substance use) interact with each other and a 
child's biology to affect brain development and, ultimately, social, 
behavioral, health and other outcomes. As part of the Collaborative 
Research on Addiction (CRAN), a trans-NIH consortium involving NIDA, 
NIAAA, and NCI, and in partnership with NICHD, NINDS, NIMH, NIMHD, and 
OBSSR, the ABCD study intends to address this knowledge gap. As the 
largest ever longitudinal brain-imaging study of youth, the ABCD study 
will follow approximately 10,000 U.S. children from ages 9-10 into 
early adulthood, who will provide behavioral, neuroimaging, genetic, 
and other health data throughout development. The ABCD study will yield 
critical insights into the foundational aspects of adolescence that 
shape life trajectories. The committee also recommends and recognizes 
that the cost of this comprehensive study should not inhibit 
investigator initiated studies or any potential special appropriation 
for its ongoing support.
    Marijuana Research. The Committee is concerned that marijuana 
public policies in the States (medical marijuana, recreational use, 
etc.) are being changed without the benefit of scientific research to 
help guide those decisions. The Committee is also concerned that 
restrictions associated with Schedule 1 of the Controlled Substance Act 
effectively limit the amount or type of research that can be conducted 
on marijuana or its component chemicals. NIDA is encouraged to continue 
supporting a full range of research on the effects of marijuana and its 
components, including policy research focused on policy change and 
implementation across the country. The Committee also directs NIDA to 
provide a short report on the barriers to research that result from the 
classification of marijuana as a Schedule 1 substance.
    Raising Awareness and Engaging the Medical Community in Drug Abuse 
and Addiction Prevention and Treatment. Education is a critical 
component of any effort to curb drug use and addiction, and it must 
target every segment of society, including healthcare providers 
(doctors, nurses, dentists, and pharmacists), patients, and families. 
Through its NIDAMeD initiative, NIDA is advancing addiction awareness, 
prevention, and treatment in primary care practices through seven 
Centers of Excellence for Physician Information. Intended to serve as 
national models, these centers target physicians-in-training, including 
medical students and resident physicians in primary care specialties 
(e.g., internal medicine, family practice, and pediatrics). NIDA also 
developed, in partnership with the Office of National Drug Control 
Policy, two online continuing medical education courses on safe 
prescribing for pain and managing patients who abuse prescription 
opioids. These courses were viewed by over 200,000 individuals and 
completed for credit by over 100,000 clinicians combined. The Committee 
continues to be pleased with NIDAMed, and urges the Institute to 
continue its focus on activities to provide physicians and other 
medical professionals with the tools and skills needed to incorporate 
drug abuse screening and treatment into their clinical practices.
    Medications Development. The Committee recognizes that new 
technologies are required for the development of next-generation 
pharmaceuticals. In the context of NIDA funding, chief among these are 
NIDA's current approaches to develop viable immunotherapeutic or 
biologic (e.g., bioengineered enzymes) approaches for treating 
addiction. The goal of this research is the development of safe and 
effective vaccines or antibodies that target specific addictive drugs, 
like nicotine, cocaine, and heroin, or drug combinations. The Committee 
is encouraged by this approach--if successful, immunotherapies, alone 
or in combination with other medications, behavioral treatments, or 
enzymatic approaches, stand to revolutionize how we treat, and 
ultimately prevent addiction.
    Drug Treatment in Justice System Settings. The Committee 
understands that providing evidence-based treatment for substance use 
disorders offers the best alternative for interrupting the drug use/
criminal justice cycle for offenders with drug problems. Untreated 
substance using offenders are more likely to relapse into drug use and 
criminal behavior, jeopardizing public health and safety and taxing 
criminal justice system resources. Treatment has consistently been 
shown to reduce the costs associated with lost productivity, crime, and 
incarceration caused by drug use. This reality represents a significant 
opportunity to intervene with a high-risk population. In 2013 NIDA 
launched the Juvenile Justice Translational Research on Interventions 
for Adolescents in the Legal System (JJ-TRIALS) program to identify and 
test strategies for improving the delivery of evidence-based substance 
abuse and HIV prevention and treatment services for justice-involved 
youth. The JJ-TRIALS initiative will provide insight into the process 
by which juvenile justice and other service settings can successfully 
adopt and adapt existing evidence-based programs and strategies to 
improve treatment for at-risk youth. The Committee supports this 
important work and asks for a progress report in the next 
appropriations cycle.
    Electronic Cigarettes. The Committee understands that electronic 
cigarettes (e-cigarettes) are increasingly popular among adolescents. 
Lack of regulation, easy availability, and a wide array of cartridge 
flavors may make them particularly appealing to this age group. In 
addition to the unknown health effects, early evidence suggests that e-
cigarette use may serve as an introductory product for youth who then 
go on to use other tobacco products, including conventional cigarettes, 
which are known to cause disease and lead to premature death. Early 
evidence also reveals that these devices are widely used as tools for 
smoking derivatives of marijuana (hash oil, ``shatter,'' etc.) The 
Committee requests that NIDA fund research on the use and consequences 
of these devices.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our Nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease --this new knowledge has helped to correctly 
emphasize the fact that drug addiction is a serious public health issue 
that demands strategic solutions. By supporting research that reveals 
how drugs affect the brain and behavior and how multiple factors 
influence drug abuse and its consequences, scholars supported by NIDA 
continue to advance effective strategies to prevent people from ever 
using drugs and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern include the recent increase in lethalities due 
to heroin and synthetic fentanyl, as well as the continued abuse of 
prescription opioids and the recent increase in availability of 
designer drugs and their deleterious effects. The need to increase our 
knowledge about the effects of marijuana is most important now that 
decisions are being made about its approval for medical use and/or its 
legalization. We support NIDA in its efforts to find successful 
approaches to these difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2017 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
             Prepared Statement of the Columbia University
    On behalf of my colleagues at Columbia University, I would like to 
thank this subcommittee and the rest of your congressional colleagues 
for the long standing support this subcommittee has provided to this 
Nation's biomedical research enterprise. Your support of the National 
Institutes of Health (NIH) and other research agencies is vital to the 
long term health of this Nation.
    I am very pleased to submit this testimony which recommends funding 
the NIH in fiscal year 2017 at a level of $34.5 billion. The fiscal 
year 2017 appropriation for NIH must build on and expand the agency's 
capacity to fund research in order to improve quality of life, address 
the rising costs of caring for our aging population, and reduce illness 
and disability.
    The National Institutes of Health (NIH) is the largest source of 
funding for biomedical research in the world. More than 83 percent of 
NIH funds are distributed through competitive grants to over 300,000 
scientists employed at universities, medical schools, and other 
research institutions in all 50 States and nearly every congressional 
district. To date, 145 Nobel Laureates were funded by NIH over the 
course of their careers, including the 2014 winner of the Nobel Prize 
in Chemistry. My own research has been supported almost entirely by NIH 
grants over a period of nearly 40 years. NIH has produced an 
outstanding legacy of discoveries that have improved health, saved 
lives, and generated new knowledge. Many of these advances arose from 
scientists investigating questions designed to explain fundamental 
molecular, cellular, and biological mechanisms. Research supported by 
NIH has also expanded our understanding of the molecular roots of 
various cancers and led to important insights into how microbial 
communities affect a range of chronic diseases including obesity and 
diabetes. In addition, research supported by NIH led to the development 
of innovative technologies and created entirely new global industries 
that are a critical component of our Nation's economic growth. 
Investment in biomedical research funded by NIH has supported 
discoveries that lowered death and disability from polio, heart 
disease, and cancer, prolonging life and reducing suffering. New 
scientific breakthroughs have given us the opportunity to dramatically 
accelerate desperately needed progress on therapies for thousands of 
diseases and conditions.
    One example of the importance of NIH funding is the developing 
Precision Medicine Initiative which is aimed at tailoring medical care 
to the individual patient. The Precision Medicine Initiative will 
pioneer a new model of patient-powered research that promises to 
accelerate biomedical discoveries and provide clinicians with new 
tools, knowledge, and therapies to select which treatments will work 
best for which patients.
    Most medical treatments have been designed for the ``average 
patient.'' As such treatments can be very successful for some patients 
but not for others. This is changing with the emergence of precision 
medicine that takes into account individual differences in people's 
genes, environments, and lifestyles. Precision medicine gives 
clinicians tools to better understand the complex mechanisms underlying 
a patient's health, disease, or condition, and to better predict which 
treatments will be most effective.
    Advances in precision medicine have already led to powerful new 
discoveries and several new treatments that are tailored to specific 
characteristics of individuals, such as a person's genetic makeup, or 
the genetic profile of an individual's tumor. This is leading to a 
transformation in the way we can treat diseases such as cancer. 
Patients with breast, lung, and colorectal cancers, as well as 
melanomas and leukemias, for instance, routinely undergo molecular 
testing as part of patient care, enabling physicians to select 
treatments that improve chances of survival and reduce exposure to 
adverse effects.
    Translating initial successes to a larger scale will require a 
coordinated and sustained national effort. Through collaborative public 
and private efforts, the Precision Medicine Initiative (PMI) will 
leverage advances in genomics, emerging methods for managing and 
analyzing large data sets while protecting privacy, and health 
information technology to accelerate biomedical discoveries. The 
Initiative will also engage a million or more Americans to volunteer to 
contribute their health data to improve health outcomes, fuel the 
development of new treatments, and catalyze a new era of data-based and 
more precise medical treatment.
    A key feature of the PMI is to build a large research cohort that 
will provide the platform for expanding our knowledge of precision 
medicine approaches and that will benefit the Nation for many years to 
come. In March 2015, NIH Director, Dr. Francis Collins formed the PMI 
Working Group of the Advisory Committee to the NIH Director to develop 
a plan for creating and managing such a research cohort. In September 
2015, this working group released its report which identified a number 
of high value scientific opportunities including:
  --Development of quantitative estimates or risk for a range of 
        diseases by integrating environmental exposures, genetic 
        factors, and gene-environment interactions;
  --Identification of determinants of individual variation in efficacy 
        and safety of commonly used therapeutics;
  --Discovery of biomarkers that identify people with increased or 
        decreased risk of developing common diseases;
  --Use of mobile health technologies to correlate activity, 
        physiologic measures and environmental exposures with health 
        outcomes; determination of the health impact of heterozygous 
        loss of function mutations;
  --Development new disease classifications and relationships;
  --Empowerment of participants with data and information to improve 
        their own health; and
  --Creation of a platform to enable trials of targeted therapy.
               precision medicine at columbia university
    Precision medicine in practice and research at Columbia University 
is realized via collaborations across all of our academic centers, 
ranging from law, business, ethics and engineering to the basic 
sciences, converging on clinical practice. Our diverse scientific 
expertise readily contributes to enhancing precision medicine: 
genomics, proteomics, bioinformatics, systems biology, data and 
computational science, as well as core science, engineering, and other 
disciplines. The results should improve patient outcomes, reduce 
adverse treatment effects, and yield greater patient satisfaction.
    In particular, Columbia University Medical Center's (CUMC's) 
efforts play a vital role in Columbia University's institution-wide 
priority to realize the potential of precision medicine. Through the 
efforts of the Precision Medicine Task Force, the University's internal 
expertise is coordinated and growing. The synergies of CUMC 
specialists' biomedical expertise with that of other University faculty 
and leaders will define the medical, legal, policy, and economic 
implications anticipated from the applications of precision medicine.
    Many of the more than 40 state-of-the-art shared research 
facilities within CUMC participate in precision medicine initiatives. 
Already our discoveries are making a difference. For example, using 
genomic analysis, scientists sequence the DNA of individual tumors to 
find FDA-approved drugs likely to target crucial areas of each tumor's 
genetics. In addition, scientists developed a way to recreate an 
individual's immune system in a mouse, an unprecedented tool for 
customized analysis of autoimmune diseases such as type 1 diabetes. The 
tool also may be useful to analyze a patient's response to existing 
treatments or to develop new therapies.
    Among CUMC's plans for precision medicine is a comprehensive 
biological repository that will store and allow analysis of 100,000 
patient specimens to enable translational researchers to develop new 
therapies that, in turn, will transform the way clinicians diagnose and 
treat patients. Along with our clinical partner, the New York-
Presbyterian Hospital, we are founding members of the New York Genome 
Center, which has brought together all of the New York academic, 
medical, and industry leaders in a consortium dedicated to translating 
genomic research into clinical solutions for treating disease.
                          concluding thoughts
    The rising costs of drug development and healthcare in the U.S. 
suggest that a new model of clinical care is needed that will rely on 
robust and innovative health research. Drug discovery has slowed, and 
only a small fraction of proposed medications is successfully 
translated into approved and prescribed therapeutics. Clinical trials 
of new therapeutics may often be underpowered due to unrecognized 
heterogeneity in disease pathogenesis among enrolled patients such that 
drugs that are highly beneficial for a definable subset are rejected 
because the majority of patients in the trial fail to respond. The 
discovery of genetic factors underlying disease can be used to identify 
drug targets as well as to selectively give those drugs to patients 
that are most likely to have the greatest efficacy with the least 
adverse effects. Understanding the genetics of disease and biomarkers 
will allow us to rationally select patient groups that are most likely 
to respond to particular agents, not only improving ``numbers'' (e.g., 
lower cholesterol) but also improving health outcomes (e.g., reduced 
heart attacks) and quality of life.
    To be successful, it would be ideal and cost effective to study a 
single, very large cohort that would provide sufficient power to study 
ostensibly all relatively common diseases within a single cohort. The 
barriers to such a study have been the relatively high cost of 
ascertaining cohort members, collecting comprehensive clinical and 
experimental data, and following participants over time. Over the last 
decade, however, a number of technological advances have converged to 
dramatically reduce the barriers to the assembly, evaluation, and 
analysis of cohorts of one million or more people--including 
information technology improvements related to data storage and 
computation; vast improvements in DNA sequencing; and the emergence of 
electronic health records.
    Given these rapid and ongoing transformations in medicine, 
technology, and society, the time is right for the U.S. to undertake an 
ambitious expanded research agenda focused on development and 
implementation of precision medicine to improve the health of the 
Nation.
    We urge the subcommittee to provide the NIH with an appropriation 
totaling $34.5 billion to enable the NIH and its partners in the 
biomedical research enterprise to develop better, more targeted, more 
effective, and more efficient healthcare for society.
    Thank you for the opportunity to provide this information to the 
subcommittee.

    [This statement was submitted by Dr. Tom Maniatis, Director, 
Columbia Precision Medicine Initiative.]
                                 ______
                                 
                Prepared Statement of Community Servings
    We are pleased to submit this testimony to the members of this 
subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Community Servings is part of a nationwide coalition, the Food is 
Medicine Coalition, of over 80 food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide half a million 
medically tailored, home delivered meals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion

    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by David B. Waters, CEO, Community 
Servings.]
                                 ______
                                 
  Prepared Statement of the Consortium of Social Science Associations
    Mr. Chairman and members of the subcommittee, the Consortium of 
Social Science Associations (COSSA) appreciates and welcomes the 
opportunity to comment on the fiscal year 2017 appropriations of the 
agencies under the subcommittee's jurisdiction. COSSA recommends that 
the National Institutes of Health (NIH) receive at least $34.6 billion 
in fiscal year 2017 and urges the subcommittee to appropriate $7.8 
billion for the Centers for Disease Control and Prevention (CDC), $170 
million for the National Center for Health Statistics (NCHS), $364 
million for the Agency for Healthcare Research and Quality (AHRQ), $728 
million for the Institute of Education Sciences (IES), and $78.7 
million for the Department of Education's International Education and 
Foreign Language programs.
    COSSA serves as a united voice for a broad, diverse network of 
organizations, institutions, communities, and stakeholders who care 
about a successful and vibrant social science research enterprise. It 
represents the collective interests of all fields of social and 
behavioral science research, including but not limited to sociology, 
anthropology, political science, psychology, economics, statistics, 
language and linguistics, population studies, law, communications, 
educational research, criminology and criminal justice research, 
geography, history, and child development. It is appreciative of the 
Subcommittee's and the Congress' continued support of NIH, CDC, NCHS, 
AHRQ, IES, and Title VI and Fulbright-Hays programs. Strong, sustained 
funding for these agencies is essential to our national priorities of 
better health and economic revitalization.
NIH (at least $34.6 billion), U.S. Department of Health and Human 
        Services
    Since 2003, NIH funding has declined by 23 percent after adjusting 
for biomedical inflation, despite recent budget increases provided by 
the Congress the past two fiscal years. The agency's budget remains 
lower than it was in fiscal year 2012 in actual dollars. COSSA 
appreciates the subcommittee's leadership and its long-standing 
bipartisan support of NIH, as demonstrated by the $2 billion increase 
provided in the fiscal year 2016 omnibus spending bill. There are, 
however, ongoing and emerging health challenges confronting the United 
States and the world. To that end, COSSA believes that to address these 
challenges the NIH requires a funding level of at least $34.6 billion 
in fiscal year 2017, representing 5 percent real growth above the 
projected rate of biomedical inflation.
    As this subcommittee knows, the NIH mission is to support 
scientifically rigorous, peer/merit-reviewed, investigator-initiated 
research, including basic and applied behavioral and social science 
research, in fulfilling its mission: ``Science in pursuit of 
fundamental knowledge about the nature and behavior of living systems 
and the application of that knowledge to enhance health, lengthen life 
and reduce illness and disability.'' COSSA, however, remains extremely 
concerned about continued criticism of the NIH's funding decisions and 
the accompanying mischaracterization of NIH-supported research. The 
ongoing targeting of specific grants produces a chilling effect across 
the scientific community.
    The behavioral and social sciences regularly make important 
contributions to the well-being of this Nation. Due in large part to 
the behavioral and social science research sponsored by the NIH, we are 
now aware of the enormous role behavior plays in our health. At a time 
when genetic control over disease is tantalizingly close but not yet 
possible, knowledge of the behavioral influences on health is a crucial 
component in the Nation's battles against the leading causes of 
morbidity and mortality: obesity, heart disease, cancer, AIDS, 
diabetes, age-related illnesses, accidents, substance abuse, and mental 
illness.
    The fundamental understanding of how disease works, including the 
impact of social environment on disease processes, underpins our 
ability to conquer devastating illnesses. Perhaps the grandest 
challenge we face is to understand the brain, behavior, and society-- 
from responding to short-term pleasures to self-destructive behavior, 
such as addiction, to lifestyle factors that determine the quality of 
life, infant mortality rate and longevity. Congress' continued support 
of the BRAIN (Brain Research through Advancing Innovative 
Neurotechnologies) initiative is an important first step to begin to 
address these challenges.
    Thanks to strong congressional commitment to the NIH in years past, 
our knowledge of the social and behavioral factors surrounding chronic 
disease health outcomes is steadily increasing. The NIH's behavioral 
and social science portfolio has emphasized the development of 
effective and sustainable interventions and prevention programs 
targeting those very illnesses that are the greatest threats to our 
health, but the work is just beginning.
    COSSA continues to applaud the administration's Precision Medicine 
Initiative (PMI) and the NIH's involvement of its Office of Behavioral 
and Social Sciences Research (OBSSR) in the planning phase of this 
million-person cohort, including its commitment to including 
behavioral, physiological, and environmental measures. To this end, 
recent advances in mobile and wireless sensor technologies, also known 
as mHealth, to assess these behavioral, physiological, and 
environmental parameters are an integral aspect of this initiative. 
This technology has great potential to transform medical research. 
OBSSR has led the NIH's efforts in using, understanding, and training 
scientists in the use of mHealth which allows for more rapid and 
accurate assessment in modifying behavior, biological states, and 
contextual variables. Its support of the NIH mHealth Training 
Institutes is designed to break down to scientific silos by bringing 
together scientists from diverse fields to enhance the quality of 
mHealth research.
CDC ($7.8 billion) and NCHS ($170 million), U.S. Department of Health 
        and Human Services
    COSSA urges the subcommittee to appropriate $7.8 billion for the 
Centers for Disease Control and Prevention (CDC), including $170 
million for the CDC's National Center for Health Statistics. As the 
country's leading health protection and surveillance agency, the CDC 
works with State, local, and international partners to keep Americans 
safe and healthy. CDC relies on insights from the social and behavioral 
sciences to ``explore the effects of behavioral, social, and cultural 
factors on public health problems'' and to rigorously evaluate public 
health interventions, policies, and programs.\1\
---------------------------------------------------------------------------
    \1\ Deborah Holtzman, M. Neumann, E. Sumartojo, and A. Lansky, 
``Behavioral and Social Sciences and Public Health at CDC,'' Morbidity 
and Mortality Weekly Report, December 22, 2006, http://www.cdc.gov/
mmwr/preview/mmwrhtml/su5502a6.htm.
---------------------------------------------------------------------------
    Scientists from fields ranging from psychology, sociology, 
anthropology, and geography to health communications, social work, and 
demography work in every CDC Center to design, analyze, and evaluate 
behavioral surveillance systems, public health interventions, and 
health promotion and communication programs using a variety of both 
quantitative and qualitative methods. These scientists play a key role 
in the CDC's surveillance and monitoring efforts, which collect and 
analyze data to better target public health prevention efforts, and in 
identifying and understanding health disparities. The social and 
behavioral sciences also play an important role in the evaluation of 
CDC programs, helping policymakers make informed, evidence-based 
decisions on how to prioritize in a resource-scarce environment.
    COSSA requests $170 million in budget authority for the National 
Center for Health Statistics (NCHS), the Nation's principal health 
statistics agency. NCHS collects data on chronic disease prevalence, 
healthcare disparities, emergency room use, teen pregnancy, infant 
mortality, causes of death, and rates of insurance, to name a few. It 
provides critical data on all aspects of our healthcare system through 
data cooperatives and surveys that serve as the gold standard for data 
collection around the world. Data from NCHS surveys like the National 
Health Interview Survey (NHIS), the National Health and Nutrition 
Examination Survey (NHANES), and the National Vital Statistics System 
(NVSS) are used by agencies across the Federal Government, State and 
local governments, public health officials, Federal policymakers, and 
demographers, epidemiologists, health services researchers, and other 
scientists.
    The requested increase for NCHS' budget would be used to support 
NCHS's major data collection systems--the National Vital Statistics 
System, the National Health Interview Survey, the National Health and 
Nutrition Examination Survey, and the National Health Care Surveys. The 
increase would also allow NCHS to continue its expansion of electronic 
death reporting, which improves the availability and specificity of 
data on deaths of public health importance, such as from prescription 
drug overdoses.
AHRQ ($364 million), U.S. Department of Health and Human Services
    COSSA urges the subcommittee to appropriate $364 million for the 
Agency for Healthcare Research and Quality (AHRQ). AHRQ funds research 
on improving the quality, safety, efficiency, and effectiveness of 
America's healthcare system. It is the only agency in the Federal 
Government with the expertise and explicit mission to fund research on 
improving healthcare at the provider level (i.e., in hospitals, medical 
practices, nursing homes, and other medical facilities). Its work 
complements--not duplicates--research supported by other HHS agencies.
    AHRQ-funded research provides us with the evidence and tools we 
need to tackle some of the healthcare system's greatest challenges. For 
example, AHRQ-funded research:
  --Has been instrumental in reducing healthcare-associated infections 
        (HAIs) by 17 percent in 5 years, translating to 87,000 lives 
        and nearly $20 billion in healthcare costs saved.
  --Improves care for people suffering from multiple chronic 
        conditions, a group that accounts for two-thirds of U.S. 
        healthcare spending.
  --Helps doctors make better decisions and improve patients' health by 
        taking advantage of electronic health records and other IT 
        advances.
    AHRQ reports and data give us vital information about the state of 
the U.S. healthcare system and identify areas we can improve. The 
congressionally-mandated National Healthcare Quality & Disparities 
Report is the only comprehensive sources of information on healthcare 
quality and healthcare disparities among racial and ethnic minorities, 
women, children, and low-income populations. AHRQ's Medical Expenditure 
Panel Survey (MEPS) collects data on the how Americans use and pay for 
medical care, providing vital information on the impact of healthcare 
on the U.S. economy.
    COSSA urges the subcommittee to ensure robust support for AHRQ's 
critical health services research.
IES ($728 million), U.S. Department of Education
    The Institute of Education Sciences is the research arm of the 
Department of Education. COSSA recommends a funding level of $728 
million for IES, which would restore funding for the Regional 
Educational Laboratories and the National Center for Special Education 
Research to the fiscal year 2010 funding level. As this subcommittee 
knows, IES supports research and produces statistics and data to 
improve our understanding of education at many levels--early childhood, 
elementary and secondary education, and higher education. Research 
examining special education, rural education, teacher effectiveness, 
education technology, student achievement, reading and math 
interventions, and many other areas is also supported by IES.
    More important, IES-supported research has substantially improved 
the quality of education research, led to the development of early 
interventions for improving child outcomes, generated and validated 
assessment measures for use with children, and led to the establishment 
of the ``What Works Clearinghouse'' for education research 
(highlighting interventions that work and identifying those that do 
not). There is an increasing demand for evidence-based practices in 
education. Adequate funding for IES would support studies that not only 
increase knowledge of the factors that influence teaching and learning, 
but also apply those findings to improve educational outcomes. Further, 
adequate funding will allow IES to continue to support this important 
research, data collection and statistical analysis, and dissemination. 
The COSSA-recommended funding level will also allow IES to build upon 
existing findings and to conduct much-needed new research.
International Education and Foreign Language Programs ($78.7 million), 
        U.S. Department of Education
    The Department of Education's International Education and Foreign 
Language programs play a significant role in developing a steady supply 
of graduates with deep expertise and high quality research on foreign 
languages and cultures, international markets, world regions, and 
global issues. COSSA urges a total appropriation of $78.7 million 
($70.15 million for Title VI and $8.56 million for Fulbright-Hays) for 
these programs. This sum represents a modest increase in funding, which 
would broaden opportunities for students in international and foreign 
language studies. It would also allow for the strengthening of the 
U.S.' human resource capabilities on strategic areas of the world that 
impact our national security and global economic competitiveness.
    Thank you for the opportunity to present this testimony on behalf 
of the social and behavioral science research community. Please do not 
hesitate to contact me should you require additional information.

            Governing Associations
American Anthropological Association
American Association for Public Opinion Research
American Economic Association
American Educational Research Association
American Political Science Association
American Psychological Association
American Society of Criminology
American Sociological Association
American Statistical Association
Association of American Law Schools
Law And Society Association
Linguistic Society of America
Midwest Political Science Association
National Communication Association
Population Association of America
Society for Personality and Social Psychology
Society for Research in Child Development

    [This statement was submitted by Angela L. Sharpe, MG, Deputy 
Director, Consortium of Social Science Associations.]
                                 ______
                                 
   Prepared Statement of the Corporation for National and Community 
                                Service
    Dear Chairman Blunt and Ranking Member Murray: We write to 
respectfully urge your support for the Corporation for National and 
Community Service (CNCS) in fiscal year 2017 Appropriations and for an 
increased funding level for CNCS to $1.47 billion which includes $720.1 
million for AmeriCorps State and National; $35 million for the NCCC; 
$142.1 million for VISTA; $444.3 million for the National Service Trust 
(Education Awards); and $24.6 million for State Commissions. Thank you 
for the opportunity to provide written testimony for the record. We 
also greatly appreciate your efforts in the fiscal year 2016 Omnibus to 
ensure AmeriCorps received additional funding. While there are many 
critical priorities under your jurisdiction, we know programs like 
CNCS' AmeriCorps meet some of the most vital public needs in 
communities around the country, leverage significant additional private 
funding and resources, and save the government money in the long run. A 
recent study put the return on investment in AmeriCorps at 4:1.
    The Corps Network (TCN) represents the Nation's 130+ Service and 
Conservation Corps (Corps) as they harness the power of youth and 
veterans to tackle some of America's greatest challenges and transform 
their own lives. Corps are comprehensive youth development service 
programs that work in all states and the District of Columbia and 
enroll around 24,000 youth each year. Corps follow a model of adult 
mentors (Crewleaders) guiding crews of youth (Corpsmembers, ages 16-25 
and veterans up to 35) which perform community and conservation service 
projects in urban areas or on public lands. Tied to those projects, 
Corpsmembers receive educational, workforce development, and supportive 
services. Corps enroll diverse Corpsmembers, and prioritize providing 
opportunity for disconnected youth to have opportunities to serve in 
AmeriCorps. Over 60 percent of Corpsmembers were below the poverty 
line, unemployed, not in school and had no High School Diploma/GED, or 
were formerly incarcerated or court-involved.
    As a result of CNCS' AmeriCorps State and National, AmeriCorps 
VISTA, and AmeriCorps NCCC, Corps are able to leverage additional match 
funds to accomplish a wealth of conservation, infrastructure 
improvement, and human service projects identified as critical by local 
communities and partners. Recently, 45 AmeriCorps members with 
Washington Conservation Corps were deployed in response to flooding in 
Grays Harbour County, WA and conducted damage assessments, debris 
removal, and volunteer support. Another instance of severe weather in 
Van, Texas led to the engagement of nine AmeriCorps members from 
American Youth Works Texas Conservation Corps in the set up and 
management of a volunteer reception center that saw more than 1,000 
volunteers. Corps also work on other infrastructure projects like 
transportation and water infrastructure and specifically engage 
veterans in Conservation and Fire Corps and Native Americans through 
conservation and restoration projects on Tribal land like in Acoma 
Pueblo and the Navajo Nation. Many Corps improve and preserve our 
public lands and national parks while others provide energy 
conservation services, including weatherization and alternative energy 
installation. Corps also restore natural habitats and create urban 
parks and gardens.
    In particular, The Corps Network urges your support for the Summer 
Opportunity Youth Initiative. According to CNCS' budget justification, 
``The request includes an Opportunity Youth initiative that would 
enable up to 8,000 disconnected youth to serve as AmeriCorps members 
during the summer, giving them a chance to help their communities while 
exploring potential career paths, developing skills, and earning an 
education award they can use for college. CNCS is interested in 
expanding funding for summer service programs that expand opportunity 
for youth.'' There is a significant need to reengage disconnected 
youth, and help them get on a path to furthering their education and 
into the workforce.
    The Corps Network is presently operating a full-time Opportunity 
Youth Service Initiative with support from CNCS to enroll thousands of 
out of school and out of work youth in national service environmental 
stewardship initiatives at Corps around the country. While serving, 
they gain career skills, hands on work experience, and advance their 
education. They also earn AmeriCorps education awards that help 
encourage them to enroll in postsecondary education/training. As of 
2015, there are approximately 5.8 million young Americans who meet the 
definition of Opportunity Youth. These young men and women represent a 
social and economic opportunity: many of them are eager to further 
their education, gain work experience and help their communities, but 
need meaningful ways to do so. Not investing in these young people, and 
those that might be at-risk of fully disconnecting at 14 or 15, means 
greater cost to taxpayers and society in the hundreds of thousands of 
dollars later on as they remain disconnected.
    CNCS has worked for many years in communities around the country 
and with non-profit organizations like ours to address the most 
pressing social challenges with significant buy-in from local public 
and private entities. We are pleased to be able to participate in new 
partnerships that CNCS has established through the President's National 
Service Task Force and urge your support for encouraging more of such 
partnerships. For example, The Corps Network has been able to enroll 
court-involved youth in AmeriCorps and partner them with mentors while 
helping them be seen as an asset to their community, not a liability. 
Additionally, we've worked with CNCS and the U.S. Department of 
Agriculture to enroll AmeriCorps members in a 21st Century Conservation 
Service Corps to accomplish important work on public lands and help 
address the millions of dollars in backlogged maintenance and meet 
wildfire suppression and fighting needs.
    As you can see, CNCS supports many important initiatives that 
engage a diverse population of youth serving in Corps including 
veterans, Native Americans and individuals with disabilities. With 
increasing strains on public support systems, it is more important than 
ever to support this type of community-needs-based service to fill-in 
the gaps of need. There is also significant demand for these positions, 
with all of our Corps being oversubscribed and CNCS reporting in 2011, 
582,000 AmeriCorps applications were received with only 82,000 slots 
available. Through your support, we can provide more service 
opportunities for our youth to reengage in education, work, and their 
communities and get on a productive path for the United States' 
continued growth and prosperity.
    Thank you for the opportunity to provide written testimony for the 
record. We again respectfully urge your support for CNCS and for 
increased funding of $1.47 billion for the Corporation for National and 
Community Service in fiscal year 2017. Thank you for your time and 
consideration of this testimony.
    Sincerely.

    [This statement was submitted by Mary Ellen Sprenkel, President & 
CEO, Corporation for National and Community Service.]
                                 ______
                                 
     Prepared Statement of the Council of Academic Family Medicine
    The member organizations of the Council of Academic Family Medicine 
(CAFM) are pleased to submit testimony on behalf of programs under the 
jurisdiction of the Health Resources and Services Administration (HRSA) 
and the Agency for Healthcare Research and Quality (AHRQ). The CAFM 
collectively includes family medicine medical school and residency 
faculty, community preceptors, residency program directors, medical 
school department chairs, research scientists, and others involved in 
family medicine education. We urge the subcommittee to appropriate at 
least $59 million for the health professions program, Primary Care 
Training and Enhancement, authorized under Title VII, Section 747 of 
the Public Health Service Act under the jurisdiction of the Health 
Resources and Services Administration (HRSA.) In addition, we recommend 
the subcommittee fund the Agency for Healthcare Research and Quality 
(AHRQ) at no less than $364 million in base discretionary funding to 
support research vital to primary care.
    More than 44,000 primary care physicians will be needed by 2035, 
and current primary care production rates will be unable to meet the 
demand, noted the authors of a recent article in Annals of Family 
Medicine (Petterson, et al Mar/Apr 2015) The programs we support in our 
testimony will help build upon our Nation's workforce and health 
infrastructure. They improve primary care services that will produce 
better health outcomes and help reduce the ever rising costs of 
healthcare. In this difficult fiscal climate, we hope the subommittee 
will recognize that the production of a robust primary care workforce 
is a necessary investment that will ultimately produce long term 
savings.
                 primary care training and enhancement
    The Primary Care Training and Enhancement Program (Title VII, 
Section 747 of the Public Health Service Act) has a long history of 
providing indispensible funding for the training of primary care 
physicians. With each successive reauthorization, Congress has modified 
the Title VII health professions programs to address relevant and 
timely workforce needs. The most recent authorization directs HRSA to 
prioritize training in the new competencies that provide care in the 
patient-centered medical home model. It also calls for the development 
of infrastructure within primary care departments, as well as 
innovations in team management of chronic disease, integrated models of 
care, and health transitions.
    As experimentation with new or different models of care continues, 
departments of family medicine and family medicine residency programs 
will rely further on Title VII, Section 747, grants to help develop 
curricula and research training methods for transforming practice 
delivery. Passage of the Medicare Access and Chip Reauthorization Act 
(MACRA), which changes Medicare payment methodologies to incentivize 
alternatives to traditional fee for service, increases the need for 
adequate Section 747 funding. Some areas in need of support for future 
training include: training in clinical environments that are 
transforming to include integrated care with other health professionals 
(e.g. behavioral health, care coordination, nursing, oral health); 
development and implementation of curricula to give trainees the skills 
necessary to build and work in interprofessional teams that include 
diverse professions; and development and implementation of curricula to 
develop leaders and teachers in practice transformation.
    The Advisory Committee on Training in Primary Care Medicine and 
Dentistry December 2014 report states that ``[r]esources currently 
available through Title VII, Part C, sections 747 and 748 have 
decreased significantly over the past 10 years, and are currently 
inadequate to support the [needed] system changes.'' \1\ In order to 
address some of these challenges, the Advisory Committee recommends 
that Congress increase funding levels for training under the primary 
care training health professions program, both in fiscal year 2017 and 
for the next 5 years. The current funding of $38.9 million does not 
allow for the pent up demand caused by reduced and stagnant funding 
levels. Only 35 schools or institutions were able to obtain grant 
funding in the fiscal year 2015 cycle; we expect approximately another 
37 awards to be made in fiscal year 2016, and no new awards in fiscal 
year 2017 without additional appropriations. Family medicine alone has 
over 100 departments in medical schools and over 450 residencies.
---------------------------------------------------------------------------
    \1\ http://www.hrsa.gov/advisorycommittees/bhpradvisory/actpcmd/
Reports/eleventhreport.pdf.
---------------------------------------------------------------------------
    A recent study in the Annals of Family Medicine (Phillips and 
Turner, March/April 2012) stated that ``Meeting this increased demand 
[for primary care physician production] requires a major investment in 
primary care training.'' The study continues, ``Expansion of Title VII, 
Section 747 with the goal of improving access to primary care would be 
an important part of a needed, broader effort to counter the decline of 
primary care. Failure to launch such a national primary care workforce 
revitalization program will put the health and economic viability of 
our Nation at risk.''
    Primary care health professions training grants under Title VII is 
vital to the continued development of an updated workforce designed to 
care for the most vulnerable populations. We urge your continued 
support for this program and an increase in funding to $59 million in 
fiscal year 2017 to allow for a robust competitive funding cycle. The 
following information contains real world examples of Title VII at work 
in several of your districts.
    KANSAS: The University of Kansas in Wichita used primary care 
training grant funding to improve research and scholarly activities in 
residency programs and to improve Patient Centered Medical Home (PCMH) 
training through curriculum changes and junior faculty mentoring. The 
faculty development grant greatly improved scholarly production, 
research and teaching and faculty retention.
    ALABAMA: The University of South Alabama used primary care training 
funding to lead in curricular innovation being the first to incorporate 
multimedia education, standardized patients, and point of care 
evidence-based teaching and patient-based evaluation of medical 
students. This resulted in a new primary care patient curriculum for 
first and second year medical students.
    RHODE ISLAND: Brown University has used primary care training funds 
to transform medical student education and the PCMH, including new 
curricula and rotations, as well as the facilitation work to transform 
10 family medicine teaching practices and to run three national ``think 
tanks'' to discuss practical and theoretical issues related to models 
for practice transformation.
    ARKANSAS: University of Arkansas Medical School (UAMS) in Little 
Rock used a five year grant to increase their medical student family 
medicine match by 67 percent over 3 years. The Federal increase relied 
heavily on the Arkansas growth. Grant strategies included program 
development, increasing program visibility, and support for interested 
students.
           agency for health care research and quality (ahrq)
    We are grateful that Congress included budget authority for AHRQ in 
the fiscal year 16 omnibus funding bill. This strengthens the viability 
of an agency that supports primary care research around the country. 
The majority of research funding in the United States supports research 
of one specific disease, organ system, cellular, or chemical process--
not for primary care despite the fact that the overall health of a 
population is directly linked to the strength of its primary healthcare 
system. Primary care research includes: translating science into caring 
for patients, better organizing healthcare to meet patient and 
population needs, evaluating innovations to provide the best healthcare 
to patients, and engaging patients, communities, and practices to 
improve health. AHRQ is uniquely positioned to support such research 
and to help disseminate it nationwide.
    There are six areas that AHRQ highlights that are not available 
elsewhere in the biomedical research infrastructure: primary care 
research through Practice-based Research Networks (PBRNs), practice 
transformation, patient quality and safety in non-hospital settings, 
multi-morbidity research, mental and behavioral health provision in 
communities and primary care practices, and training future primary 
care investigators. Primary care research needs more adequately trained 
researchers and AHRQ deliberately promotes this training. Below are 
some examples of successful AHRQ work that supports primary care 
practice and patient safety:
    OKLAHOMA: The University of Oklahoma, College of Medicine, in 
Oklahoma City, created the Oklahoma Primary Healthcare Improvement 
Center to serve as a resource to the emerging Oklahoma Primary 
Healthcare Extensions System. Part of the Evidence Now Initiative, this 
grant will support the dissemination of patient-centered outcomes 
research findings into practices, support 300 primary care practices in 
risk management around smoking cessation, blood pressure control, 
statins, and low-dose aspirin, and evaluate the intervention's impact 
on practice performance. Similar to Oklahoma, as part of the nationwide 
AHRQ Evidence Now initiative, grants fund six other collaboratives in 
11 additional States; they are all led by primary care (general 
internal medicine or family medicine) and are all working to help small 
to medium primary care practices do a better job of reducing 
cardiovascular risk in their patients. These other collaboratives, 
include: Northwest (led by Group Health, Seattle)--involving practices 
in Washington, Idaho, and Oregon; Southwest (led by U Colorado DFM)--
involving Colorado and New Mexico; Midwest (led by Northwestern)--
involving Wisconsin, Illinois, and Indiana; North Carolina (led by 
UNC); Virginia, (led by VCU) and New York (led by NYU).
    MISSOURI: AHRQ funding has allowed the University of Missouri to 
build infrastructure for patient-centered outcomes research in three 
arenas. The first study evaluated the advantages and disadvantages of 
endovascular vs. open surgery for legs with inadequate blood flow. The 
second project focuses on improved discharge plans from skilled nursing 
facilities through improved primary care connections. Missouri 
partnered with the AAFP to create a national research network to 
improve chronic pain for the third project.
    NEW MEXICO: The University of New Mexico School of Medicine has 
used AHRQ funding to create and evaluate an innovative model for 
disseminating evidence-based information to rural primary care 
providers. A Health Extension Regional Officer conducted individual 
academic detailing visits with providers to reinforce evidence-based 
information on the management of chronic non-cancer pain in continuing 
professional development workshops. This detailing identified and 
adapted information for the longitudinal learning needs of the rural 
providers.
    OREGON: Through AHRQ funding at the Oregon Health & Science 
University, the Rural Practice-based Research Network is helping lead 
Healthy Hearts Northwest by recruiting 100 primary care practices to 
develop team-based quality improvement infrastructure improvements in 
small to medium-size practices. The Evidence Now Initiative will 
attempt to reach 130 practices, operating as health extension agents in 
frontier communities.
    AHRQ's funds research into multiple chronic conditions--a hallmark 
of primary care practice. Additionally, funding will be used for data 
collection to identify how healthcare teams are organized and if care 
and outcomes look different in team based practices, compared to 
traditional practices.
    Highlighting the success of AHRQ's patient safety initiatives, a 
2014 \2\ report showed hospital care to be much safer in 2013 compared 
to 2010. The report noted a decline of 17 percent in hospital-acquired 
conditions, in harm to1.3 million individuals, as well as 50,000 lives 
saved, and $12 billion savings in health spending during that period. 
Research related to the most common acute, chronic, and comorbid 
conditions treated by primary care clinicians is lacking. AHRQ supports 
this research that is essential to create a robust primary care system 
for our Nation. Despite this need, little is known about how patients 
can best decide how and when to seek care, how to introduce and 
disseminate new discoveries into real life practice, and how to 
maximize appropriate care. Sufficient funding for AHRQ can help 
researchers address these problems. We recommend the subcommittee fund 
AHRQ at a base, discretionary level of at least $364 million for fiscal 
year 2017.
---------------------------------------------------------------------------
    \2\ Publication # 15-0011-EF.

    [This statement was submitted by Todd Shaffer, MD, MBA, Chair, 
Council of Academic Family Medicine.]
                                 ______
                                 
       Prepared Statement of the Council on Social Work Education
    On behalf of the Council on Social Work Education (CSWE), I am 
pleased to offer this written testimony to the Senate Appropriations 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies for inclusion in the official Committee record. CSWE 
is a nonprofit national association representing more than 2,500 
individual members and more than 750 baccalaureate and master's 
programs of professional social work education. I will focus my 
testimony on the importance of fostering a skilled, sustainable, and 
diverse social work workforce to meet the health-care needs of the 
Nation through professional education, training, and financial support 
programs for social workers at the Department of Health and Human 
Services (HHS) and the Department of Education (ED). CSWE requests:

------------------------------------------------------------------------
   Agency        Account           Program           Funding requested
------------------------------------------------------------------------
        HHS          HRSA   Title VII Health      $280 million
                             Professions
                             Programs
 
        HHS          HRSA   Title VII Mental and  $1 million for the
                             Behavioral HealthP    Leadership in Public
                             Education and         Health Social Work
                             Training Program      Education (LPHSWE)P
                                                   Program
 
        HHS          HRSA   HRSA Behavioral       $56 million
                             Health Workforce
                             Education and
                             Training Grant
                             Program
 
        HHS        SAMHSA   Minority Fellowship   $11.7 million
                             Program               including at least
                                                   $6.4 million for MFP
                                                   core activities
 
         ED           N/A   Pell Grant            $5,935 for the maximum
                                                   Pell Grant
 
         ED           N/A   GAANN                 $31 million
 
         ED           N/A   Loan Repayment        Support without a cap
                             Programs              on forgiveness
 
        HHS           NIH   Overall Funding for   $34.5 billion
                             National Institutes
                             of Health
------------------------------------------------------------------------

    Recruitment and retention in social work continues to be a serious 
challenge that threatens the workforce's ability to meet societal 
needs. The U.S. Bureau of Labor Statistics estimates that employment 
for social workers is expected to grow faster than the average for all 
occupations through 2022.\1\ While CSWE understands the difficult 
funding decisions facing Congress, it is my hope that the Committee 
will prioritize funding for health professions training in fiscal year 
2017 to help ensure that the Nation continues to foster a sustainable, 
skilled, and culturally competent workforce that will be able to 
accommodate the increasing demand for social work services and meet the 
unique health-care needs of diverse communities.
---------------------------------------------------------------------------
    \1\ U.S. Bureau of Labor Statistics. 2012. Occupational Outlook 
Handbook: Social Workers, http://data.bls.gov/cgi-bin/print.pl/oco/
ocos060.htm. Retrieved March 21, 2014.
---------------------------------------------------------------------------
              health resources and services administration
          title vii and title viii health professions programs
    CSWE urges the Committee to provide $280 million in fiscal year 
2017 for the health professions education programs authorized under 
Titles VII of the Public Health Service Act and administered through 
the Health Resources and Services Administration (HRSA). HRSA's Title 
VII health professions programs represent Federal programs designed to 
train health-care providers in an interdisciplinary way to meet the 
health-care needs of all Americans, including the underserved and those 
with special needs, and expand minority representation in the health-
care workforce. The Title VII programs, for which social workers and 
social work students are eligible, provide loans, loan guarantees, and 
scholarships to students, as well as grants to institutions of higher 
education and non-profit organizations to help build and maintain a 
robust health-care workforce.
    CSWE urges the Committee to provide $1 million for the Leadership 
in Public Health Social Work Education (LPHSWE). This funding supports 
the next generation for public health and social workers and ensures 
critical leadership, resources, and training.\2\
---------------------------------------------------------------------------
    \2\ HRSA Congressional Budget Justification for fiscal year 2017 
http://www.hrsa.gov/about/budget/budgetjustification2017.pdf. Retrieved 
February 26,2016.
---------------------------------------------------------------------------
              health resources and services administration
       behavioral health workforce education and training program
    CSWE urges the Committee to provide $56 million for the Behavioral 
Health Workforce Education and Training (BHWET) Program at HRSA. 
Previously, this program was a partnership between HRSA and the 
Substance Abuse and Mental Health Services Administration (SAMHSA); 
however, the President's budget request would move this funding to HRSA 
to administer the program. The BWHET program has provided critical 
support to increase the number of behavioral health professionals. This 
program builds on HRSA's mental and behavioral health training efforts 
by providing important grant funding for mental health and substance 
abuse workforce serving children, adolescents, and transitional-age 
youth at risk for developing, or who have developed, a recognized 
behavioral health disorder.\3\ This program is significant to CSWE and 
social work. In 2015, for the first year of this program, social work 
programs were awarded about $19,087,780 and we estimate about 4,196 
students will be served through this program. This makes important 
progress in meeting the workforce needs for mental and behavioral 
health providers.
---------------------------------------------------------------------------
    \3\ Http://www.integration.samhsa.gov/integrated-care-models/
safety_net_providers.
---------------------------------------------------------------------------
    The President's fiscal year 2017 budget request would continue to 
support this program by providing $56 million. This funding is an 
increase of $6 million above the fiscal year 2016 enacted level and 
would expand behavioral health workforce activities and award 
additional grants. CSWE urges the Committee to support $56 million for 
the BHWET Grant Program. CSWE also encourages the Committee to include 
language specifying that accredited master's-level schools and programs 
of social work must be CSWE accredited to receive funding. Similar 
criteria has been placed on mental and behavioral health grants at 
HRSA.
       substance abuse and mental health services administration
                      minority fellowship program
    CSWE urges the Committee to appropriate the highest level possible 
for the Minority Fellowship Program (MFP) in fiscal year 2017. The goal 
of the SAMHSA Minority Fellowship Program (MFP) is to achieve greater 
numbers of minority doctoral students preparing for leadership roles in 
the mental health and substance use fields.\4\ CSWE is one of six 
grantees of this critical program and administers funds to exceptional 
minority doctoral social work students. Other grantees include national 
organizations representing nursing, psychology, psychiatry, marriage 
and family therapy, and professional counselors. SAMHSA makes grants to 
these six organizations, who in turn recruit minority doctoral students 
into the program from the six distinct professions. CSWE administers 
the funds to qualified doctoral students and helps facilitate mentoring 
and networking throughout the duration of the fellowship as well as 
facilitates an alumni group to help continue to engage former fellows 
long after their formal fellowship has ended.
---------------------------------------------------------------------------
    \4\ According to SAMHSA, minorities make up over one-fourth of the 
population, but less than 20 percent of behavioral health providers 
come from ethnic minority communities. Retrieved from SAMHSA Minority 
Fellowship Program, http://www.samhsa.gov/minorityfellowship/.
---------------------------------------------------------------------------
    In addition, CSWE also administers funds for the Minority 
Fellowship Program-Youth (MFP-Y). The purpose of the program is to 
reduce health disparities and improve behavioral health-care outcomes 
for racially and ethnically diverse populations by increasing the 
number of culturally competent master's-level behavioral health 
professionals serving children, adolescents, and populations in 
transition to adulthood (aged 16-25).
    Since its inception in 1974, the MFP has helped support doctoral-
level professional education for over 1,000 ethnic minority social 
workers, psychiatrists, psychologists, psychiatric nurses, and family 
and marriage therapists. Still, the program struggles to keep pace with 
the demands facing these health professions. Severe shortages of mental 
health professionals often arise in underserved areas due to the 
difficulty of recruitment and retention in the public sector. Nowhere 
are these shortages more prevalent than within Tribal communities, 
where mental illness and substance use go largely untreated and 
incidences of suicide continue to increase. Studies have shown that 
ethnic minority mental health professionals practice in underserved 
areas at a higher rate than non-minorities. Also, a direct positive 
relationship exists between the numbers of ethnic minority mental 
health professionals and the utilization of needed services by ethnic 
minorities.\5\ The President's fiscal year 2017 budget request includes 
$11,669,000 to support six MFPs, two MFP-Y, two MFP-AC grants, and 
three technical assistance and evaluation support contracts. CSWE urges 
the Committee to support this request, including at least $6.4 million 
for MFP core activities, the same as the fiscal year 2016 enacted 
level.
---------------------------------------------------------------------------
    \5\ U.S. Department of Health and Human Services, Substance Abuse 
and Mental Health Services Administration, Center for Mental Health 
Services. (2001). Mental Health: Culture, Race, and Ethnicity--A 
Supplement to Mental Health: A Report of the Surgeon General. Retrieved 
from http://www.surgeongeneral.gov/library/mentalhealth/cre/sma-01-
3613.pdf.
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             department of education: student aid programs
    CSWE supports full funding to bring the maximum individual Pell 
Grant to $5,935 in fiscal year 2017. Pell Grants are one of the most 
important programs in increasing access and improving affordability to 
ensure that all students, regardless of their economic circumstances, 
can access higher education. Moreover, as described above with regard 
to the SAMHSA Minority Fellowship Program, one goal of social work 
education is recruiting students from diverse backgrounds (which 
includes racial, economic, religious, and other forms of diversity) 
with the hope that they will return to serve diverse communities once 
they have completed their education. In many cases, this includes 
encouraging social workers to return to their own communities and apply 
the skills they have acquired through their social work education to 
individuals, groups, or families in need. Without support like Pell 
Grants, many low-income individuals would not be able to access higher 
education, and in turn, would not acquire the skills needed to best 
serve in the communities that would most benefit from their service.
    The Graduate Assistance in Areas of National Need (GAANN) program 
provides graduate traineeships in critical fields of study. Currently, 
social work is not defined as an area of national need for this 
program; however, it was recognized by Congress as an area of national 
need in the Higher Education Opportunity Act of 2008. We encourage ED 
to include social work in the GAANN program in future years. Inclusion 
of social work would enhance graduate education opportunities in social 
work, which is critically needed to foster a sustainable health 
professions workforce. CSWE urges the Subcommittee to provide the 
fiscal year 2012 pre-sequester funding level of $31 million for the 
GAANN Program and include social work as an area of national need.
    CSWE supports efforts at ED to help students with high debt loads 
serve in low paying positions. The income-driven repayment programs and 
the Public Service Loan Forgiveness program, in particular, provide 
financial stability and support to students graduating from social work 
programs who wish to serve in high-needs communities, often at a low 
salary level. CSWE urges the Subcommittee to support loan repayment 
programs without a cap on loan forgiveness.
          national institutes of health: support for research
    CSWE supports the community's recommendation for at least $34.5 
billion for the National Institutes of Health (NIH) in fiscal year 2017 
and advocates for continued investments in biomedical and health-
related research that incorporates the social and behavioral science 
research necessary to better understand, and appropriately address, the 
needs of high-risk populations including children, racial and ethnic 
minority populations, and geriatric populations.
    Thank you for the opportunity to express these views. Please do not 
hesitate to call on the Council on Social Work Education should you 
have any questions or require additional information.

    [This statement was submitted by Dr. Darla Spence Coffey, 
President, Council on Social Work Education.]
                                 ______
                                 
  Prepared Statement of the Crohn's and Colitis Foundation of America
              summary of fiscal year 2017 recommendations
_______________________________________________________________________

  --$34.5 Billion for the National Institutes of Health (NIH). 
        Increased funding for the National Institute of Diabetes and 
        Digestive and Kidney Diseases (NIDDK).
  --Continued Focus on Digestive Disease Research and Education at NIH, 
        and Support for the Inflammatory Bowel Disease (IBD) Portfolio.
  --$1,000,000 for the Centers for Disease Control and Prevention's 
        (CDC) IBD Epidemiology Activities.
_______________________________________________________________________

    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the priorities on behalf of 
the Crohn's and Colitis Foundation of America (CCFA). CCFA has remained 
committed to its mission of finding a cure for Crohn's disease and 
ulcerative colitis and improving the quality of life of children and 
adults affected by these diseases for over 46 years.
    Impacting an estimated 1.4 million Americans, 30 percent of whom 
are diagnosed in their childhood years, Inflammatory Bowel Diseases 
(IBD) are chronic disorders of the gastrointestinal tract which cause 
abdominal pain, fever, and intestinal bleeding. IBD represents a major 
cause of morbidity from digestive illness and has a devastating impact 
on both patients and their families.
    The social and economic impact of digestive disease is enormous and 
difficult to grasp. Digestive disorders afflict approximately 65 
million Americans. This results in 50 million visits to physicians, 
over 10 million hospitalizations, collectively 230 million days of 
restricted activity. The total cost associated with digestive diseases 
has been conservatively estimated at $60 billion a year.
    CCFA would like to thank the subcommittee for its past support of 
digestive disease research and prevention programs at the National 
Institutes of Health (NIH) and the Centers for
    Disease Control and Prevention (CDC).
                     national institutes of health
    For NIH, CCFA recommends:
  --$34.5 billion for NIH
  --$2.165 billion for the National Institute of Diabetes and Digestive 
        and Kidney Disease (NIDDK)
    We at CCFA respectfully request that any increase for NIH does not 
come at the expense of other Public Health Service agencies. With the 
competing and the challenging budgetary constraints the Subcommittee 
currently operates under, CCFA would like to highlight the research 
being accomplished by NIDDK which warrants the increase for NIH.
    In recent years researchers have made significant progress in the 
fight against IBD. The CCFA encourages the subcommittee to continue its 
support of IBD research at NIDDK and NIAID at a level commensurate with 
the overall increase for each institute. CCFA commends NIH for 
continuing to support cross-cutting research at multiple institutes and 
centers through the Human Microbiome Project supported through the 
Common Fund. Specifically, CCFA is excited about the NIH-funded 
research being done characterizing the gut microbial ecosystem for 
diagnosis and therapy in IBD. CCFA applauds NIDDK for its strong 
commitment to IBD research through the Inflammatory Bowel Disease 
Genetics Research Consortium which has contributed to furthering our 
understanding of how these diseases operate on a molecular and 
biological level. The Committee urges NIDDK to continue efforts to 
identify the etiology of the disease in order to inform the development 
of cures for inflammatory bowel disease.
               centers for disease control and prevention
    CDC, in collaboration with a nationwide, geographically diverse 
network of large managed healthcare delivery systems, has led an 
epidemiological study of IBD to understand IBD incidence, prevalence, 
demographics, and healthcare utilization. The group, comprised of 
investigators at the Massachusetts General Hospital in Boston, Rhode 
Island Hospital, CCFA, and CDC, has piloted the Ocean State Crohn's and 
Colitis Registry (OSCAR), which includes both pediatric and adult 
patients. Since 2008, OSCAR investigators have recruited 22 private-
practice groups and hospital based physicians in Rhode Island and are 
that enrolling newly diagnosed patients into the registry. This study 
found an average annual incidence rate of 8.4 per 100,000 people for 
Crohn's disease and 12.4 per 100,000 for Ulcerative Colitis; published 
in Inflammatory Bowel Disease Journal, April 2007.
  --Over the course of the initial 3-year epidemiologic collaboration, 
        CDC laboratory scientists and epidemiologists worked to improve 
        detection tools and epidemiologic methods to study the role of 
        infections (infectious disease epidemiology) in pediatric IBD, 
        collaborating with extramural researchers who were funded by an 
        NIH research award.
  --Since 2006, CDC epidemiologists have been working in conjunction 
        with CCFA and a large health maintenance organization to better 
        understand the natural history of IBD as well as factors that 
        predict the course of disease.
    CCFA commends CDC for implementing a robust IBD epidemiology study 
and communicating study results with the public. In this regard, recent 
research has shown a shifting paradigm in the populations that IBD 
effects. IBD is historically prevalent in Jews of European descent 
(Ashkenazi Jews), however, minority populations in the United States 
are increasingly affected. One study of IBD patients in California 
looked at interracial variations in disease characteristics. It 
included Caucasian, African American, Hispanic, and Asian subjects. 
Asians were diagnosed with IBD at older ages than Caucasians and 
African Americans, and Hispanics were diagnosed at older ages than 
Caucasians. Incidence also seemed to rise over the course of a period 
of time. Nationwide epidemiologic data (such as incidence and 
prevalence) about minority populations with IBD is very limited and as 
the incidence of IBD rises in minority populations, investment in this 
area becomes increasingly important.
    CCFA supports the continued exploration of the disease burden of 
IBD, and communication of these findings to patients and providers in 
an effort to improve current interventions and inform best public 
health practices in managing IBD.
    CCFA encourages CDC to continue to support a nationwide IBD 
surveillance and epidemiological program at $1 million in fiscal year 
2017 to expand current efforts to identify the incidence and prevalence 
of IBD, specifically in minority populations.
    Conclusion
    CCFA understands the challenging budgetary constraints that this 
Subcommittee is operating under, yet we hope you will carefully 
consider the tremendous benefits to be gained by supporting a strong 
research and education program at NIH and CDC. Millions of Americans 
are pinning their hopes for a better life, or even life itself, on 
digestive disease research conducted through NIH. On behalf of our 
patients, we appreciate your consideration of our views. We look 
forward to working with you and your staff.

    [This statement was submitted by Laura Wingate, Vice President, 
Patient and Professional Services.]
                                 ______
                                 
              Prepared Statement of Cure Alzheimer's Fund
    Chairman Blunt, Ranking Member Murray, and members of the Senate 
Labor, Health & Human Services, Education, and Related Agencies 
Appropriations Subcommittee, I am Tim Armour, President and CEO of Cure 
Alzheimer' s Fund. I appreciate the opportunity to thank Congress for 
the additional funding for Alzheimer's disease research through NIH, 
and to submit this written testimony to request at least an additional 
$400 million in fiscal year 2017 for Alzheimer's disease research at 
the National Institutes of Health (NIH).
    Cure Alzheimer's Fund is a national nonprofit, based in 
Massachusetts that funds research throughout the United States and 
internationally, starting with the genetic aspects of Alzheimer's 
disease. It is the belief of Cure Alzheimer's Fund that we will not be 
able to cure the disease if we do not know what causes the disease.
    Cure Alzheimer's Fund has a venture philanthropy model which 
invests in proven talent and empowers them to succeed; invests in ideas 
early for the biggest possible impact; evaluates potential projects 
rigorously, but funds them quickly; takes smart risks for the biggest 
rewards; and has a focused strategy, but is nimble to react to, and 
take advantage of, new developments. Cure Alzheimer ' s Fund takes no 
intellectual property interest in the research it supports.
    Since its founding in 2004, Cure Alzheimer's Fund has invested 
almost $40 million m Alzheimer' s research . Often, this investment has 
been in projects that are considered too risky or early for NIH 
investment. But because Cure Alzheimer's Fund has provided the vital 
initial philanthropic investment, researchers are able to prove their 
concept and compile the necessary data to secure NIH investment.
    The $40 million invested by Cure Alzheimer's Fund has led to more 
than $45 million in NIH grants for a total of more than $85 million 
invested in Alzheimer ' s disease research as a result of Cure 
Alzheimer's Fund's willingness to fund basic research.
    The research supported by these investments have led to more than 
160 published papers which have been cited more than 10,000 times. This 
demonstrates the value of ``priming the pump'' for research and 
investment in early stage and basic research.
    Cure Alzheimer's Fund has assembled a Research Consortium of the 
leading Alzheimer's researchers. These researchers say that Alzheimer's 
research is budget, not science, constrained. We are entering a very 
exciting stage of Alzheimer's disease research with a very real 
possibility of meeting the National Plan's goal of preventing and 
effectively treating Alzheimer's disease by 2025.
    Recent advancements funded by Cure Alzheimer's Fund include 
research on the effect of gamma secretase modulators, how beta amyloid 
is an anti-microbial and part of the body's immune system, moving from 
gene discovery to therapy development, and the Alzheimer's in a Dish 
project which will dramatically speed the screening of therapeutic 
interventions.
    These advancements were funded initially by Cure Alzheimer's Fund 
and then were supported by NIH and others once the proof of concept was 
established. They are concrete examples of the importance of public-
private partnerships and the role each will play in finally curing 
Alzheimer's disease.
    Cure Alzheimer's Fund has worked closely with other advocacy 
organizations and with Congressional members and staff to showcase the 
need for additional resources for Alzheimer's disease research. Cure 
Alzheimer's Fund is very thankful and appreciative of the efforts of 
this Subcommittee in providing more funding for Alzheimer's disease 
research at NIH. Cure Alzheimer's Fund realizes how difficult this can 
be during these times of continuing budget constraints, so it truly 
appreciates these ongoing efforts by the Subcommittee members and 
staff, as well as the full Committee members and staff.
    For the first time in history, NIH is approaching nearly $1 billion 
in funding for Alzheimer's disease research funding. This is a more 
than doubling from where the funding was just a few years ago.
    As outstanding as this increase has been, the non-Federal members 
of the Advisory Council established by the National Plan passed by 
Congress has called for $2 billion a year in Alzheimer's disease 
research funding being necessary to meet the 2025 goal of the National 
Plan.
    An additional $400 million for Alzheimer's disease research at NIH 
would be another step in the right direction in meeting the $2 billion 
investment level called for by the research community. And it would be 
an important step toward ensuring that promising research funded by 
organizations like Cure Alzheimer's Fund will have the necessary 
resources available for it to continue on the discovery continuum 
without interruption.
    Cure Alzheimer's Fund see itself as a partner in this process. It 
realizes that both government and private organizations have an 
important role in reaching the day when we can say we have cured 
Alzheimer's disease. We must all worked together to reach this goal.
    Because of this, Cure Alzheimer's Fund fully endorsed the House 
Report Language last year calling on NIH and private organizations to 
develop a system to generate investment in meritorious but unfunded 
grants at NIH. Cure Alzheimer' s Fund, along with other organizations, 
has been working with NIH on this, and the hope is to have a system in 
place shortly to spur greater research investment.
    This system would allow private organizations to identify worthy 
research proposals that match their own organizational focus and 
expertise. It would help get early investment into promising research 
and would generate more understanding of Alzheimer's disease and 
targets for intervention. It could be a model for public-private 
partnerships in other diseases.
    But for the partnership to work effectively, there needs to be 
sufficient public investment in Alzheimer's disease research. An at 
least additional $400 million for Alzheimer's disease research at NIH 
would support even more new discoveries that can be fully vetted and 
developed.
    As we all know, we are paying for Alzheimer's disease already. 
Alzheimer's disease is the only Top Ten Mortality condition that has 
its mortality rates increasing. It is the only condition without a 
therapeutic intervention. It is the only condition that will bankrupt 
the Centers for Medicare &Medicaid Services. It has to be stopped.
    Cure Alzheimer' s Fund knows that as it is asking Congress for 
additional funding, it must also increase its commitment. In 2015, Cure 
Alzheimer's Fund more than doubled its yearly commitment to research 
funding to more than $10 million. The goal for 2016 is to have an 
additional increase of approximately 25 percent to $12.5 million.
    Cure Alzheimer's Fund sees the advancements being made in 
Alzheimer's disease research and the opportunities these advancements 
are creating. As I stated earlier, we are entering a very exciting and 
productive time for Alzheimer's disease research. Cure Alzheimer's Fund 
has worked closely with the Subcommittee in the past and looks forward 
to working with it in the future as we continue toward our shared goal 
of curing Alzheimer's disease.
    The Subcommittee has shown its commitment to this issue, and at 
times when allocating additional funding has not been easy. But know 
that this increased funding has produced much progress in combatting 
Alzheimer's disease. As this progress is being made, I hope that it can 
continue with increased research funding.
    Thank you for the opportunity to submit this written testimony and 
to respectfully request at least an additional $400 million in fiscal 
year 2017 for Alzheimer's disease research at NIH. Cure Alzheimer's 
Fund looks forward to working with you as the appropriations process 
continues and to being a resource to the Subcommittee on Alzheimer's 
disease research issues.
    Respectfully.

    [This statement was submitted by Timothy Armour, President and CEO, 
Cure Alzheimer's Fund.]
                                 ______
                                 
          Prepared Statement of the Cystic Fibrosis Foundation
    On behalf of the Cystic Fibrosis Foundation (CFF) and the 30,000 
people with cystic fibrosis (CF) in the United States, we submit the 
following testimony to the Senate Appropriations Committee's 
Subcommittee on Labor, Health and Human Services, Education, and 
Related Agencies on our funding requests for fiscal year 2017. The 
Foundation requests funding levels of at least $34.5 billion for the 
National Institutes of Health (NIH) for the coming year. We encourage 
special consideration and support for the National Center for Advancing 
Translational Sciences (NCATS) and programs under its jurisdiction, 
including the Cures Acceleration Network (CAN) and the Clinical and 
Translational Science Awards (CTSA) as well as the National Institute 
of Diabetes and Digestive and Kidney Diseases (NIDDK), the National 
Institute of General Medical Sciences (NIGMS), and the National Heart, 
Lung, and Blood Institute (NHLBI), all of which play a vital role in CF 
research.
    We also recommend that the Committee provide robust resources to 
the Health Resources and Services Administration (HRSA) and the Centers 
for Disease Control and Prevention (CDC), particularly their work to 
support nationwide newborn screening programs. Further, we urge the 
Committee to provide ample funding for the Center for Medicare and 
Medicaid Innovation (CMMI) to allow this agency the resources to update 
and streamline payment systems as well as the provision of robust 
resources for the Agency for Healthcare Research and Quality (AHRQ) and 
the Patient-Centered Outcomes Research Institute (PCORI).
  consistent, robust funding for nih is critical for american research
    The National Institutes of Health is a showcase for American 
ingenuity and a shining example of our country's generational legacy. 
NIH effectively uses appropriated funds to promote basic research and 
encourage collaboration across academic and commercial sectors to 
develop the building blocks of drug development. Basic research is a 
vital prerequisite for the discovery of new treatments and cures, and 
consistent, robust funding for NIH is crucial to support efforts that 
are developing novel therapies for serious and life threatening 
diseases.
    The NIH received a $2 billion budget increase in fiscal year 2016, 
and it is critical that this momentum continue in this year's 
appropriations process. Researchers need consistent, reliable funding 
to run successful laboratories and plan long-term projects. Further, 
this one-time increase has not overcome the devastating and lasting 
effects of many years of sequestration and stagnant funding on American 
research labs both at the NIH and in collaborative programs across the 
country. Funding success rates for all investigators remain below 
sustainable levels, and promising young investigators struggle to 
obtain sufficient funding to remain in the field. The result has been a 
marked erosion of the U.S. biomedical infrastructure.
    Cuts to funding at the NIH have been detrimental to those seeking 
support for cystic fibrosis research. Large Center Core Grants, awarded 
by the NIDDK, support shared resources and facilities for use by 
multiple investigators and provide much needed funding for clinical and 
basic cystic fibrosis research centers. The funding increase in fiscal 
year 2016 has provided much needed financial relief for these programs, 
but if this momentum does not continue, large centers may be at risk of 
losing research programs and infrastructure. This is both detrimental 
to the individual centers and causes immense interruption and 
uncertainty in CF research overall.
    Additionally, work performed at the NIH has had large benefits for 
the U.S. economy. The agency supports more than 400,000 jobs across the 
country, and a report by Families USA estimates every $1 of NIH funding 
generates more than double that in local economic growth. Increased 
investment in this agency can provide even greater economic payoff and 
support for the scientific progress that makes the United States the 
worldwide leader in biomedical research.
          research at nih supports advances in cf therapeutics
    As the Committee considers its funding priorities for the coming 
fiscal year, we urge consideration of the critical role that NIH plays 
in the development of treatments for cystic fibrosis and other rare 
diseases. NIH-funded advances in fundamental cellular and molecular 
processes, such as the mapping of the human genome, and the development 
of high throughput screening were essential for the creation of two 
therapies that have been approved to treat the underlying cause of CF 
in more than 50 percent of those with the disease. These breakthrough 
drugs, Kalydeco and Orkambi, developed by Vertex Pharmaceuticals with 
significant support from the CF Foundation, relied heavily on 
discoveries funded by the NIH.
    More exciting advancements are in the pipeline, and the Foundation 
is supporting 45 studies in 2016, including examination of several new 
genetically targeted therapies. Robust NIH funding is critical to 
maintain innovation in basic research and ensure a full pipeline of 
efficacious and affordable therapies for those with CF.
    In particular, we urge the committee to support funding for 
behavioral research, especially with regard to treatment adherence in 
chronic conditions like CF. Cystic fibrosis is a progressive condition 
with complex treatment regimens that often require several hours per 
day. Adherence research can help those with CF optimize the efficacy of 
available treatments.
           nih collaboration promotes cost-efficient research
    Research supported by the NIH takes place at thousands of 
institutions across the country, and support of funding for the agency 
is a vital and effective way to foster collaboration among public and 
private stakeholders and allows for an efficient, well-funded research 
process. The CF Foundation collaborates with the NIH to fund and 
organize a number of research initiatives. For example, the OPTIMIZE 
study, which receives joint funding from the NIH and the CF Foundation, 
has brought together hospital systems in nearly 30 States to compare 
efficacy of antibiotic treatments for lung infections in those with 
cystic fibrosis. The CF Foundation urges the committee to allow 
expansion of cost-effective and efficient collaboration nationwide by 
providing funding for the NIH to continue growing its efforts.
    NIH and the CF Foundation also jointly fund a research program at 
the University of Iowa to study the effects of CF in a pig model. The 
program is yielding fundamental new insights to help advance 
developments in the search for a cure. The University of Alabama has 
also developed a CF rat model using joint funding from NIH and the 
Foundation to examine methods for studying basic mechanisms and 
treatment of the disease.
    We also urge the Committee to support collaboration through the 
expansion of research networks, such as NIH's Childhood Liver Disease 
Research Network (ChiLDReN) consortium at the NIDDK. This collaboration 
helps researchers discover treatments not only for CF liver disease but 
for other diseases that affect thousands of children each year.
    The CF Foundation also urges the Committee to support and 
facilitate collaborative efforts by the FDA and NIH, such as the 
Regulatory Science Initiative and programs that allow for the placement 
of employees who will be engaged part-time at FDA and part-time at the 
NIH. The Foundation additionally encourages the creation of 
collaborative workshops with the NIH and FDA to promote pediatric drug 
development and novel methodologies to streamline the research and 
development process.
             supporting the next generation of researchers
    We strongly urge the Committee to provide robust resources for the 
NIH to support the next generation of researchers. Recruiting and 
retaining a strong scientific workforce, especially in the area of 
pediatric specialties is critical in the fight to find a cure for CF 
and countless other diseases for which there are not adequate treatment 
options. Challenges in this area include recruiting new researchers to 
the CF field, ensuring funding for promising work, and retaining 
talented researchers who are committed to research careers. Again, this 
will simply not happen without sustained support and infrastructure 
that is supported by the NIH
                   the precision medicine initiative
    There are more than 1800 mutations within the CF gene that are 
linked to the underlying cause of CF, and with the advent of precision 
medicine, therapies like KalydecoTM and OrkambiTM 
are being customized to treat a patient's genetic makeup. We urge the 
Committee to support the President's Precision Medicine Initiative by 
providing robust funding to the NIH to spearhead the development of new 
therapies that target the genetic cause of serious diseases. The CF 
Foundation urges the NIH to adopt precision medicine as a focus in an 
array of applicable areas, but this powerful initiative can only be 
possible through Federal funding and resources.
         prioritizing a centralized institutional review board
    Trials evaluating CF therapies are multi-site studies that can be 
slowed by repetitive review of local institutional review boards 
(IRBs). We commend the National Institutes of Health (NIH) for 
publishing and seeking comment on a policy that is intended to produce 
efficiencies in the clinical trials process while still protecting 
research participants by centralizing and simplifying the rigorous 
clinical trial review process. The CF Foundation sees the NIH as the 
logical choice to lead the centralization of institutional review 
boards and requests that the Committee take special consideration of 
the funds needed to implement this valuable initiative. At a time when 
research resources are restrained, efforts to reduce redundancy and 
improve efficiency in research are of the utmost importance.
               advancing translational science at the nih
    The Foundation requests robust funding for NIH's National Center 
for Advancing Translational Sciences (NCATS), which catalyzes 
innovation by improving the diagnostics and therapeutics development 
process and removing obstacles to translating basic scientific research 
into treatments. Research in dissemination and implementation science 
that focuses on integrating scientific findings and effective clinical 
practice into real-world service settings is crucial to providing the 
best possible care to those with CF and other conditions.
    The specific programs housed in NCATS are integral to this mission, 
including the Clinical and Translational Science Awards (CTSA), the 
Cures Acceleration Network (CAN), and the Therapeutics for Rare and 
Neglected Diseases (TRND) program. Such initiatives transform the way 
in which clinical and translational research is conducted and funded. 
NIH Director Dr. Francis Collins has cited the CF Foundation's 
Therapeutics Development Network (TDN) as a model for TRND's innovative 
therapeutics development model.
                      clinical trial data sharing
    The CF Foundation is enthusiastic about the potential for clinical 
trial, clinical care, claims, and other healthcare-related data to be 
used to advance drug discovery and development. The Foundation has been 
a pioneer in the advancement and utilization of a robust data 
repository through the CF Patient Registry, and our Therapeutics 
Development Network (TDN) has successfully encouraged clinical partners 
to share data. We ask that Congress support efforts by the NIH to 
explore strategies and guidelines for clinical trial data sharing. As 
drug development research advances, data sharing is vital to the 
acceleration of new discovery.
            supporting greater access to quality health care
    The CF Care Center Network is a model of quality, coordinated care 
that can be used as an example by policymakers and the rare disease 
community. We urge the Committee to allow greater access to this 
specialized care network by providing adequate resources and support 
for the Center for Medicare and Medicaid Innovation (CMMI) and their 
work to promote affordable access to specialized care. We also 
encourage funding for programs and agencies that promote research in 
healthcare quality and systems as well as clinical effectiveness and 
patient reported outcomes, including the Agency for Healthcare Research 
and Quality (AHRQ) and Patient-Centered Outcomes Research Institute 
(PCORI).
                 nationwide newborn screening programs
    Newborn screening is critically important to the CF community 
because it allows for the early detection and treatment of symptoms as 
well as early use of CF modulator therapies, which can significantly 
reduce cumulative damage caused by the disease. The Foundation urges 
the Committee to provide ample funding for HRSA, which evaluates the 
effectiveness of newborn screening and follow-up programs and provides 
grants for programs to support other critical aspects of newborn 
screening. We also encourage the Committee to provide adequate funding 
to the CDC, which is responsible for strengthening and enhancing 
laboratory quality assurance programs; enabling public health 
laboratories to develop and refine screening tests; conducting pilot 
studies; implementing new methods to improve detection of treatable 
disorders; and enhancing newborn disorder detection through the 
Innovative Molecular Quality Program.
                               conclusion
    Cystic fibrosis is a rare genetic disease that causes the body to 
produce thick mucus that clogs the lungs and other bodily systems, 
resulting in life-threatening infections, diabetes, malnutrition, and 
other medical complications. This is a time of great hope and optimism 
for the CF community and those with other rare diseases as more 
research is being conducted to effectively treat these life threatening 
conditions. We urge you to provide at least $34.5 billion for the 
National Institutes of Health as well as robust funding for other 
relevant agencies to support and expand work already being done in 
biomedical programs and translational science and encourage cost-
efficient collaboration of varied experts and stakeholders.
    We stand ready to work with the Committee and Congressional leaders 
on the challenges ahead. Thank you for your consideration.

    [This statement was submitted by Preston W. Campbell, III, M.D., 
President and CEO, Cystic Fibrosis Foundation.]
                                 ______
                                 
             Prepared Statement of DefeatMalnutrition.Today
    Chairman Blunt, Ranking Member Murray: I thank you for the 
opportunity to offer testimony in support of the Department of Health 
and Human Services' proposed increase of $13.8 million for Older 
Americans Act Title III(C) senior nutrition programs within the 
Administration for Community Living. This testimony is on behalf of 
DefeatMalnutrition.Today, a coalition of 36 community, healthy aging, 
nutrition, advocacy, healthcare professional, faith-based, and private 
sector stakeholders and organizations who share the goals of achieving 
the recognition of malnutrition as a key indicator and vital sign of 
adult health and working to achieve a greater focus on malnutrition 
screening and intervention through regulatory and/or legislative change 
across the Nation's healthcare system.
    Older Americans Act congregate and home-delivered meals programs 
are provided in every State and congressional district in this Nation. 
Approximately 2.4 million seniors in 2014 received these services.
    In fiscal year 2016, Older Americans Act Title III(C) programs 
received appropriations in the amount of $835 million. Though we are 
thankful that this represents an increase from fiscal year 2015, 
unfortunately, this does not keep pace with the rising cost of food, 
inflation, and the growing numbers of older adults. In fact, the number 
of older adults receiving meals is shrinking even as the need grows.
    The additional $13.8 million in funding for congregate and home-
delivered meals will help to counteract inflation and provide more than 
1.3 million additional meals. This does not keep up with the growing 
demand for services, but it would at least prevent further reductions 
in services.
    Studies have found that 50 percent of all persons age 85 and over 
need help with instrumental activities of daily living, including 
obtaining and preparing food. Older Americans Act nutrition programs 
address these concerns. These meal recipients are thus able to remain 
independent in their homes and communities and are not forced into 
hospitals or nursing homes due to an inability to maintain a proper 
diet.
    Investing in these programs is cost-effective because many common 
chronic conditions such as hypertension, heart disease, diabetes, and 
osteoporosis can be effectively prevented and treated with proper 
nutrition. The Academy of Nutrition and Dietetics estimates that 87 
percent of older adults have or are at risk of hypertension, high 
cholesterol, diabetes, or some combination of all of these. These 
seniors need healthy, nutritious meals that may be medically tailored 
for various conditions, access to lifestyle programs, and nutrition 
education and counseling to avoid serious medical care.
    Older adults who are not receiving proper meals can also become 
malnourished and undernourished. This makes it harder for them to 
recover from surgery and disease, makes it more difficult for their 
wounds to heal, increases their risk for infections and falls, and 
decreases their strength that they need to take care of themselves. 
Malnourished older adults are more likely to have poor health outcomes 
and to be readmitted to the hospital--their health costs can be 300 
percent greater than those who are not malnourished on entry to the 
healthcare system.
    Keeping older adults well-nourished is essential to keeping them in 
the community--and studies have consistently found that the highest 
rates of malnutrition in older adults are found in those who live in 
care settings as opposed to community-based settings. A Kaiser study 
found 38 percent prevalence of malnutrition among older adults in their 
communities, as compared to 91 percent in rehabilitation facilities, 86 
percent in hospitals, and 67 percent among those in nursing homes. 
While direct cause and effect has not entirely been established, it 
also seems that older adults in the community who are well-nourished 
are less likely to need to move to these care settings in the first 
place. We would also note that there is a great need here for tools for 
providers and practitioners to support the discovery and reduction of 
senior malnutrition, whether older adults are in care settings or not--
38 percent is still an extremely high number of malnourished community-
dwelling older adults, considering that fewer than 5 percent of older 
adults live in nursing homes.
    Access to Older Americans Act meals is essential to keeping these 
older adults out of costly nursing facilities and hospitals. On 
average, a senior can be fed for a year for about $1,300. (And, on 
average, only 37 percent of this funding comes from the Federal 
Government; the rest of the funding for Older Americans Act meals comes 
from local, State and private sources, making this nutrition program a 
true public-private partnership.) The cost of feeding a senior for a 
year is approximately the same as the cost of one day's stay in a 
hospital or less than the cost of 10 days in a nursing home. The cost 
savings to Medicare and Medicaid that this creates cannot be over-
emphasized. One study estimates that for every dollar invested in the 
Older Americans Act nutrition programs, Medicaid saves $50.
    Further, these services are designed to target those in the 
``greatest social and economic need,'' according to the Older Americans 
Act. According to ACL's studies, approximately two-thirds of home-
delivered meal recipients have annual incomes of $20,000 or less. 
Sixty-two percent of these recipients report that these meals represent 
at least half their food intake each day. And yet, the Government 
Accountability Office found that only about 9 percent of low-income 
older adults are even receiving meal services. For a small investment, 
more at-risk older adults could receive nutritious meals.
    For over 40 years, the Older Americans Act nutrition programs have 
been serving older adults who are frail, isolated, and in great need of 
assistance. With more than 10,000 seniors turning 65 every day, now is 
the time to provide an even greater investment in these proven and 
cost-effective programs.
    Thank you for your past and future support.

    [This statement was submitted by Robert Blancato, National 
Coordinator, DefeatMalnutrition.Today.]
                                 ______
                                 
          Prepared Statement of the disAbility Resource Center
    I respectfully submit this written testimony to request that you 
increase funding in the HHS budget for Centers for Independent Living 
(CIL) by $200 million, for a total of $301 million for the Independent 
Living line item in fiscal year 2017. This is an important opportunity 
for Congress to reaffirm its commitment to the more than 57 million 
Americans with disabilities.
    The disAbility Resource Center (dRC) is one of 17 CILs in Virginia, 
providing services to over 2,000 people each year in the Fredericksburg 
Region. These services assist people in maintaining independence, 
contributing to the community, and avoiding costly and restrictive 
institution. CILs are cross-disability, non-residential, community-
based, nonprofit organizations that are designed and operated by 
individuals with disabilities. Our organizations are unique in that 
they are directly governed and staffed by people with all types of 
disabilities, including people with mental, physical, sensory, 
cognitive, and developmental disabilities.
    Each of the 365 federally funded centers provides five core 
services: information and referral, individual and systems advocacy, 
peer support, independent living skills training, and transition 
services, which were added with the passage of the Workforce Innovation 
and Opportunity Act (WIOA). From 2012-2014, CILs provided the core 
services to nearly 5 million people with disabilities, and provided 
additional services such as housing assistance, transportation, 
personal care attendants, and employment services to hundreds of 
thousands of individuals. During this same period, prior to transition 
being added as a core service, CILs transitioned 13,030 people with 
disabilities from nursing homes and other institutions into the 
community.
    Transition services were added recently as a fifth core service 
with the passage of the Workforce Innovation and Opportunity Act and 
reauthorization of the Rehabilitation Act within WIOA. Transition 
services include transitioning individuals with significant 
disabilities from nursing homes and other institutions to home and 
community-based residences with appropriate supports and services, 
helping individuals with significant disabilities at risk of entering 
institutions to remain in the community, and assisting youth with 
significant disabilities transition to adult life. This core service is 
vital to achieving full participation for people with disabilities.
    Now that transition services have been added, the need for funding 
is more critical than ever.
    Every day, CILs are fighting to ensure that people with 
disabilities gain and maintain control over their own lives. We know 
that this cannot occur when people reside in institutional settings. 
While opponents of deinstitutionalization say that allowing people with 
disabilities to live in the community will result in harm, we know that 
the 13,030 people with disabilities who CILs successfully transitioned 
out of nursing homes and institutions across the country from 2012-2014 
prove otherwise. Additionally, when services are delivered in an 
individual's home, the result is a tremendous cost savings to Medicaid, 
Medicare, and States. Community-based services enable people with 
disabilities to become less reliant on long-term government supports 
and they are significantly less expensive than nursing home placements. 
We are grateful that Congress demonstrated their understanding and 
support for community-based services when WIOA was passed and 
transition was added as a fifth core service.
    The dRC, like many other CILs, maximizes every dollar and 
accomplishes its broad ranging mission with relatively little funding. 
CILs need additional funding to restore the devastating cuts to the 
Independent Living program, make up for inflation costs, and address 
the increased demand for independent living services. In 2016, the 
Independent Living Program is receiving nearly $2.5 million less in 
funding than it was in 2010. It is simply not possible to meet the 
demand for services and to effectively provide transition services 
without additional funding. Increased funding should be reinvested from 
the billions currently spent to keep people with disabilities in costly 
Medicaid nursing homes and institutions and out of mainstream society.
    CILs play a crucial role in the lives of people with disabilities, 
and work tirelessly to ensure that people with disabilities have a real 
choice in where and how they live, work, and participate in the 
community. Additionally, CILs are an excellent service and a bargain 
for America, keeping people engaged with their communities and saving 
taxpayer money.
    Please increase funding for Independent Living.
    Thank you for the opportunity to provide this written testimony.

    [This statement was submitted by Debra Fults, Executive Director, 
disAbility Resource Center.]
                                 ______
                                 
     Prepared Statement of the Dystonia Medical Research Foundation
            summary of recommendations for fiscal year 2017
_______________________________________________________________________

  --Provide $34.5 billion for the National Institutes of Health (NIH) 
        and proportional increases across its Institutes and Centers
  --Continue to support natural history studies on dystonia, like the 
        Dystonia Coalition within the Rare Disease Clinical Research 
        Network (RDCRN) coordinated by the Office of Rare Diseases 
        Research (ORDR) in the National Center for Advancing 
        Translational Sciences (NCATS)
  --Expand dystonia research supported by NIH through the National 
        Institute on Neurological Disorders and Stroke (NINDS), the 
        National Institute on Deafness and other Communication 
        Disorders (NIDCD), the National Eye Institute (NEI), and NCATS
_______________________________________________________________________

    Dystonia is a neurological movement disorder characterized by 
involuntary muscle spasms that cause the body to twist, repetitively 
jerk, and sustain postural deformities. Focal dystonia affects specific 
parts of the body, while generalized dystonia affects multiple parts of 
the body at the same time. Some forms of dystonia are genetic but 
dystonia can also be caused by injury or illness. Although dystonia is 
a chronic and progressive disease, it does not impact cognition, 
intelligence, or shorten a person's life span. Conservative estimates 
indicate that between 300,000 and 500,000 individuals suffer from some 
form of dystonia in North America alone. Dystonia does not 
discriminate, affecting all demographic groups. There is no known cure 
for dystonia and treatment options remain limited.
    Although little is known regarding the causes and onset of 
dystonia, two therapies have been developed that have demonstrated a 
great benefit to patients and have been particularly useful for 
controlling patient symptoms. Botulinum toxin (e.g., Botox, Xeomin, 
Disport and Myobloc) injections and deep brain stimulation have shown 
varying degrees of success alleviating dystonia symptoms. Until a cure 
is discovered, the development of management therapies such as these 
remains vital, and more research is needed to fully understand the 
onset and progression of the disease in order to better treat patients.
      dystonia research at the national institutes of health (nih)
    The DAN urges the subcommittee to continue its support for natural 
history studies on dystonia that will advance the pace of clinical and 
translational research to find better treatments and a cure. In 
addition, Congress should support NINDS, NCATS, NIDCD, and NEI in 
conducting and expanding critical research on dystonia.
    Currently, dystonia research at NIH is supported by the National 
Institute of Neurological Disorders and Stroke (NINDS), the National 
Institute on Deafness and Other Communication Disorders (NIDCD), the 
National Eye Institute (NEI), and the Office of Rare Diseases Research 
(ORDR) within the National Center for Advancing Translational Sciences 
(NCATS).
    ORDR coordinates the Rare Disease Clinical Research Network (RDCRN) 
which provides support for studies on the natural history, 
epidemiology, diagnosis, and treatment of rare diseases. RDCRN includes 
the Dystonia Coalition, a partnership between researchers, patients, 
and patient advocacy groups to advance the pace of clinical research on 
cervical dystonia, blepharospasm, spasmodic dysphonia, craniofacial 
dystonia, and limb dystonia. The Dystonia Coalition has made tremendous 
progress in preparing the patient community for clinical trials as well 
as funding promising studies that hold great hope for advancing our 
understanding and capacity to treat primary focal dystonias. Studies 
like the Coalition remain a priority for the community and Congress 
should continue to support these initiatives.
    The majority of dystonia research at NIH is supported by NINDS. 
NINDS has utilized a number of funding mechanisms in recent years to 
study the causes and mechanisms of dystonia. These grants cover a wide 
range of research including the genetics and genomics of dystonia, the 
development of animal models of primary and secondary dystonia, 
molecular and cellular studies in inherited forms of dystonia, 
epidemiology studies, and brain imaging.
    NIDCD and NEI also support research on dystonia. NIDCD has funded 
many studies on brainstem systems and their role in spasmodic 
dysphonia, or laryngeal dystonia. Spasmodic dysphonia is a form of 
focal dystonia which involves involuntary spasms of the vocal cords 
causing interruptions of speech and affecting voice quality. NEI 
focuses some of its resources on the study of blepharospasm. 
Blepharospasm is an abnormal, involuntary blinking of the eyelids which 
can render a patient legally blind due to a patient's inability to open 
their eyelids.
    In summary, the DAN recommends the following for fiscal year 2017:
  --Provide $34.5 billion for NIH and a proportional increase for its 
        Institutes and Centers
  --Support natural history studies on dystonia like the Dystonia 
        Coalition, part of the Rare Diseases Clinical Research Network 
        coordinated by ORDR within NCATS
  --Expand the dystonia research portfolio at NIH through NINDS, NIDCD, 
        NEI, and NCATS
                         awareness & education
    The Dystonia Medical Research Foundation (DMRF) provides a number 
of resources to help patients and families become informed about the 
disorder and treatment options. The DMRF offers newsletters, brochures, 
and fact sheets on dystonia subtypes and dystonia-related topic. These 
publications are available in print and online. The DMRF offers a 
comprehensive website and is available to the community by phone, 
email, and social media for inquiries. Educational patient meetings 
featuring movement disorder specialists and other experts are scheduled 
in communities across the country; online educational webinars on 
treatment and research topics are also provided.
    The DMRF works year round to promote greater public awareness of 
dystonia. Dystonia Moves Me is the DMRF's awareness campaign that takes 
place each September during Dystonia Awareness Month. Individuals who 
have been impacted by dystonia use their experiences to educate others 
in their local communities and via social media.

Personal Story
Pamela Sloate--New York, New York

    Pamela Sloate can barely remember life before dystonia. Her 
symptoms began over 40 years ago when she was just 8 years old. She 
recalls the bizarre feeling of not being able to physically keep her 
right arm on the table as she wrote. Then her left leg began to move 
unpredictably. Her involuntary movements spread to her left arm and 
right leg. She felt like a marionette on strings; an unseen puppeteer 
commandeered control of her body, limbs, and speech.
    To this day, dystonia is Pamela's constant unwelcome sidekick, 
inserting chaos into nearly every move she makes. She explains: 
``Imagine you're trying to . . .[walk] across a room. You lift your leg 
to begin that first step when a mischievous troll screws up your 
balance by pulling your foot inward, causing you to land on the side of 
your foot and desperately search for stability. Simultaneously, some 
imp twists your knee while your hip dips and swings in a motion that 
would swirl a hula-hoop.''
    Walking her dog down the block requires focusing every ounce of her 
energy on each laborious step. Crowds of people rush past as she 
precariously carries her folded walker down three flights of stairs to 
the subway. It is a challenge to stay still for a routine MRI. Despite 
access to leading movement disorder clinicians, her cocktail of oral 
medications requires constant fine-tuning in search of a balance 
between reducing the dystonia symptoms while avoiding intolerable side-
effects that limit her functioning even further.
    As a self-admitted perfectionist and born go-getter, Pamela has 
fought the limitations imposed by dystonia every step of the way. She 
rejects the suggestion that she is ``disabled'' in the conventional 
sense. Pamela graduated Brown University and earned a law degree from 
New York University School of Law. She has held positions with Bozell 
Worldwide and BEN Marketing Group, free-lanced as a marketing 
consultant, and worked as an attorney.
    Well into her 20s, Pamela often felt isolated and alone. Until that 
time she had never met another person with dystonia. The Internet 
allowed her to connect with others in the dystonia community from 
around the world, and she eventually started a widely recognized blog, 
Chronicles Of A Dystonia Muse. She is a multi-tasking dystonia 
advocate, engaging in legislative advocacy, leading a dystonia support 
group, fundraising to support medical research, and promoting dystonia 
awareness.
    Thank you for the opportunity to present the views of the dystonia 
community, we look forward to providing any additional information.

    [This statement was submitted by Janet Hieshetter, Executive 
Director, Dystonia Medical Research Foundation.]
                                 ______
                                 
              Prepared Statement of the Easter Seals, Inc.
    Easter Seals respectfully asks that you add four key Federal 
programs to your fiscal year Labor-HHS-Education appropriations Member 
submission form to help homeless veteran and older adult find jobs in 
their communities and to ensure that children with disabilities can 
access the early intervention and educational supports they require to 
grow and develop.
    Easter Seals is a national nonprofit that break down barriers for 
Americans through individualized, evidence-based services from one of 
our 74 statewide and local affiliates. We urge you to prioritize 
funding, at no less than the President's fiscal year 2017 budget 
recommendations, for the Homeless Veterans' Reintegration Program 
($50,000,000), Early Intervention Grants for Infants and Families 
($503,556,000), Community Service Employment for Older Americans 
($434,371,000), and Preschool Grants for Children with Disabilities 
($403,238,000).
                homeless veterans' reintegration program
Easter Seals Request: $50,000,000
    The Homeless Veterans' Reintegration Program (HVRP) provides job 
training, counseling, and placement services to help homeless veterans 
reintegrate into society and the labor force. With the dramatic 
decrease in veterans' homelessness since 2010, HVRP employment services 
are needed now more than ever to ensure those veterans who were 
formerly homeless secure employment to help them maintain their 
housing. Recognizing the growing demand for services among homeless and 
at-risk veterans, Congress has authorized HVRP funding at $50 million 
annually. The President's fiscal year 2017 budget request would, for 
the first-time, meet this authorized level and allow community 
providers to serve an additional 5,000 veterans.
    Submission Form Information:

 
 
 
Program:                           Homeless Veterans' Reintegration
                                    Program
Federal Department or Agency:      U.S. Department of Labor
Account:                           Veterans Employment & Training
FY 2017 LHHS Request:              $434,371,000
FY 2017 President's Budget:        $434,371,000
FY 2016 Enacted:                   $434,371,000
FY 2015 Enacted:                   $434,371,000
FY 2014: Enacted:                  $434,371,000
 

           early intervention grants for infants and families
Easter Seals Fiscal Year 2017 Request: $503,556,000
    The Early Intervention Grants for Infants and Families program 
(also known as Part C of the Individuals with Disabilities Education 
Act) provides formula grants to all 50 States to implement statewide 
systems of coordinated, comprehensive, multidisciplinary, interagency 
programs and make early intervention services available to children 
with disabilities, aged birth through 2. The increased prevalence of 
childhood disability and stagnant funding levels has meant fewer 
children benefit from the early intervention services and supports they 
need to meet key developmental milestones. The President's recommended 
increase will help to demonstrate innovative strategies to meet the 
needs of at-risk infants and toddlers and increase the State grant 
size.
    Submission Form Information:

 
 
 
Program:                           Early Intervention Grants for Infants
                                    and Families
Federal Department or Agency:      U.S. Department of Education
Account:                           Special Education
FY 2017 LHHS Request:              $503,556,000
FY 2017 President's Budget:        $503,556,000
FY 2016 Enacted:                   $458,556,000
FY 2015 Enacted:                   $438,556,000
FY 2014: Enacted:                  $438,498,000
 

            community service employment for older americans
Easter Seals Fiscal Year 2017 Request: $442,263,738
    The Community Service Employment for Older Americans program (also 
known as the Senior Community Service Employment Program or SCSEP) 
assists unemployed, low-income older adults in developing new work 
skills and experience through paid, work-based training in their 
communities. SCSEP-funded services are available in nearly all 3,000 
U.S. counties and territories. In addition to helping thousands of 
older Americans find jobs, the program strengthens communities through 
the training contributions participants make to local nonprofit and 
public facilities, such as libraries, schools and senior centers. 
Easter Seals was disappointed that the President's request failed to 
account for the increased operating costs (nearly $8 million) due to 
increases in State minimum wages. Easter Seals requests no less than 
the President's fiscal year 2017 budget request for SCSEP.
    Submission Form Information:

 
 
 
Program:                           Community Service Employment for
                                    Older Americans
Federal Department or Agency:      U.S. Department of Labor
Account:                           Employment & Training Administration
FY 2017 LHHS Request:              $434,371,000
FY 2017 President's Budget:        $434,371,000
FY 2016 Enacted:                   $434,371,000
FY 2015 Enacted:                   $434,371,000
FY 2014: Enacted:                  $434,371,000
 

            preschool grants for children with disabilities
Easter Seals Fiscal Year 2017 Request: $403,238,000
    Preschool Grants for Children with Disabilities (Part B of the 
Individuals with Disabilities Education Act) supports the educational 
needs of children between the ages of 3 and 5 years who have 
disabilities and also require special education services. Through IDEA, 
Congress guaranteed the right of these children to free, appropriate, 
public education and set a goal of providing $1500 to States for each 
eligible child. Past funding levels have fallen well short of this per 
pupil goal. The President proposes to build upon the investments made 
last year by Congress by recommending $46 more per child, for an 
average of $535 per child. Easter Seals support no less than the 
President's fiscal year 2017 proposal to ensure the only Federal 
program dedicated to preschool-aged children with disabilities has 
resources to meet its statutory obligations in providing these children 
with the critical academic and behavior supports.
    Submission Form Information:

 
 
 
Program:                           Preschool Grants for Children with
                                    Disabilities
Federal Department or Agency:      U.S. Department of Education
Account:                           Special Education
FY 2017 LHHS Request:              $403,238,000
FY 2017 President's Budget:        $403,238,000
FY 2016 Enacted:                   $368,238,000
FY 2015 Enacted:                   $353,238,000
FY 2014: Enacted:                  $353,238,000
 

    Thank you in advance for your consideration of Easter Seals' Labor-
HHS-Education funding priorities for fiscal year 2017. Please let us 
know if you have any questions or need any additional information in 
support of your submission forms. Thank you.
                                 ______
                                 
           Prepared Statement of the Elder Justice Coalition
    Chairman Blunt, Ranking Member Murray: On behalf of the bipartisan 
Elder Justice Coalition and its 3,000 members, we thank you for the 
opportunity to offer testimony in support of $25 million in funding for 
the Elder Justice Act within the Department of Health and Human 
Services' Administration for Community Living, as well as for 
maintaining funding for the Social Services Block Grant.
    Our topic must always be a bipartisan issue: preventing elder 
abuse, neglect and exploitation. We ask this subcommittee to provide 
this funding in a bipartisan fashion as part of the solution to the 
national disgrace of elder abuse.
    According to the Department of Justice, there are more than six 
million victims of elder abuse per year; roughly one of every 10 
persons over 60 will end up a victim of elder abuse. However, a New 
York State study found for every elder abuse case known to agencies, 24 
were unreported. Victims of elder financial abuse lose at least $2.9 
billion per year, which can include entire life savings. A 2015 study 
published by True Link Financial found that the problem of financial 
exploitation may be as great as $36 billion per year. One-half of those 
with dementia will fall victim to elder abuse, neglect and/or 
exploitation. In short, the situation is dire.
    The Elder Justice Act, passed in 2010, would address these 
problems. The Act, if funded, would strengthen the State Long-Term Care 
Ombudsman Program. It would provide for the development of forensic 
centers to study the problem of abuse and how we can better detect 
abuse and potential abusers. It would also enhance and train long-term 
care staffing in facilities.
    Funding for the Elder Justice Act has not been provided to fulfill 
the provisions of the Act. We are very grateful for the funding from 
the Appropriations Committee last year for the Act in the amount of $8 
million, but the Act needs more of an investment in order to fulfill 
its potential. This is why we support funding for the Act at last 
year's proposed $25 million level.
    Data collection is essential to understanding and preventing elder 
abuse. Other forms of crime, such as child abuse, have standardized 
national databases--the National Child Abuse and Neglect Data System 
(NCANDS) database has been in existence since 1998. This allows States 
to more easily discover trends and researchers to learn about 
perpetrators and victims. A lack of data has also hurt the elder 
justice community's efforts to call awareness to the problem of elder 
abuse and to compete effectively for resources in an era where data 
often drives dollars. Continuing the work started in fiscal year 2013 
with the continued funding of a National Adult Maltreatment Reporting 
System (NAMRS), a national Adult Protective Services (APS) data 
collection system, is vital for consistency in the field.
    The Coalition also supports the evaluation and analysis of APS 
programs using an evidence-based approach and best practices. To be 
effective, APS programs must have consistency and high quality 
nationally. Elder abuse happens in all States and congressional 
districts, and in some cases, elder abuse happens across county and 
State lines. Thus, having uniform best practices is key to ensuring 
that victims receive uniform services.
    Research in the elder abuse field, like data collection, is 
desperately needed. Money has never been specifically appropriated for 
research; the limited resources that the field has go straight into 
assisting victims. However, victims can be more appropriately--and 
cost-effectively--assisted if they are identified early via effective 
screening. A great deal of trauma can be prevented with effective 
screening. Thus, research into how to screen accurately is exceedingly 
important.
    This increased investment of $25 million would mean that current 
Federal and State resources could be used more effectively while also 
responding to elder abuse systematically. For these reasons, as well as 
the potential of lowering rates of future victimization, the investment 
would provide a solid return on investment.
    This is an investment because, according to the National Center on 
Elder Abuse, the direct medical costs associated with elder abuse now 
exceed $5 billion annually. Since these victims are older adults, 
Medicare and Medicaid bear the bulk of these costs. Other Federal 
programs may end up paying for elder abuse victims, including income 
support programs, because financial abuse victims who were once self-
supporting may lose everything in one scam. We can begin to save money 
for the Federal Government if we make this relatively small investment 
today.
    We also support maintaining, if not increasing, the amount of money 
available for Social Services Block Grant programs, which in addition 
to providing APS funding, also provides important funding for 
supportive services available to elder abuse victims. APS is primarily 
funded through optional State distributions from their Social Services 
Block Grant allotment; only 37 States provide any additional Federal 
funding for their Federal APS programs.
    Since the Elder Justice Act has many more important provisions that 
are not funded in this proposal, please view this $25 million as a 
floor to build on, and not a ceiling. We look forward to working with 
you to ensure that this elder justice appropriation provides our Nation 
with the best possible return on investment and outcomes.
    Thank you for your past and future support.

    [This statement was submitted by Robert Blancato, National 
Coordinator, Elder Justice Coalition.]
                                 ______
                                 
         Prepared Statement of the Eldercare Workforce Alliance
    Chairman Blunt, Ranking Member Murray, and members of the 
subcommittee: We are writing on behalf of the Eldercare Workforce 
Alliance (EWA), which is comprised of 31 national organizations united 
to address the immediate and future workforce crisis in caring for an 
aging America. As the subcommittee begins consideration of funding for 
programs in fiscal year 2017, the Alliance \1\ urges you to provide 
adequate funding for programs designed to increase the number of 
healthcare professionals prepared to care for America's growing senior 
population and to support family caregivers in the essential role they 
play in this regard.
---------------------------------------------------------------------------
    \1\ The positions of the Eldercare Workforce Alliance reflect a 
consensus of 75 percent or more of its members. This testimony reflects 
the consensus of the Alliance and does not necessarily represent the 
position of individual Alliance member organizations. The Eldercare 
Workforce Alliance is a project of The Advocacy Fund.
---------------------------------------------------------------------------
    Today's healthcare workforce is inadequate to meet the special 
needs of older Americans, many of whom have multiple chronic physical 
and mental health conditions and cognitive impairments. It is estimated 
that an additional 3.5 million trained healthcare workers will be 
needed by 2030 just to maintain the current level of access and 
quality. Without a national commitment to expand training and 
educational opportunities, the workforce will be even more constrained 
in its ability to care for the growth in the elderly population as the 
baby boomer generation ages. Reflecting this urgency, the Health 
Resources and Services Administration (HRSA) has identified ``enhancing 
geriatric/elder care training and expertise'' as one of its top five 
priorities.
    Of equal importance is supporting the legions of family caregivers 
who annually provide billions of hours of uncompensated care that 
allows older adults to remain in their homes and communities. The 
estimated economic value of family caregivers' unpaid care was 
approximately $470 billion in 2013, an increase from an estimated $450 
billion in 2009.
    The number of Americans over age 65 is expected to reach 70 million 
by 2030, representing a 71 percent increase from today's 41 million 
older adults. That is why Title VII geriatrics programs and 
Administration for Community Living (ACL) programs that support family 
caregivers, and the research efforts of the National Institute on Aging 
(NIA) are so critical to ensure that there is a skilled eldercare 
workforce and knowledgeable, well-supported family caregivers available 
to meet the complex and unique needs of older adults.
    Specifically, we recommend the following levels:
  --$45 million for Title VII Geriatrics Workforce Enhancement Program;
  --$197 million for Family Caregiver Support Programs;
  --$1.7 billion for National Institute on Aging; and
  --$9.7 million for additional workforce programs.

EWA specifically requests the following levels of funding:

Title VII Geriatrics Workforce Enhancement Progra1: \2\ Appropriations 
        Request: $45 Million
---------------------------------------------------------------------------
    \2\ In December 2014, HRSA combined the existing Title VIII 
Comprehensive Geriatric Education Program and the Title VII Geriatric 
Academic Career Award, Geriatric Education Centers, and Geriatric 
Training for Physicians, Dentists and Behavioral and Mental Health 
Providers programs into the Geriatrics Workforce Enhancement Program. 
The fiscal year 2016 Omnibus also consolidated these programs, citing 
HRSA's combined competition for the program.

    The Geriatrics Workforce Enhancement Program (GWEP) seeks to 
improve high quality, inter-professional geriatric education and 
training to the health professions workforce, including geriatric 
specialists, as well as increase geriatrics competencies of primary 
care providers and other health professionals to improve care for this 
often underserved population. It supports the development of a 
healthcare workforce that improves health outcomes for older adults by 
integrating geriatrics with primary care, maximizing patient and family 
engagement, and transforming the healthcare system.
    GWEP is the only Federal program that increases the number of 
faculty with geriatrics expertise in a variety of disciplines who 
provide training in clinical geriatrics, including the training of 
interdisciplinary teams of health professionals.
    In fiscal year 2015, the Title VII geriatrics programs provided 
continuing education on Alzheimer's disease and related dementias, 
among other topics, to more than 150,000 providers. Additionally, in 
academic year 2014-2015 alone, Title VII supported 54 fellows in 
medicine, geriatrics, dentistry, and psychiatry who cared for older 
adults. Overall, in the 2014-2015 academic year, these geriatrics and 
gerontology programs provided training to more than 200,000 
individuals.
    In May 2015, HRSA announced 41 three-year grant funded programs. 
For fiscal year 2017, we request increased funding for this program to 
close current geographic and demographic gaps in geriatric workforce 
training.

Administration for Community Living Family Caregiver Support: 
        Appropriations Request: $197 million

    These programs support caregivers, elders, and people with 
disabilities by providing critical respite care and other support 
services for family caregivers, training and recruitment of care 
workers and volunteers, information and outreach, counseling, and other 
supplemental services.
  --Family Caregiver Support Services: EWA requests $158.5 million. 
        This program provides a range of support services to 
        approximately 700,000 family and informal caregivers annually 
        in States, including counseling, respite care, training, and 
        assistance with locating services that assist family and 
        informal caregivers in caring for their loved ones.
  --Native American Caregiver Support: EWA requests $8 million. This 
        program provides a range of services to Native American 
        caregivers, including information and outreach, access 
        assistance, individual counseling, support groups and training, 
        respite care and other supplemental services.
  --Alzheimer's Disease Support Services: EWA requests $10.5 million. 
        One critical focus of this program is to support the family 
        caregivers who provide countless hours of unpaid care, thereby 
        enabling their family members with dementia to continue living 
        in the community. It funds evidence-based interventions and 
        expands the dementia-capable home and community-based services.
  --Lifespan Respite Care: EWA requests $5 million. This program funds 
        grants to improve access to respite care for family caregivers 
        of children or adults with special needs.
  --Family Support Initiative: EWA requests $15 million. The new 
        initiative will encourage use of community assets and 
        opportunities to help families reduce stress, improve emotional 
        well-being, develop support skills and knowledge, and plan for 
        the future. Special attention will be given to efforts that 
        assist families with balancing workforce participation and 
        caregiving responsibilities, and those facing the dual demands 
        of caring for older parents while raising children and/or 
        supporting a family member with disabilities.

National Institute on Aging: Appropriations Request: $1.7 billion

    The National Institute on Aging, one of the 27 Institutes and 
Centers of the National Institute of Health, leads a broad scientific 
effort to understand the aging process in order to promote the health 
and well-being of older adults. Funding will aid in researching 
training initiatives for the workforce that cares for older adults and 
research on physician-family communications during end-of-life and 
critical care.

Additional Workforce Programs: Appropriations Request: $9.7 million

  --National Health Care Workforce Commission: EWA requests $3 million. 
        The National Health Care Workforce Commission, established by 
        the ACA, plays a central role in formulating a national 
        strategy for bolstering the healthcare workforce in order to 
        meet the needs of the burgeoning numbers of older Americans. On 
        behalf of the members of the Eldercare Workforce Alliance, 
        thank you for your past support for geriatric workforce 
        programs.
  --Geriatric Career Incentive Awards Program: EWA requests $3.3 
        million. Congress authorized this new program through the ACA. 
        Assuming it is extended, these funds foster greater interest 
        among a variety of health professionals in entering the field 
        of geriatrics, long-term care, and chronic care management.
  --Training Opportunities for Direct Care Workers: EWA requests $3.4 
        million. In the ACA, Congress approved a program administered 
        by HHS that will offer advanced training opportunities for 
        direct care workers. While this vital training program was left 
        out of President Obama's budget, EWA believes Congress must 
        extend and fund it to create new employment opportunities by 
        offering new skills through training.
    On behalf of the members of the Eldercare Workforce Alliance, we 
commend you on your past support for geriatrics workforce programs and 
ask that you join us in supporting the eldercare workforce at this 
critical time--for all older Americans deserve quality care, now and in 
the future. Thank you for your consideration.

    [This statement was submitted by Nancy Lundebjerg, MPA, Alliance 
Co-Convener, and Michele Saunders, DMD, MS, MPH, Alliance Co-Convener.]
                                 ______
                                 
         Prepared Statement of the Emergency Nurses Association
    The Emergency Nurses Association (ENA), with more than 40,000 
members worldwide, is the only professional nursing association 
dedicated to defining the future of emergency nursing and emergency 
care through advocacy, expertise, innovation, and leadership. Founded 
in 1970, ENA develops and disseminates education and practice standards 
and guidelines, and affords consultation to both private and public 
entities regarding emergency nurses and their practice. ENA has a great 
interest in the work of the Senate Labor, Health and Human Services, 
Education Subcommittee and especially its efforts to improve the 
quality of emergency care for patients in the United States.
    For fiscal year 2017, ENA respectfully requests $28 million for 
Trauma and Emergency Care Programs (HHS; ASPR), $244 million for 
Nursing Workforce Development programs (HHS; HRSA), $20.213 million for 
the Emergency Medical Services for Children program (HHS; HRSA), 
$22.846 million to fund poison control centers (HHS; HRSA) and $157 
million for the National Institute of Nursing Research (HHS; NIH).
                   trauma and emergency care programs
    Trauma is the leading cause of death for persons younger than 44 
and the fourth-leading cause of death for all ages. In States with an 
established trauma system, patients are 20 percent more likely to 
survive a traumatic injury. Further, victims of traumatic injury 
treated at a Level I trauma center are 25 percent more likely to 
survive than those treated at a general hospital.
    Our trauma and emergency medical systems are designed to transport 
seriously injured individuals to trauma centers quickly. However, due 
to a lack of financial resources, 45 million Americans do not have 
access to a major trauma center within the ``golden hour'' following an 
injury when chances of survival are highest.
    Trauma and emergency care programs, which are authorized under the 
Public Health Service Act, provide much-needed money to the States to 
develop and enhance of trauma systems. These programs are critical to 
the efficient delivery of services through trauma centers, as well as 
to the development of regionalized systems of trauma and emergency care 
that ensure timely access for injured patients to appropriate 
facilities. This modest investment can yield substantial returns in 
terms of cost efficiencies and, most importantly, saved lives.
    Therefore, ENA respectfully requests $28 million in fiscal year 
2017 for trauma and emergency care programs.
                 nursing workforce development programs
    The nursing profession faces significant challenges to ensure that 
there will be an adequate number of qualified nurses to meet the 
growing healthcare needs of Americans.
    A growing elderly population will seek healthcare services in a 
multitude of settings and the care they depend upon will require a 
highly educated and skilled nursing workforce. In addition, demand for 
nurses will grow because of the increased emphasis on preventative care 
and the growing number of Americans with health insurance. A 2014 
projection from the U.S. Bureau of Labor Statistics' 2014 Occupational 
Outlook Handbook anticipates that the number of practicing RNs will 
grow 26 percent by 2020 and the employment of Advanced Practice 
Registered Nurses will grow even more rapidly.
    At the same time, the aging of the Baby Boom generation will 
deplete the nursing ranks as well. During the next 10 to 15 years, 
approximately one-third of the current nurse workforce will reach 
retirement age. The retirement of these experienced nurses has the 
potential to create a serious deficit in the nursing pipeline. At the 
same time, our colleges cannot keep up with the demand for new nurses. 
According to a 2013-2014 survey by the American Association of Colleges 
of Nursing, 78,089 qualified applications were turned away from nursing 
schools in 2013 alone.
    Title VIII Nursing Workforce Development programs address these 
factors and help support the training of qualified nurses. They not 
only enhance nursing education at all levels, from entry-level to 
graduate study, but they also support nursing schools that educate 
nurses for practice in rural and medically underserved communities. 
Another important part of Title VIII is the Faculty Loan Program which 
is critical to alleviating the large shortage in nursing faculty. 
Overall, more than 65,000 nurses and nursing students were trained and 
educated last year with the help of Title VIII nursing workforce 
development programs.
    Therefore, ENA respectfully requests $244 million in fiscal year 
2017 for the Nursing Workforce Development programs authorized under 
Title VIII of the Public Health Service Act.
                emergency medical services for children
    The Emergency Medical Services for Children (EMSC) program is the 
only Federal program that focuses specifically on improving the 
pediatric components of the emergency medical services (EMS) system. 
EMSC aims to ensure state-of-the-art emergency medical care for ill and 
injured children or adolescents; that pediatric services are well 
integrated into an EMS system backed by optimal resources; and that the 
entire spectrum of emergency services is provided to children and 
adolescents no matter where they live, attend school, or travel.
    The Federal investment in the EMSC program produces a wide array of 
benefits to children's health through EMSC State Partnership Grants, 
EMSC Targeted Issue Grants, the Pediatric Emergency Care Applied 
Research Network, and the National EMSC Data Analysis Resource Center.
    Therefore, ENA respectfully requests $20.213 million in fiscal year 
2017 for the EMSC program.
                         poison control centers
    Poisoning is the second most common form of unintentional death in 
the United States. In 2009, 31,768 deaths nationwide were attributed to 
unintentional poisoning. Children are especially vulnerable to injury 
by poisoning and each day 300 children are treated for poisoning in 
emergency departments across the country and two die.
    The Nation's 55 poison control centers handle 3.4 million calls 
each year, including approximately 680,000 calls from nurses and 
doctors who rely on poison centers for an immediate assessment and 
expert advice on poisoning cases.
    Not only are America's network of poison centers invaluable for 
treating victims of poisonings, but the work of the centers also 
results in substantial savings to our healthcare system. About 90 
percent of people who call with poison emergencies are treated at home 
and do not have to visit an emergency department. In more severe 
poisoning cases, the expertise provided by poison control centers can 
decrease the length of hospital stays. It has been estimated that every 
dollar spent on America's poison control centers saves $13.39 in 
healthcare costs and lost productivity. The positive impact to the 
Federal budget is also significant. A 2012 study by the Lewin Group 
found that poison control centers resulted in $313.5 million in savings 
to Medicare and $390.2 million in savings to Medicaid.
    Therefore, ENA respectfully requests $22.846 million in fiscal year 
2017 for poison control centers.
           the national institute of nursing research (ninr)
    As one of the 27 Institutes and Centers at the NIH, NINR funds 
research that lays the groundwork for evidence-based nursing practice. 
NINR's mission is to promote and improve the health of individuals, 
families, communities, and populations. The Institute supports and 
conducts clinical and basic research on health and illness to build the 
scientific foundation for clinical practice, prevent disease and 
disability, manage and eliminate symptoms caused by illness, and 
improve palliative and end-of-life care.
    NINR nurse-scientists examine ways to improve care models to 
deliver safe, high-quality, and cost-effective health services to the 
Nation. Our country must look toward prevention as a way of reducing 
healthcare expenditures and improving outcomes. The work of NINR is an 
important part of this effort.
    Moreover, NINR helps to provide needed faculty to support the 
education of future generations of nurses. Training programs at NINR 
develop future nurse-researchers, many of whom also serve as faculty in 
our Nation's nursing schools.
    Therefore, ENA respectfully requests $157 million in fiscal year 
2017 for the NINR.
                                 ______
                                 
              Prepared Statement of the Endocrine Society
    The Endocrine Society thanks the subcommittee for the opportunity 
to submit the following testimony regarding fiscal year 2017 Federal 
appropriations for biomedical research.
    The Endocrine Society is the world's largest and most active 
professional organization of endocrinologists representing more than 
18,000 members worldwide. Our organization is dedicated to promoting 
excellence in research, education, and clinical practice in the field 
of endocrinology. The Society's membership includes basic and clinical 
scientists who receive Federal support from the NIH to fund endocrine-
related research focusing on, among other challenges, diabetes, cancer, 
fertility, aging, obesity and bone disease. Our membership also 
includes clinicians who depend on new scientific advances to better 
treat and cure their patients' diseases.
 100 years of endocrine research: an investment in the nation's health
    Sustained investment by the United States Federal Government in 
biomedical research has dramatically advanced the health and improved 
the lives of the American people. The United States' NIH-supported 
scientists represent the vanguard of researchers making fundamental 
biological discoveries and developing applied therapies that advance 
our understanding of, and ability to treat human disease. Their 
research has led to new medical treatments, saved innumerable lives, 
reduced human suffering, and launched entire new industries.
    Endocrine scientists are a vital component of our Nation's 
biomedical research enterprise and integral to the healthcare 
infrastructure in the United States. Endocrine Society members study 
how hormones contribute to the overall function of the body, and how 
the glands and organs of the endocrine system work together to keep us 
healthy. Consequently, endocrinologists have a unique approach to and 
understanding of how the various systems of the human body communicate 
and interact to maintain health. The areas governed by the endocrine 
system are broad and essential to overall wellbeing; endocrine 
functions include reproduction, the body's response to stress and 
injury, sexual development, energy balance and metabolism, bone and 
muscle strength, and others. Endocrinologists study glands such as the 
adrenal glands, pancreas, thyroid, and specific sections of the brain, 
such as the hypothalamus, that control these glands. Endocrinologists 
also study interrelated systems, for example how hormones produced by 
fat can influence the development of bone disease.
    This year, the Endocrine Society is celebrating its centennial 
anniversary. The past 100 years have seen hundreds of millions of 
people helped by the lifesaving treatments and quality care developed 
through research on hormones funded by the Federal Government. Some 
examples include:
  --Endocrine scientists discovered and figured out how the hormone 
        insulin works, resulting in treatments for diabetes.
  --Endocrine scientists identified and characterized the effects of 
        hormones such as aldosterone on the heart, leading to new 
        treatments for heart failure.\1\
---------------------------------------------------------------------------
    \1\ Richard J. Auchus ``Classics in Cardiovascular Endocrinology: 
Aldosterone Action Beyond Electrolytes'' Endocrinology, February 2016, 
157(2):429-431.
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  --Endocrine scientists discovered that hormones produced by the 
        thyroid gland are necessary for normal cognitive and physical 
        development. Subsequent isolation and characterization of 
        thyroid hormones lead to the development of new, better, and 
        safer therapies for patients with thyroid disorders.\2\
---------------------------------------------------------------------------
    \2\ Anthony N. Hollenberg ``The Endocrine Society Centennial: The 
Thyroid Leads the Way'' Endocrinology, January 2016, 157(1):1-3.
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  --Endocrine scientists have used animal models for obesity to better 
        understand the neuroendocrine basis of obesity, discovering new 
        hormones that regulate energy balance and hunger, such as 
        leptin.\3\
---------------------------------------------------------------------------
    \3\ Manuel Tena-Sempere ``The Endocrine Society Centennial: Genes 
and Hormones in Obesity . . . or How Obesity Met Endocrinology'' 
Endocrinology, March 2016, 157(3):979-982.
---------------------------------------------------------------------------
  --Endocrine scientists improved our understanding of hormone-
        responsive cancers, such as estrogen-sensitive breast cancer. 
        This knowledge has improved our treatment of certain cancers; 
        tamoxifen, for example, has been used for over 30 years to 
        treat hormone-receptor positive breast cancer by selectively 
        blocking estrogen receptors.\4\
---------------------------------------------------------------------------
    \4\  http://www.cancer.gov/types/breast/breast-hormone-therapy-
fact-sheet#q6 Accessed April 11, 2016.
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                    the future of endocrine research
    More research progress is within reach and could lead to exciting 
new treatments for serious diseases, for example:
  --For patients with diabetes, new treatments could use stem cells 
        derived from skin cells to replace pancreatic cells lost during 
        the progression of the disease; more research has begun to 
        enable the creation of a bionic pancreas that automatically 
        responds to a patient's needs throughout the day.
  --New classes of drugs could be developed to combat the obesity 
        epidemic.\5\
---------------------------------------------------------------------------
    \5\ Ken K. Y. Ho ``Endocrinology: the next 60 years'' Journal of 
Endocrinology (2006) 190, 3-6.
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  --Combination approaches that combine chemotherapy with hormonal 
        therapy could improve the treatment of metastatic prostate 
        cancer.\6\
---------------------------------------------------------------------------
    \6\ Harrison Wein ``Combination Therapy for Metastatic Prostate 
Cancer'' NIH Research Matters August 24, 2015. http://www.nih.gov/news-
events/nih-research-matters/combination-therapy-metastatic-prostate-
cancer Accessed April 6, 2015.
---------------------------------------------------------------------------
  --Hormonal therapies could help women with primary ovarian 
        insufficiency restore their bone density to normal levels.\7\
---------------------------------------------------------------------------
    \7\ http://www.nih.gov/news-events/news-releases/hormone-treatment-
restores-bone-density-young-women-menopause-condition Accessed April 6, 
2015.
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    As we enter a new era of precision medicine, endocrine scientists 
are also learning how genetic and biologic markers can be used to 
understand what causes a disease, the risk factors that predispose to 
disease, and how patients will respond to a particular treatment. 
Translating these new discoveries and technologies into personalized 
patient care offers the possibility of more effective treatments, less 
toxicity, increased disease prevention, improved quality of life, and 
lower healthcare costs. Several endocrine-specific conditions are on 
the cusp of a breakthrough in diagnostic testing. The ability to test 
for specific genetic mutations that cause the syndrome of resistance to 
thyroid hormone can dramatically alter potential treatment options. 
Additionally, rare adrenal tumors called pheochromocytomas and 
paragangliomas are notoriously challenging to diagnose. Genetic tests 
can reduce delays in diagnosis, help determine whether a tumor is 
likely to be malignant, and provide doctors with critical data to help 
monitor family members who might also carry a problematic mutation.\8\
---------------------------------------------------------------------------
    \8\ Eric Seaborg, ``Family History.'' Endocrine News, Feb. 2015. 
15-17.
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               flat funding threatens scientific momentum
    The Endocrine Society was encouraged by the $2 billion increase for 
NIH in the fiscal year 2016 Omnibus Appropriations bill. This increase 
was desperately needed to allow the NIH to keep pace with inflation. 
However, the biomedical research community requires steady, sustainable 
increases in funding to ensure that the promise of scientific discovery 
can efficiently be translated into new cures. NIH grant success rates 
are predicted to remain at historically low averages, meaning that 
highly skilled scientists will continue to spend more time writing 
highly meritorious grants that will not be funded. Young scientists 
will also continue to be driven out of biomedical research careers due 
to the lack of funding.
    The lack of sustained Government support compounded by austerity 
measures such as sequestration has created an environment that is 
leading to a ``brain drain,'' as gifted scientists pursue other careers 
or leave the United States to develop important research breakthroughs 
and therapies elsewhere. In 2013, the number of NIH-supported 
scientists declined significantly, with nearly 1,000 NIH scientists 
dropping out of the workforce.\9\ NIH scientists run labs that support 
high-quality jobs and education while generating breakthrough 
innovations. In 2011, the NIH directly or indirectly supported over 
432,000 jobs across the country.\10\
---------------------------------------------------------------------------
    \9\ Jeremy Berg ``The impact of the sequester: 1,000 fewer funded 
investigators.'' ASBMB Today. March (2014). https://www.asbmb.org/
asbmbtoday/201403/PresidentsMessage/ Accessed March 20, 2014.
    \10\ Everett Ehrlich ``Engine Stalled: Sequestration's Impact on 
NIH and the Biomedical Research Enterprise.'' United for Medical 
Research. (2012).
---------------------------------------------------------------------------
    We may never be able to quantify the opportunities we have missed 
to improve the health and economic status of the United States due to 
persistent underinvestment in research. We do know however, that when 
``laboratories lose financing; they lose people, ideas, innovations and 
patient treatments.'' \11\ Based on the personal stories of researchers 
who have been forced to curtail research programs, we know that 
research programs to understand how genetics can influence heart 
disease, develop therapeutic treatments for Parkinson's disease, and 
evaluate the effect of metal contaminants on reproductive health, among 
many others, are delayed or terminated.\12\
---------------------------------------------------------------------------
    \11\ Teresa K. Woodruff ``Budget Woes and Research.'' The New York 
Times. September 10, 2013.
    \12\ Sequester Profiles: How Vast Budget Cuts to NIH are Plaguing 
U.S. Research Labs. United for Medical Research. http://
www.unitedformedicalresearch.com/advocacy_reports/sequestration-
profiles/ Accessed March 20, 2014.
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                  fiscal year 2017 nih funding request
    The Endocrine Society recommends that the Subcommittee provide at 
least $35 billion in funding for NIH in the fiscal year 2017 Labor-HHS-
Education appropriations bill. This funding recommendation represents 
the minimum investment necessary to avoid further loss of promising 
research and at the same time allows the NIH's budget to keep pace with 
biomedical inflation.
    It is critical that we continue to invest in biomedical research to 
improve the Nation's future financial situation. Rising healthcare 
costs threaten to consume an increasing percentage of the United 
States' GDP and also the individual budgets of workers and 
businesses.\13\ The cost of diabetes, in particular, represents a 
staggering $245 billion in 2012 alone.\14\
---------------------------------------------------------------------------
    \13\ Dan Mangan ``Job health insurance costs rising faster than 
wages.'' CNBC. 9 Dec. 2014. http://www.cnbc.com/id/102249938#. Accessed 
March 19, 2015.
    \14\ http://www.diabetes.org/advocacy/news-events/cost-of-
diabetes.html Accessed March 19, 2015.
---------------------------------------------------------------------------
    We live during an age of tremendous scientific opportunity that can 
only be realized through Federal funding of biomedical research. 
Researchers are just beginning to harness the power of big data to 
solve complicated problems. Innovative new experiments and clinical 
research hold promise to solve some of the United States' greatest 
medical challenges and discover new ways to improve our quality of 
life. Government support is critical to these opportunities, and we 
encourage the Appropriations Committee to actively support promising 
and innovative research. We fully understand that the Appropriations 
Committee faces challenging decisions in fiscal year 2017; however, we 
assert that additional cuts to the NIH and other non-defense 
discretionary programs is not the way to solve the budgetary issues 
facing the United States.
    The Endocrine Society remains deeply concerned about the future of 
biomedical research in the United States without sustained support from 
the Federal Government. Flat funding levels would threaten the Nation's 
scientific enterprise. The Society strongly supports increased Federal 
funding for biomedical research in order to provide the additional 
resources needed to enable American scientists to address scientific 
opportunities and maintain the country's status as the preeminent 
research engine in the world. The Endocrine Society therefore asks that 
the NIH receive at least $35 billion in fiscal year 2017.

    [This statement was submitted by Henry Kronenberg, MD, President, 
Endocrine Society.]
                                 ______
                                 
       Prepared Statement of the Entomological Society of America
    The Entomological Society of America (ESA) respectfully submits 
this statement for the official record in support of funding for 
arthropod-borne disease research at the U.S. Department of Health and 
Human Services (HHS). ESA requests a robust fiscal year 2017 
appropriation for the National Institutes of Health (NIH), including 
funding equal to fiscal year 2016 enacted levels for arthropod-borne 
disease research at the National Institute of Allergy and Infectious 
Diseases (NIAID). The Society also supports the President's increased 
investment in the core infectious diseases budget and the global health 
budget within the Centers for Disease Control and Prevention (CDC) in 
order to fund scientific activities related to vector-borne diseases.
    Cutting-edge research in the biological sciences, including the 
field of entomology, is essential for addressing societal needs related 
to environmental and human health. Many species of insects and their 
arachnid relatives (including ticks and mites) serve as vectors of a 
diversity of infectious diseases that threaten the health and well-
being of people across the globe, including populations in every State 
and territory of the United States and U.S. military personnel serving 
abroad. Vector-borne diseases can be particularly challenging to 
control; effective vaccines are not available for many of these 
diseases, and controlling the vectors is complicated by their mobility 
and their propensity for developing pesticide resistance. The risk of 
emerging infectious diseases grows as global travel increases in speed 
and frequency and as environmental conditions conducive to vector 
population growth continue to expand globally. The exponential rise of 
the Zika virus in the Americas is an example of the astonishing 
rapidity with which an insect-borne disease can become pandemic. 
Entomological research aimed at elucidating the relationships between 
arthropod vectors and the diseases they transmit--including, in the 
case of mosquitoes, dengue, Zika virus, and chikungunya, and, in the 
case of ticks, Lyme disease, human anaplasmosis and ehrlichiosis --is 
essential for reliable monitoring and prediction of outbreaks, 
effective prevention of disease transmission, and rapid diagnosis and 
treatment of diseases. The magnitude of the challenges presented by 
vector-borne diseases cannot be overstated; mosquitoes alone are 
considered responsible for the deaths of more people than all other 
animal species together (including humans). Given the enormous impact 
of arthropod vectors on human health, ESA urges the subcommittee to 
support vector-borne disease research programs that incorporate the 
entomological sciences as part of a comprehensive approach to 
addressing infectious diseases.
    NIH, the Nation's premier medical research agency, advances human 
health by support of research on basic human and pathogen biology and 
by development of prevention and treatment strategies. More than 80 
percent of NIH funding is competitively awarded to scientists at 
approximately 2,500 universities, medical schools, and other research 
institutions across the Nation. As one of NIH's 27 institutes and 
centers, NIAID conducts and supports fundamental and applied research 
related to the understanding, prevention, and treatment of infectious, 
immunologic, and allergic diseases. One example of NIAID-funded 
research on infectious diseases is a study examining the mechanism by 
which DEET, a widely used synthetic mosquito repellent discovered more 
than 60 years ago, is perceived by the southern house mosquito, a 
vector of St. Louis encephalitis and West Nile virus. DEET was shown to 
bind to and activate a specific odorant receptor on the antennae of 
female mosquitoes; moreover, inactivating the gene that codes for the 
receptor protein dramatically reduced the repellency of DEET. These 
investigators also showed that methyl jasmonate, a plant-derived 
mosquito repellent, activates the same receptor, opening up the 
possibility that this specific odorant receptor may be a useful target 
for developing new, safe and affordable repellents.\1\ Another example 
of infectious disease research supported by NIAID is an ongoing study 
aimed at understanding the molecular mechanisms underlying the feeding 
behavior of the black-legged tick and the lone star tick; these two 
species are principal vectors for multiple human tick-borne diseases in 
the United States, including Lyme disease. These ticks, which must feed 
for several days, remain attached to their hosts by producing an 
adhesive secretion known as tick cement. In this study, investigators 
are working to identify the proteins in tick cement that are injected 
first into the feeding site, before transmission of disease-causing 
pathogens, including the Lyme disease agent. Identifying these proteins 
and disabling them can provide an entirely new strategy for disrupting 
the transmission cycle of Lyme disease and other tick-borne human 
illnesses.\2\ To ensure funding for future groundbreaking projects of 
great utility for public health, ESA supports increased funding for 
NIAID and encourages the committee to support vector-borne disease 
research at NIH. In particular, ESA supports funding equal to the 
fiscal year 2016 enacted level of $1.375 billion for Biodefense and 
Emerging Infectious Diseases.
---------------------------------------------------------------------------
    \1\ Xu, P et al. 2014. Mosquito odorant receptor for DEET and 
methyl jasmonate. Proc. Natl. Acad. Sci. USA 111: 16593-16597 (NIAID 
NIH Award R01AI095514).
    \2\ Mulenga, A. 2016. Ixodes scapularis and Ambylomma americanum 
tick cement proteome. (NIAID NIH Award 1R21AI119873-01A1.
---------------------------------------------------------------------------
    CDC, serving as the Nation's leading health protection agency, 
conducts science and provides health information to prevent and respond 
to infectious diseases and other global health threats, irrespective of 
whether they arise naturally or via acts of bioterrorism. Within the 
core infectious diseases budget of CDC, the Division of Vector-Borne 
Diseases (DVBD) aims to protect the Nation from the threat of viruses 
and bacteria transmitted primarily by mosquitoes, ticks, and fleas. 
DVBD's mission is carried out by a staff of experts in several 
scientific disciplines, including entomology. For example, among the 
activities supported by DVBD are the ArboNET surveillance system for 
mosquito-borne diseases and the TickNET system for tick-borne diseases. 
ArboNET is a nationwide network managed by CDC and State health 
departments that monitors West Nile virus, Zika virus and other 
arthropod-borne diseases through a variety of activities, including the 
collection and testing of mosquitoes. TickNET is a partnership between 
State and local health departments and the CDC's Division of Vector-
Borne Diseases and Division of Parasitic diseases that tracks tick-
borne diseases such as Lyme disease and funds applied research aimed at 
prevention and pathogen discovery. As well, a component of CDC's global 
health budget supports activities on malaria and other parasitic 
diseases, which include maintaining a global reference insectary that 
houses colonies of mosquitoes from around the world to be used by the 
agency for studies on malaria transmission.
    Specifically, within the President's fiscal year 2017 budget 
request for CDC, there was a proposed increase of $34.6 million for 
Core Infectious Diseases over the fiscal year 2016 enacted level, which 
includes the vector-borne diseases program. The CDC fiscal year 2017 
budget justification also highlights the Zika virus, along with several 
other vector-borne diseases, including dengue, chikungunya, West Nile 
virus, and Lyme disease, as program priorities. ESA applauds the 
identification of vector-borne diseases as a fiscal year 2017 priority 
for CDC and encourages the inclusion of entomological sciences in 
future research addressing these diseases. Given that the contributions 
of the CDC are vital for the health security of the Nation, ESA 
requests that the subcommittee provide the President's requested 
increased support for CDC programs addressing vector-borne diseases.
    ESA, headquartered in Annapolis, Maryland, is the largest 
organization in the world serving the professional and scientific needs 
of entomologists and individuals in related disciplines. Founded in 
1889, ESA has nearly 7,000 members affiliated with educational 
institutions, health agencies, private industry, and government. 
Members are researchers, teachers, extension service personnel, 
administrators, marketing representatives, research technicians, 
consultants, students, pest management professionals, and hobbyists.
    Thank you for the opportunity to offer the Entomological Society of 
America's support for HHS research programs. For more information about 
the Entomological Society of America, please see http://
www.entsoc.org/.

    [This statement was submitted by May Berenbaum, Ph.D., President, 
Entomological Society of America.]
                                 ______
                                 
    Prepared Statement of the Federation of American Societies for 
                          Experimental Biology
    The Federation of American Societies for Experimental Biology 
(FASEB) respectfully requests a minimum of $35 billion in fiscal year 
2017 for the National Institutes of Health (NIH) within the Department 
of Health and Human Services.
    FASEB, a federation of 30 scientific societies, represents 125,000 
life scientists and engineers, making it the largest coalition of 
biomedical research associations in the United States. Our mission is 
to advance health and welfare by promoting progress and education in 
biological and biomedical sciences.
    The National Institutes of Health (NIH) is the largest source of 
funding for biomedical research in the world. Approximately 84 percent 
of NIH funds are distributed through more than 60,000 research and 
training grants to over 300,000 scientists employed at universities, 
medical schools, and other research institutions in all 50 States and 
nearly every congressional district. To date, 148 Nobel Laureates were 
funded by NIH over the course of their careers, including the 2015 
winners of the Nobel Prizes in Chemistry and Economics.
    NIH has produced an outstanding legacy of discoveries that have 
improved health, saved lives, generated new knowledge and trained 
generations of scientists. Investment in biomedical research funded by 
NIH has supported discoveries that reduced deaths from cancer and rates 
of disability due to stroke, heart disease, Hepatitis B, and 
osteoporotic fractures, prolonging life and reducing suffering. Many of 
these advances arose from scientists investigating questions designed 
to explain fundamental molecular, cellular, and biological mechanisms 
in non-human and even non-mammalian study systems. Research supported 
by NIH has expanded our understanding of the molecular roots of various 
cancers and led to important insights into how microbial communities 
affect a range of chronic diseases including diabetes. Investigators 
funded by NIH have also made critical advances in genomics and 
proteomics, leading to the discovery of more than a thousand risk 
factors for various diseases. In addition, entirely new global 
industries and innovative technologies have been created, stimulating 
our Nation's economic growth.
    New scientific breakthroughs such as advanced cellular imaging are 
being used to view the inner workings of living tissues in greater 
detail and with more accuracy. Basic research supported by NIH also 
fuels advances in our understanding of infectious diseases, improving 
the lives of millions of people worldwide.
    NIH-funded research is continuing to produce the insights that are 
needed for tomorrow's improvements in health and clinical care. Recent 
discoveries include:
  --Vaccines: Weapons in the Fight Against Disease: Vaccines are 
        powerful weapons in the fight against disease. They have 
        averted more than 100 million cases of disease in the United 
        States and continue to prevent 2.5 million deaths globally 
        every year. Using advances in immunology and molecular 
        genetics, scientists continue to develop new kinds of vaccines 
        that hold promise for better efficacy by eliciting immune 
        responses similar to those that occur naturally upon entry of 
        an intruding microbe. For example, researchers at the National 
        Institute of Allergy and Infectious Diseases have co-developed 
        a vaccine aimed at preventing the devastating disease, Ebola. 
        This vaccine was shown to be safe and induced an immune 
        response in human trials, and has moved on for further testing 
        in West African populations affected by this disease.\1\
---------------------------------------------------------------------------
    \1\ http://www.faseb.org/Portals/2/PDFs/opa/2015/10.23.15%20FASEB-
BreakthroughsIn
Bioscience-Vaccines%20-WEB.pdf.
---------------------------------------------------------------------------
  --The Microbiome: Our Personal Ecosystem: For more than 300 years, 
        scientists have observed, identified, and implicated individual 
        microorganisms in specific diseases. More recently, with a 
        convergence of scientific disciplines, an explosion in 
        technical capabilities, and revolutionary new ways of thinking, 
        scientists are exploring the organisms with which we share our 
        bodies. Understanding of the microorganisms that live in and on 
        us--our microbiome--will provide insights into how they can 
        influence human health and disease. NIH-funded researchers at 
        the Washington University in St. Louis recently discovered that 
        babies can be populated with their mother's microbes in utero 
        in contrast to the commonly held belief that the newborns' 
        microbiomes were not established until after birth. This 
        finding can help scientists further understand how a mother's 
        microbial status can impact the long-term health of the 
        child.\2\
---------------------------------------------------------------------------
    \2\ http://www.faseb.org/Portals/2/PDFs/opa/2015/
Breakthroughs%20In%20Bioscience%20
Human%20Microbiome.pdf.
---------------------------------------------------------------------------
  --Organs-on-a-Chip: Tools for Drug Discovery and Study of Disease: 
        This emerging technology of organs-on-a-chip allows scientists 
        to watch the cascade of events that takes place in organs in 
        response to drugs or during disease. These 3-D biochips contain 
        living human cells from an organ or tissue that can mimic the 
        mechanical motion of internal organs and structures. The 
        artery-on-a-chip developed by NIH-funded researchers at the 
        University of California Davis provides an unprecedented view 
        of how atherosclerosis develops in coronary arteries and how 
        activation of white blood cells related to inflammation 
        influences the risk of heart problems. This improved 
        understanding could lead to novel anti-inflammation therapies 
        and, eventually, to new tools to predict, monitor, and treat 
        atherosclerosis.\3\
---------------------------------------------------------------------------
    \3\ http://www.faseb.org/Portals/2/PDFs/opa/2015/FASEB-
HorizonsInBioscience-OrgansOnAChip-Web.pdf.
---------------------------------------------------------------------------
  --Nanoparticles: A Targeted Approach to Medicine: Nanomedicine is 
        beginning to change the way scientists and physicians diagnose 
        and treat disease. Unlike conventional therapies, these tiny 
        particles--1,000 times smaller than the diameter of a human 
        hair--can seek out diseased tissue and access hard to reach 
        places in the body. NIH-funded researchers at Clemson 
        University designed nanoparticles that can identify sites of 
        vascular injury in an animal model of cardiovascular disease. 
        Specialized imaging showed that the nanoparticles only adhere 
        to damaged blood vessels, while avoiding healthy tissue. In the 
        future, researchers hope to modify these nanoparticles to 
        deliver drugs to the sites of vascular injury and repair the 
        damaged tissue.\4\
---------------------------------------------------------------------------
    \4\ http://www.faseb.org/Portals/2/PDFs/opa/2015/
nanoparticles%20horizons%20article.pdf.
---------------------------------------------------------------------------
  --Precision Medicine: Fine-Tuning Disease Diagnosis and Treatment: 
        Precision medicine is a medical paradigm offering customizable 
        medicine based on one's genes that can be used to prevent, 
        diagnose, and treat disease. Innovations in precision medicine 
        come from technological advances that make it both feasible and 
        affordable to decipher a person's complete genetic make-up. 
        This new genetic landscape is already causing a paradigm shift 
        in how cancer is diagnosed and treated, with molecular 
        diagnosis adding to or replacing traditional pathological 
        diagnosis based on microscopic features of tumors. For example, 
        a group of scientists working with NIH's Cancer Genome Atlas 
        analyzed the DNA profiles of over 300 malignant melanoma cancer 
        tissues, the results of which unveiled a set of 13 genetic 
        mutations that can drive the cancer's growth and will enable 
        physicians to treat each patient with drugs targeted to the 
        specific mutation.\5\
---------------------------------------------------------------------------
    \5\ http://www.faseb.org/Portals/2/PDFs/opa/2014/
Individualized%20Medicine%20
Breakthroughs.pdf.
---------------------------------------------------------------------------
 sustained funding is critical to continue progress and take advantage 
                    of new scientific opportunities
    NIH needs sustained increases in funding to continue the research 
that paves the way to new therapies and to respond to urgent public 
health needs as they arise. We can now address new questions about 
biology and behavior that were previously thought to be unanswerable. 
New scientific breakthroughs such as advanced cellular imaging to view 
the inner workings of living tissues in greater detail and with more 
accuracy will be possible. Increasing collaborations between 
researchers from different fields of science are facilitating ideas for 
better strategies to prevent, diagnose, and treat a variety of 
diseases. As the fiscal year 2016-2020 NIH-wide strategic plan notes, 
``a strengthened and sustained commitment to NIH-supported research is 
critical because delays in scientific progress can have a dire impact 
on the health of individuals and the communities in which they live, as 
well as our Nation's overall public health and wellbeing''.\6\
---------------------------------------------------------------------------
    \6\ NIH-Wide Strategic Plan, fiscal years 2016--2020: Turning 
Discovery Into Health. http://www.nih.gov/sites/default/files/about-
nih/strategic-plan-fy2016-2020-508.pdf.
---------------------------------------------------------------------------
    The fiscal year 2017 appropriation for NIH must build on and expand 
the agency's capacity to fund research in order to improve quality of 
life, address the rising costs of caring for our aging population, and 
reduce illness and disability. In July 2015, the House of 
Representatives recognized the challenges facing the biomedical 
research enterprise and passed the 21st Century Cures Act (H.R. 6). The 
bipartisan bill, which was supported by more than 300 members of 
Congress, recommended that NIH receive an additional $3.0 billion per 
year in discretionary and mandatory funding in fiscal year 2016-2018. 
Related legislation is currently being developed in the U.S Senate.
    Congress took a much-needed first step towards fulfilling the goals 
of the 21st Century Cures Act by providing a $2 billion dollar increase 
for NIH in fiscal year 2016. We encourage Congress to continue the 
funding trajectory envisioned in this legislation as there are 
excellent proposals for outstanding research that are unable to be 
funded with current budget levels. When the American Recovery and 
Reinvestment Act enabled NIH institutes to support additional R01 
grants, analyses demonstrated that these added grants were as 
productive on a per-dollar basis as those that were funded with the 
regular appropriation.\7\ An increase of $3.0 billion for fiscal year 
2017 levels would enable NIH to fund more R01 grants while still 
providing much needed increases to other parts of the portfolio. If the 
percentage of the new funding used for R01 grants is the same as in 
prior years, NIH could fund more than 2,200 additional R01 grants. This 
would bring the total number of R01 grants back to the level supported 
in fiscal year 2003 (7,400), the highest in the agency's recent 
history.
---------------------------------------------------------------------------
    \7\ Narasimhan S. Danthi, Colin O. Wu, Donna M. DiMichele, W. Keith 
Hoots, and Michael S. Lauer, ``Citation Impact of NHLBI R01 Grants 
Funded Through the American Recovery and Reinvestment Act as Compared 
to R01 Grants Funded Through the Standard Payline,'' Circulation 
Research, 2015; 116:784-788.
---------------------------------------------------------------------------
    Sustained increases in funding are necessary for the NIH to 
continue to train and support the next generation of researchers. For 
example, increased funding can also be used to raise the stipends for 
postdocs and other trainees as recommended by FASEB.\8\ Additional 
funding can be used to supplement research and training grants by 5 
percent as a first step toward a multi-year commitment to reaching the 
target salary recommendations from the National Academy of Sciences,\9\ 
the National Postdoctoral Association,\10\ and FASEB.\11\
---------------------------------------------------------------------------
    \8\ Federation of American Societies for Experimental Biology, 
Sustaining Discovery, Bethesda, MD: FASEB.
    \9\ National Academies of Science. (2014). The Postdoctoral 
Experience Revisited. Washington, D.C.: The National Academies Press.
    \10\ National Postdoctoral Association website https://c.ymcdn.com/
sites/npamembers.site-ym.com/resource/resmgr/Docs/
NPA_Overtime_Response_-_08.2.pdf.
    \11\ In 2011, FASEB recommended a stipend level of $45,000 with 
subsequent cost of living increases.
---------------------------------------------------------------------------
    To continue to grow the Nation's capacity for biomedical research, 
and as a first installment of a multi-year program of sustainable 
increases, FASEB recommends at least $35.0 billion for NIH in fiscal 
year 2017.

                             FASEB MEMBERS

The American Physiological Society
American Society for Biochemistry and Molecular Biology
American Society for Pharmacology and Experimental Therapeutics
American Society for Investigative Pathology
American Society for Nutrition
The American Association of Immunologists
American Association of Anatomists
The Protein Society
Society for Developmental Biology
American Peptide Society
Association of Biomolecular Resource Facilities
The American Society for Bone and Mineral Research
American Society for Clinical Investigation
Society for the Study of Reproduction
The Teratology Society
The Endocrine Society
The American Society of Human Genetics
International Society for Computational Biology
American College of Sports Medicine
Biomedical Engineering Society
Genetics Society of America
American Federation for Medical Research
The Histochemical Society
Society for Pediatric Research
Society for Glycobiology
Association for Molecular Pathology
Society for Redox Biology and Medicine
Society for Experimental Biology and Medicine
American Aging Association
U.S. Human Proteome Organization
                      
                                 ______
                                 
                   Prepared Statement of First Focus
    Thank you for the opportunity to submit a statement for the record 
on the fiscal year 2017 Labor, Health and Human Services and Education 
Appropriations bill. On behalf of First Focus, I respectfully request 
you fund the following critical programs that greatly benefit children 
and families accordingly:
U.S. Department of Health and Human Services
  --The Runaway and Homeless Youth Act (RHYA) programs, $165,000,000;
  --Child Care and Development Block Grant (CCDBG), $3,961,000,000;
  --Head Start and Early Head Start, $9,602,095,000;
  --Childhood Lead Poisoning Prevention Program, $35,000,000; and
  --Healthy Homes Program, $35,000,000
U.S. Department of Education
  --McKinney-Vento Education for Homeless Children and Youth (EHCY) 
        program, $85,000,000
                           investing in kids
    First Focus is a bipartisan children's advocacy organization 
dedicated to making children and families the priority in Federal 
policy and budget decisions. Our organization is committed to ensuring 
that all of our Nation's children have equal opportunity to reach their 
full potential.
    There are more than 200 distinct child and family programs and the 
Appropriations Subcommittee on Labor, Health & Human Services and 
Education has jurisdiction over many. Every year for the last 10 years, 
First Focus has published an annual Children's Budget book that offers 
a detailed analysis and guide to Federal spending levels and priorities 
on children and families.
    Last year's Children's Budget 2015 showed that the share of Federal 
spending dedicated to children fell to just 7.89 percent, down from its 
highest level of 8.5 percent in 2010. Consequently, the Federal share 
of discretionary spending dedicated to children has dropped by 7.2 
percent over the last 5 years.
    On an inflation-adjusted basis, Federal discretionary spending on 
children has dropped by 11.6 percent between 2010 and 2015. 
Discretionary funding dedicated to children's health, education, child 
welfare, training, safety, and nutrition have all decreased, even 
without adjusting for inflation.
    We ask that you reverse this trend and increase funding for these 
critical programs under your subcommittee's jurisdiction that benefit 
children.
The Runaway and Homeless Youth Act Programs

 
 
 
Agency:                          U.S. Department of Health and Human
                                  Services
FY 2017 Request:                 $165,000,000
 

    National estimates have found that 1.3 to 1.7 million youth 
experience one night of homelessness a year with 550,000 youth being 
homeless for a week or longer. As a result of these significant 
numbers, we request $165 million for the Runaway and Homeless Youth Act 
programs.
    The funding would help prevent trafficking, identify survivors, and 
provide services to runaway, homeless and disconnected youth. Previous 
funding has laid the foundation for a national system of services for 
our most vulnerable young people who are at risk of becoming or have 
already been victims of exploitation and trafficking, abuse, familial 
rejection, unsafe communities, and poverty.
Child Care and Development Block Grant

 
 
 
Agency:                          U.S. Department of Health and Human
                                  Services
FY 2017 Request:                 $3,961,000,000
 

    There is great promise in the reforms included in the bipartisan 
reauthorization of CCBDG. Unfortunately, there is still insufficient 
funding to implement these reforms, which are designed to achieve the 
important goals of ensuring the health and safety of child care, 
improve quality of care, and make it easier for families to obtain and 
retain child care assistance. Without a significant increase in CCDBG 
funding, States may be forced to cut the number of children receiving 
child care assistance or reduce payment rates for already low-paid 
child care providers. We request $3.961 billion for the Child Care and 
Development Block Grant to make high-quality child care more available 
and affordable for the families who need it most.
Head Start and Early Head Start

 
 
 
Agency:                          U.S. Department of Health and Human
                                  Services
FY 2017 Request:                 $9,602,095,000
 

    Head Start and Early Head Start play an important role in providing 
vulnerable children under age five with the comprehensive care and 
education that they need to prepare for school. At the current funding 
level, Head Start can serve only slightly over two out of five eligible 
preschoolers. Early Head Start serves just 4 percent of eligible 
infants and toddlers. Proposals for more Head Start programs to provide 
full-school-day, full-school-year services would help to ensure that 
our lowest-income children receive a strong early learning experience. 
We request $9,602,095,000 for Head Start and Early Head Start to 
improve the outcomes of our earliest learners and future generations.
Childhood Lead Poisoning Prevention Program

 
 
 
Agency:                          U.S. Department of Health and Human
                                  Services
FY 2017 Request:                 $35,000,000
 

    Current lead poisoning surveillance is limited to 29 States and the 
District of Columbia due to severe funding cuts. National lead 
poisoning surveillance would enable communities to identify lead 
poisoning outbreaks to prevent catastrophes such as that of Flint, 
Michigan.
    The Centers for Disease Control and Prevention is the only agency 
that houses the information regarding where and when children are 
poisoned, maintaining it through a surveillance system that monitors 
blood test results for 4 million children each year. The U.S. 
Department of Housing and Urban Development (HUD), as well as State and 
local health and housing agencies, rely on this surveillance system to 
target funds and enforcement to the highest-risk areas. The recent 
funding cuts have geographically restricted the surveillance effort and 
hurt local health departments in their prevention and case management 
efforts. We request $35 million for the Childhood Lead Poisoning 
Prevention program.
Healthy Homes Program

 
 
 
Agency:                          U.S. Department of Health and Human
                                  Services
FY 2017 Request:                 $35,000,000
 

    The Healthy Homes Program helps children and families avoid the 
effects multiple childhood diseases and injuries in the home. This 
initiative takes a comprehensive approach to these activities by 
focusing on housing-related hazards in a coordinated effort, rather 
than addressing a single hazard at a time.
    Through robust grants, enforcement efforts, research, and outreach, 
the Healthy Homes program has been instrumental in achieving a 70 
percent reduction in childhood lead poisoning cases since the early 
1990s. In addition to saving lives and improving the health of 
children, this program has saved the Nation billions of dollars by 
increasing productivity, decreasing medical and special education 
costs, and potentially reducing criminal activity. In order to continue 
this progress, we request $35 million for the Healthy Homes program.
McKinney-Vento Education for Homeless Children and Youth Program

 
 
 
Agency:                          U.S. Department of Education
FY 2017 Request:                 $85,000,000
 

    Public schools identified a record 1,301,239 homeless children and 
youth in 2013-2014. This is a 7 percent increase from the previous 
year, and a 100 percent increase since 2006-2007. With this rise in 
homeless children and youth, we request $85 million to implement the 
McKinney-Vento Act's Education for Homeless Children and Youth program. 
This amount was authorized in the recently enacted Every Student 
Succeeds Act which is an increase of $10 million.
    This funding would provide services to and identify homeless 
children and youth, who are at high risk of human trafficking. The EHCY 
program is effective in mitigating the devastating effects of child and 
youth homelessness. With the support of EHCY program grants, local 
education agencies have provided identification, enrollment and 
transportation assistance, as well as academic support and referrals 
for basic services. The EHCY program has given homeless children and 
youth the extra support they need to enroll and succeed in school.

    [This statement was submitted by Bruce Lesley, President, First 
Focus.]
                                 ______
                                 
                  Prepared Statement of Food & Friends
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIVIAIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Food & Friends is part of a nationwide coalition, the Food is 
Medicine Coalition, of over 80 food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide over 1 million 
medically tailored, home delivered meals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWTI enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, arc fundamental to 
making healthcare work for PWH. Support services for PWH arc not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docslkey_resources/housing_and_supportive_services/
chain factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(20 I I); Singe A W, Weiser SO, McCoy, Sl. Does Food Insecurity 
Undermine Adherence to Antiretroviral Therapy? A Systematic Review. 
AIDS Behav (2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141 st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use or 
        antiretroviral therapy \6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. JAm Diet Assoc. (1998) 98: 434-438; 
Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment 
to nutritional counseling in malnourished HTV-infected patients: 
randomized controlled trial. Clinical Nutrition (1999) 18(6): 371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M.S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . IIPTN 
052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SO Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association I 41st Annual Meeting, Boston, MA, November 
5, 2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HlV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, I Iogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Craig Shniderman, Executive 
Director, Food & Friends.]
                                 ______
                                 
     Prepared Statement of the Food Bank of Contra Costa and Solano
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    The Food Bank of Contra Costa and Solano is part of a nationwide 
coalition, the Food is Medicine Coalition, of over 80 food and 
nutrition services providers, affiliates and their supporters across 
the country that provide food and nutrition services to people living 
with HIV/AIDS (PWH) and other chronic illnesses. Through the Food Bank 
of Contra Costa's Extra Helpings program, we provide 30 pounds of 
nutritious food at no cost to over one hundred people living with HIV. 
Collectively, the Food is Medicine Coalition is committed to increasing 
awareness of the essential role that food and nutrition services (FNS) 
play in successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Carly Finkle, Advocacy Manager, 
Food Bank of Contra Costa and Solano.]
                                 ______
                                 
Prepared Statement of the Foundation for Individual Rights in Education
    Dear Chairman Cochran, Vice-Chairwoman Mikulski, Chairman Blunt, 
and Ranking Member Murray: The Foundation for Individual Rights in 
Education (FIRE; thefire.org) is a nonpartisan, nonprofit organization 
dedicated to defending student and faculty rights on America's college 
and university campuses. These rights include freedom of speech, 
freedom of assembly, legal equality, due process, religious liberty, 
and sanctity of conscience--the essential qualities of individual 
liberty and dignity. We write to express our opposition to requests for 
increasing the funding of the Department of Education's Office for 
Civil Rights (OCR) in the upcoming appropriations legislation.
    As you are aware, on March 17, 2016, 22 Senators sent a joint 
letter urging the Subcommittee on Labor, Health and Human Services, and 
Education to increase OCR's funding from $102 million to $137.7 million 
for fiscal year 2017. If this request were to be approved, it would 
amount to an increase of nearly 30 percent over the agency's funding 
for the current fiscal year.
    While FIRE supports OCR's goal of effectively addressing sexual 
assault and sexual harassment on college campuses, we have serious 
concerns about the manner in which the agency is pursuing that mission. 
In pursuit of this objective, OCR has unlawfully ordered institutions 
of higher education to reduce the due process protections afforded to 
individuals accused of sexual misconduct and has redefined sexual 
harassment to include speech protected by the First Amendment under 
precedent from the Supreme Court of the United States. Until OCR stops 
infringing on the First Amendment and rolling back due process 
protections, the agency should not receive budget increases.
    It should be self-evident that institutions adjudicating guilt or 
innocence in sexual assault cases must do so in a fair and impartial 
manner reasonably calculated to reach the truth. Indeed, in the April 
4, 2011, ``Dear Colleague'' letter issued by OCR, the agency 
acknowledged that ``a school's investigation and hearing processes 
cannot be equitable unless they are impartial.'' \1\
---------------------------------------------------------------------------
    \1\ U.S. Dep't of Educ., Office for Civil Rights, Dear Colleague 
Letter: Sexual Violence (Apr. 4, 2011), http://www2.ed.gov/about/
offices/list/ocr/letters/colleague-201104.html.
---------------------------------------------------------------------------
    Disappointingly, however, OCR's own rhetoric and actions have been 
decidedly one-sided, almost exclusively emphasizing the rights of the 
complainant while paying little to no attention to the rights of the 
accused. For example, OCR has mandated that institutions of higher 
education utilize our judiciary's lowest burden of proof, the 
``preponderance of the evidence'' standard, despite the absence of any 
of the fundamental procedural safeguards found in civil courts of law. 
Without basic procedural protections, campus tribunals are making life-
altering findings using a low evidentiary threshold that amounts to 
little more than a hunch that one side is right. This mandate is not 
just unfair to the accused--it reduces the accuracy and reliability of 
the findings and compromises the integrity of the system as a whole.
    Gary Pavela, editor of the Association of Student Conduct 
Administration's Law and Policy Report and former president of the 
International Center for Academic Integrity, recently told Inside 
Higher Ed that ``[c]olleges and universities are escalating and 
criminalizing the prosecution of sexual misconduct cases, while 
eliminating basic due process for the accused.'' \2\ He continued:
---------------------------------------------------------------------------
    \2\ Jake New, Out of Balance, Inside Higher Ed (Apr. 14, 2016), 
https://www.insidehighered.com/news/2016/04/14/several-students-win-
recent-lawsuits-against-colleges-punished-them-sexual-assault.

    Title IX does not require this approach and courts are unlikely to 
        allow it. Silence on procedural fairness, however, sends the 
        subliminal message that due process is an impediment to more 
        ``convictions.'' We're seeing the fruits of OCR's due process 
        silence now. University sexual misconduct policies are losing 
        legitimacy in the eyes of the courts. That's a disaster for 
        Title IX enforcement. And OCR shares ample responsibility for 
        it.
    The merits of the preponderance of the evidence standard aside, 
there is little doubt that OCR's insistence that institutions of higher 
education use any particular standard exceeds the agency's authority. 
The Dear Colleague letter was not subjected to the notice-and-comment 
process required under the Administrative Procedure Act before an 
agency like OCR can impose new substantive rules.\3\ Despite repeated 
sworn testimony to congressional committees from top officials at the 
Department of Education insisting that the terms of the Dear Colleague 
letter are not binding on institutions of higher education,\4\ OCR 
continues to demand conformance with those terms when negotiating 
agreements with institutions of higher education.\5\
---------------------------------------------------------------------------
    \3\ 5 U.S.C. Sec. 553.
    \4\ Help Committee GOP, Alexander Questions Dept. of Ed. Witness at 
HSGAC Hearing on Regulatory Guidance, YouTube (Sept. 23, 2015), https:/
/www.youtube.com/watch?v=dIiXuv-Oirw; Joe Cohn, Second Department of 
Education Official in Eight Days Tells Congress Guidance Is Not 
Binding, Found. for Individual Rights In Educ.: The Torch (Oct. 2, 
2015), https://www.thefire.org/second-department-of-education-official-
in-eight-days-tells-congress-guidance-is-not-binding.
    \5\ See, e.g., U.S. Dep't of Educ., Office for Civil Rights, OCR 
Review No. 11-11-6001, UVA Letter of Finding (Sept. 21, 2015), http://
www2.ed.gov/documents/press-releases/university-virginia-letter.pdf; 
U.S. Dep't of Educ., Office for Civil Rights, OCR Review No. 15-11-2098 
and 15-14-2113, MSU Letter of Finding (Sept. 1, 2015), http://
www2.ed.gov/documents/press-releases/michigan-state-letter.pdf; U.S. 
Dep't of Justice, Civil Rights Division, and U.S. Dep't of Educ., 
Office for Civil Rights, DOJ No. DJ 169-44-9, OCR No. 10126001, UM 
Letter of Finding (May 9, 2013), https://www.justice.gov/sites/default/
files/opa/legacy/2013/05/09/um-ltr-findings.pdf.
---------------------------------------------------------------------------
    The agreement OCR and the Department of Justice entered into with 
the University of Montana on May 9, 2013, is a particularly galling 
example of OCR's willingness to exceed its authority. In the findings 
letter accompanying that agreement, OCR rejected the university's 
sexual harassment policy, stating that ``sexual harassment should be 
more broadly defined as `any unwelcome conduct of a sexual nature,' '' 
including ``verbal conduct''--that is, speech. The letter, which 
proclaimed itself a ``blueprint'' for schools across the Nation to 
follow, then explicitly stated that allegedly harassing expression need 
not even be offensive to an ``objectively reasonable person of the same 
gender in the same situation.'' If the listener takes offense to sex-
related speech for any reason, no matter how irrationally or 
unreasonably, the speaker may be punished. To comply with this 
``blueprint,'' institutions nationwide are adopting unconstitutionally 
broad speech codes.\6\
---------------------------------------------------------------------------
    \6\ Found. for Individual Rights In Educ., Spotlight on Speech 
Codes 2016: The State of Free Speech on Our Nation's Campuses, 
available at https://www.thefire.org/spotlight-on-speech-codes-2016.
---------------------------------------------------------------------------
    OCR's overreach is so blatant that it has drawn criticism from 
Senators Lamar Alexander \7\ and James Lankford,\8\ the American 
Association of University Professors,\9\ Feminists for Free 
Expression,\10\ the National Coalition Against Censorship,\11\ former 
American Civil Liberties Union president and New York Law School 
professor Nadine Strossen,\12\ columnist George Will,\13\ and 
University of California System president and former secretary of the 
Department of Homeland Security Janet Napolitano.\14\ Napolitano's 
observations are particularly noteworthy:
---------------------------------------------------------------------------
    \7\ Susan Kruth, Senators Ask Key Questions at Hearing on Campus 
Sexual Assault, Found. for Individual Rights In Educ.: The Torch (June 
30, 2014), https://www.thefire.org/senators-ask-key-questions-at-
hearing-on-campus-sexual-assault.
    \8\ Letter from Senator James Lankford to Acting Secretary John B. 
King, Jr., U.S. Department of Education (Jan. 7, 2016), available at 
https://www.thefire.org/sen-james-lankford-letter-to-the-education-
department.
    \9\ The History, Uses, and Abuses of Title IX, Am. Ass'n of Univ. 
Professors (Mar. 24, 2016), http://www.aaup.org/file/TitleIX-
Report.pdf.
    \10\ Dept. of Education Challenged by FIRE, Coalition about Silence 
on Threats to Student Rights, Found. for Individual Rights In Educ.: 
The Torch (May 7, 2012), https://www.thefire.org/dept-of-education-
challenged-by-fire-coalition-about-silence-on-threats-to-student-rights 
(listing Feminists for Free Expression as a member of the coalition 
challenging the Department of Education).
    \11\ Id.
    \12\ Alex Morey, Strossen Praises FIRE at Harvard Free Press 
Lecture, Criticizes OCR for Chilling Speech, Found. for Individual 
Rights In Educ.: The Torch (Oct. 21, 2015), https://www.thefire.org/
strossen-praises-fire-at-harvard-free-press-lecture-criticizes-ocr-for-
chilling-speech.
    \13\ George F. Will, The legislative and judicial branches strike 
back against Obama's overreach, Wash. Post (Feb. 19, 2016), https://
www.washingtonpost.com/opinions/the-legislative-and-judicial-branches-
strike-back-against-obamas-overreach/2016/02/19/15f403b8-d672-11e5-
be55-2cc3c1e4b76b_story.html.
    \14\ Janet Napolitano, ``Only Yes Means Yes'': An Essay on 
University Policies Regarding Sexual Violence and Sexual Assault, 33 
Yale L. & Pub. Pol'y 387 (2015), available at http://ylpr.yale.edu/
sites/default/files/YLPR/33.2_policy_essay_-_napolitano_final.pdf.
---------------------------------------------------------------------------
    Unfortunately, OCR neglected to provide notice or an opportunity 
for comment in advance of issuing either the Dear Colleague Letter or 
the April 2014 Questions and Answers guidance regarding Title IX and 
sexual violence, even though both documents clearly imposed new 
mandates on schools. Campuses facing these new mandates had no 
opportunity to provide feedback for the Department of Education's 
consideration prior to the issuance of the guidance documents and were 
left with significant uncertainty and confusion about how to 
appropriately comply after they were implemented.\15\
---------------------------------------------------------------------------
    \15\ Id. at 394-95.
---------------------------------------------------------------------------
    FIRE is eager to work with Congress and OCR to effectively address 
campus sexual assault and sexual harassment. But until Congress holds 
OCR accountable for its unlawful abuse of power and its blatant 
disregard for campus civil liberties, the agency will continue to both 
exceed its authority and take an inappropriately one-sided approach to 
addressing these issues.
    We hope that Congress requires OCR to abide by the rule of law 
before it rewards the agency with a budget increase.
    Thank you for your consideration of our testimony. We would be 
pleased to discuss our concerns with you further. I may be reached via 
email (joe@thefire.org) at your convenience.
    Respectfully.

    [This statement was submitted by Joseph Cohn, Legislative and 
Policy Director, Foundation for Individual Rights in Education.]
                                 ______
                                 
Prepared Statement of the Friends of the Health Resources and Services 
                             Administration
    Friends of HRSA is a nonpartisan coalition of 170 national 
organizations representing millions of public health and healthcare 
professionals, academicians and consumers invested in the Health 
Resources and Services Administration's mission to improve health and 
achieve health equity. For fiscal year 2017, we recommend restoring 
HRSA's discretionary budget authority to the fiscal year 2010 level of 
$7.48 billion. HRSA is the primary Federal agency responsible for 
improving health, and does so through access to quality health 
services, a skilled workforce and innovative programs. Over the past 3 
years, HRSA's discretionary budget authority has slowly been restored, 
but still remains nearly 18 percent below the fiscal year 2010 level--
far too low to fully address the Nation's current health needs. 
Restoring funding to HRSA will allow the agency to more effectively 
fill preventive and primary care gaps.
    Our Nation's ability to deliver health services that meet the 
pressing health challenges of the 21st century is essential for a 
healthy and thriving population. To meet our Nation's persistent and 
changing health needs, and to keep pace with our growing, aging and 
diversifying population, and evolving healthcare system, we must make 
deliberate investments in robust systems of care and a high-performing 
workforce ready to respond to the current demands and able to take on 
unexpected health needs as they arise. The agency is continuously 
exploring and supporting efforts that drive quality care, better 
leverage existing investments and achieve improved health outcomes at a 
lower cost. HRSA's programs have been successful in improving the 
health of people at highest risk for poor health outcomes.
    HRSA operates programs in every State and U.S. territory. The 
agency is a national leader in improving the health of Americans by 
addressing the supply, distribution and diversity of health 
professionals and supporting training in contemporary practices, and 
providing quality health services. HRSA programs work in coordination 
with each other to maximize resources and leverage efficiencies. For 
example, Area Health Education Centers, a health professions training 
program, was originally authorized at the same time as the National 
Health Service Corps to create a complete mechanism to provide primary 
care providers for health centers and other direct providers of 
healthcare services for underserved areas and populations. AHECs serve 
as an integral part of the mechanism that recruits providers into 
primary healthcareers, diversifies the workforce and develops a passion 
for service to the underserved in these future providers.
    HRSA's programs also work synergistically across the Federal 
Government to enhance health outcomes. Through maternal and child 
health programs, HRSA has contributed to the decrease in infant 
mortality rate, a widely used indicator of the Nation's health. While 
HRSA has contributed to driving down the national rate, which is now at 
a historic low of 5.8 deaths per 1,000 live births, it would not have 
been possible without the effort of other Federal public health 
programs, including those that address perinatal care, cessation 
programs for tobacco and other substances, healthy eating and physical 
activity programs, among other efforts.
    HRSA grantees also have the potential to play an active role in 
addressing emerging health challenges. For example, HRSA's programs are 
well positioned to provide outreach, education, prevention, screening 
and treatment services for populations at risk for or infected with the 
Zika virus and are already doing so in Puerto Rico and affected 
territories. However, as we approach warmer months and the opportunity 
to encounter mosquitos that can spread the Zika virus increases, 
additional funding will be required to increase capacity in health 
centers, support additional National Health Service Corps providers to 
deliver the care needed and expand maternal and child health services. 
Strong, sustained funding would allow HRSA to build a consistent 
approach to quickly and effectively respond to emerging and 
unanticipated future needs, while continuing to address persistent 
health challenges.
    Our recommendation is based on the need to continue improving the 
health of Americans and to provide HRSA with the resources needed to 
pave the way for new achievement by supporting critical HRSA programs, 
including:
  --Primary care programs support more than 9,000 health center sites 
        in every State and territory, improving access to preventive 
        and primary care for more than 22.9 million patients in 
        geographic areas with few healthcare providers. Health centers 
        coordinate a full spectrum of health services including 
        medical, dental, behavioral and social services. Close to half 
        of all health centers serve rural populations. For 50 years, 
        health centers have delivered comprehensive, cost-effective 
        care for people who otherwise may not have obtained care and 
        have demonstrated their ability to reduce the use of costlier 
        providers of care.
  --Health workforce programs support the education, training, 
        scholarship and loan repayment of primary care physicians, 
        nurses, oral health professionals, optometrists, physician 
        assistants, nurse practitioners, clinical nurse specialists, 
        public health personnel, mental and behavioral health 
        professionals, pharmacists and other allied health providers. 
        With a focus on primary care and training in interdisciplinary, 
        community-based settings, these are the only Federal programs 
        focused on filling the gaps in the supply of health 
        professionals, as well as improving the distribution and 
        diversity of the workforce so that health professionals are 
        well-equipped to care for the Nation's changing needs and 
        demographics.
  --Maternal and child health programs, including the Title V Maternal 
        and Child Health Block Grant, Leadership Education in 
        Neurodevelopmental and Related Disabilities, Healthy Start and 
        others support initiatives designed to promote optimal health, 
        reduce disparities, combat infant mortality, prevent chronic 
        conditions and improve access to quality healthcare for 34.3 
        million children. MCH programs help assure that nearly all 
        babies born in the U.S. are screened for a range of serious 
        genetic or metabolic diseases and that coordinated long-term 
        follow-up is available for babies with a positive screen, and 
        also help improve early identification and coordination of care 
        for children with autism and other developmental disabilities.
  --HIV/AIDS programs provide the largest source of Federal 
        discretionary funding assistance to States and communities most 
        severely affected by HIV/AIDS. The Ryan White HIV/AIDS Program 
        delivers comprehensive care, prescription drug assistance and 
        support services to 512,000 people living with HIV/AIDS, which 
        accounts for nearly half of the total population living with 
        the disease in the U.S. Additionally, the programs provide 
        education and training for health professionals treating people 
        with HIV/AIDS and work toward addressing the disproportionate 
        impact of HIV/AIDS on racial and ethnic minorities. People 
        receiving care through the Ryan White HIV/AIDS Program achieve 
        significantly higher viral suppression compared to the national 
        average, and viral suppression is central to preventing new HIV 
        infections.
  --Family planning Title X services ensure access to a broad range of 
        reproductive, sexual and related preventive health services for 
        more than 4.1 million low-income women, men and adolescents. 
        Services include patient education and counseling, cervical and 
        breast cancer screening, sexually transmitted disease 
        prevention education, testing and referral, as well as 
        pregnancy diagnosis and counseling. This program helps improve 
        maternal and child health outcomes and promotes healthy 
        families. In 2014, Title X family planning helped prevent over 
        941,000 unintended pregnancies and an estimated 1,176 cases of 
        sexually transmitted disease-related infertility.
  --Rural health programs improve access to care for people living in 
        rural areas. The Office of Rural Health Policy serves as the 
        Nation's primary advisor on rural policy issues, conducts and 
        oversees research on rural health issues and administers grants 
        to support healthcare delivery in rural communities. Rural 
        health programs are designed to support community-based disease 
        prevention and health promotion projects, help rural hospitals 
        and clinics implement new technologies and strategies and build 
        health system capacity in rural and frontier areas. In addition 
        to improving the health of rural residents, an analysis 
        completed in 2013 showed that for every dollar HRSA invested, 
        about $1.63 in additional revenue was generated in the 
        community--the cumulative impact added up to $19.4 million in 
        new local economic activity over a 3-year project period of an 
        original investment of $11.9 million.
  --Special programs include the Organ Procurement and Transplantation 
        Network, the National Marrow Donor Program, the C.W. Bill Young 
        Cell Transplantation Program and National Cord Blood Inventory. 
        These programs maintain and facilitate organ marrow and cord 
        blood donation, transplantation and research, along with 
        efforts to promote awareness and increase organ donation rates. 
        Special programs also include the Poison Control Program, the 
        Nation's primary defense against injury and death from 
        poisoning for over 50 years. Poison control centers contribute 
        to significantly decreasing a patient's length of stay in a 
        hospital and save the Federal Government $662.8 billion each 
        year in medical costs and lost productivity.
    We urge you to consider HRSA's central role in strengthening the 
Nation's health and advise you to adopt our fiscal year 2017 request of 
$7.48 billion for HRSA's discretionary budget authority. Thank you for 
the opportunity to submit our recommendation to the subcommittee.
                                 ______
                                 
Prepared Statement of the Friends of the National Institute of Diabetes 
                   and Digestive and Kidney Diseases
    For the fiscal year 2017 funding cycle, the Friends of NIDDK 
encourages the Subcommittee to increase funding for research programs 
and activities at the National Institute of Diabetes and Digestive and 
Kidney Diseases (NIDDK) that focus on preventing acute and chronic 
disease and other illnesses in adults as well as youth, and reducing 
health disparities. In particular, the Friends of NIDDK request a 
funding level of $2.165 billion in fiscal year 2017 for the Institute. 
This funding level is an increase of approximately 10 percent over the 
fiscal year 2016 omnibus bill. Given the large burden that acute and 
chronic diseases place on the U.S. healthcare system, economy, and 
quality of life years, the Friends of NIDDK believe that increased 
support for efforts in fiscal year 2017 to will reduce this burden is 
warranted.
    The Friends of NIDDK is a coalition of professional societies and 
patient advocacy groups with a vested interest in promoting and 
sustaining the vital research activities of the NIDDK. The Friends of 
NIDDK was established in 2013 with the vision of uniting organizations 
to speak with one voice about the important research being conducted by 
the Institute and to ensure that the investment in the NIDDK is 
deepened in future years. The Friends of NIDDK engage Members of 
Congress and other stakeholders on the prolific scientific advances 
made through the Institute's ongoing research and the critical 
importance of increased Federal funding for future scientific 
initiatives. In just the short time since its inception, nearly 50 
national and local organizations have joined the Friends of NIDDK to 
rally their support of the Institute's activities.
 about national institute of diabetes and digestive and kidney diseases
    NIDDK is the fifth largest institute at the National Institutes of 
Health and coordinates research on many of the most serious diseases 
affecting public health. The mission of NIDDK is to ``conduct and 
support medical research and research training and to disseminate 
science-based information on diabetes and other endocrine and metabolic 
diseases; digestive diseases, nutritional disorders, and obesity; and 
kidney, urologic, and hematologic diseases, to improve people's health 
and quality of life.''
    The NIDDK supports a wide range of medical research through grants 
to universities and other medical research institutions across the 
country, and supports scientists who conduct basic, translational, and 
clinical research across a broad spectrum of research topics and 
serious chronic diseases and conditions. In addition, the NIDDK 
supports research training for students and scientists at various 
stages of their careers and a range of education and outreach programs, 
including the National Diabetes Education Program, the National Kidney 
Disease Education Program and the Weight-control Information Network, 
to bring science-based information to patients and their families, 
healthcare professionals, and the public.
                      united states disease burden
    The diseases that are included within the NIDDK research portfolio 
are some of the most common, yet costly, diseases impacting Americans 
and demand increased research funding in fiscal year 2017. Chronic 
diseases are the Nation's leading causes of morbidity and mortality and 
account for 75 cents of every dollar spent on healthcare in the U.S. 
For example, nearly 30 million Americans have diabetes and 86 million 
have prediabetes. Diagnosed and undiagnosed diabetes, prediabetes and 
gestational diabetes cost the Nation $322 billion a year, an increase 
of 48 percent in just 5 years. About 26 million American adults have 
chronic kidney disease (CKD) and millions of others are at increased 
risk, although NIH investments in kidney research are less than 1 
percent of Medicare costs for kidney care. It is estimated that 1.4 
million Americans suffer from Crohn's disease and ulcerative colitis 
with approximately 30,000 new cases diagnosed each year, costing more 
than $2.2 billion in direct and indirect costs annually in the United 
States. Urologic diseases affect people of all ages, result in 
significant healthcare expenditures, and may lead to substantial 
disability and impaired quality of life. Patients with cystic fibrosis, 
an inherited disease that primarily affects the lungs and digestive 
system, continue to face much lower life expectancy compared to healthy 
adults, despite dramatic advances in treatment. These diseases 
represent only a portion of the NIDDK research portfolio, but 
nonetheless underscore the need for continued investment.
   national institute of diabetes and digestive and kidney diseases 
                               successes
    The researchers at NIDDK are collaborating and using innovative 
technologies to discover cross-cutting solutions that will ultimately 
reduce healthcare costs and improve quality of life for millions of 
Americans. NIDDK releases an annual report to illustrate the 
Institute's scientific advances, and incorporates personal stories of 
individuals that participate in NIDDK-sponsored clinical research. 
Funding of $2.165 billion in fiscal year 2017 would allow NIDDK to move 
forward on the following recent innovations outlined in the report:
  --A proposed human kidney biopsy project that would incorporate the 
        systematic collection, storage, and preservation of kidney 
        tissue-combined with advances in genetics and precision 
        medicine-in order to lead to new research discoveries, 
        treatments, and cures for kidney disease patients.
  --Findings that indicate cells or exosomes that are shed by the 
        primary tumor in the bloodstream can potentially be used as 
        biomarkers when screening for Pancreatic Disease.
  --New research has found a link between gut sensory cells and nerves. 
        This connection shows that the gut is able to directly 
        communicate about ingested nutrients to the nervous system.
  --Advancing progress toward the development of an artificial pancreas 
        for people with Type 1 diabetes by using smartphone technology.
  --Research areas for treatment of liver disease including 
        experimental cell based approaches for liver cell regeneration.
    Thank you for this opportunity to present our views to the 
Subcommittee. We urge your fiscal year 2017 appropriations decisions 
reflect the need to address the broad spectrum of diseases in the 
Institute's portfolio. We look forward to working with you to prevent 
chronic illness, improve the quality of lives, and save billions of 
dollars in healthcare spending through an increased investment in the 
NIDDK. Should you have any questions or require additional resources 
regarding NIDDK activities, please contact the Friends of NIDDK's 
Washington representative, Jim Twaddell, at Jim.Twaddell@dbr.com.

    [This statement was submitted by Jim Twaddell, Staff Consultant, 
Friends of National Institute of Diabetes and Digestive and Kidney 
Diseases.]
                                 ______
                                 
  Prepared Statement of the Friends of the National Institute on Aging
    Chairman Blunt, Ranking Member Murray, and members of the 
Committee, this testimony is being submitted on behalf of the Friends 
of the National Institute on Aging (FoNIA), www.friendsofnia.org, a 
coalition of more than 50 academic, patient-centered and non-profit 
organizations that supports the research and training missions of the 
National Institute on Aging (NIA) by promoting and advocating for the 
NIA and its initiatives as public policies in health and research take 
shape. We appreciate the opportunity to provide testimony in support of 
the NIA and to comment on the need for sustained, long-term growth in 
aging research funding. Considering the resources the Federal 
government spends on healthcare costs associated with age-related 
diseases, we feel it makes sound economic sense to increase Federal 
resources for aging research. Specifically, given the unique challenges 
created by an aging population and the range of promising scientific 
opportunities in the field of aging research, the FoNIA recommends an 
additional $500 million in the fiscal year 2017 National Institutes of 
Health (NIH) budget to support biomedical, behavioral and social 
sciences aging research efforts at the NIH. We believe that this 
funding is the minimum essential to sustain research needed to make 
progress in attacking the chronic diseases that are driving significant 
increases in our national healthcare costs. In addition, given the 
exceptional challenges presented by Alzheimer's Disease and Related 
Disorders (ADRD), FoNIA endorses a minimum increase of an additional 
$400 million for ADRD research across NIH in fiscal year 2017 to ensure 
that overall NIH research progress continues.
    NIA's mission is urgent. The number of Americans aged 65 and older 
is growing at an unprecedented rate. By 2030, there will be 72 million 
Americans in this age group; more than double the number from 2000. The 
number of ``oldest old''--people age 85 or older--is expected to more 
than triple between 2010 and 2050. Age is a primary risk factor for 
many disabling diseases and conditions--most notably, Alzheimer's 
disease (AD). The NIA is the primary Federal agency responsible for AD 
research. We know that over 5 million Americans aged 65 years and older 
may have AD with a predicted increase to 13.8 million by 2050. NIA's 
comprehensive AD research program spans the spectrum of discovery, from 
basic neuroscience through translational research and clinical 
application. The National Alzheimer's Plan, 2012 and 2015 Research 
Summits, and allocation of additional funds over the past several years 
have accelerated momentum in this field. Recommendations from the 
Research Summits have been incorporated into new Funding Opportunity 
Announcements (FOAs) that cover virtually every aspect of AD research 
including health disparities, caregiving, epidemiology, diagnosis and 
prediction, molecular and cellular mechanisms, brain aging and clinical 
trials.
    Efforts in AD research have been bolstered by the advent of new 
technologies to generate and analyze enormous data sets. These new 
technologies have been particularly effective in identifying risk and 
protective genes for AD. Researchers can now access genome sequence 
data from the Alzheimer's Disease Sequencing Project (ADSP), a 
collaboration between the NIA and the National Human Genome Research 
Institute to facilitate identification of risk and protective genes. 
The opening of a new data sharing and analysis resource developed under 
AMP (Accelerating Medicines Partnership), the AMP-AD Knowledge Portal, 
and the release of the first wave of data will enable large and complex 
biomedical datasets to be shared and analyzed. Researchers believe this 
approach will ultimately lead to selecting novel disease targets.
    Because aging is the single biggest risk factor for the development 
of many chronic diseases, a better understanding of the basic biology 
of aging may open up new avenues for prevention and cures. Therefore 
investing in research on the basic biology of aging is a major priority 
for NIA. The establishment of the trans-NIH GeroScience Interest Group 
(GSIG) to facilitate discovery on the common risks and mechanisms 
behind age-related diseases and conditions has invigorated the field of 
basic geroscience. Recommendations from the 2013 GSIG Summit entitled 
``Advances in Geroscience: Impact on Healthspan and Chronic Disease'' 
continue to energize researchers in this field.
    Understanding that up to half of premature deaths in the United 
States are due to behavioral and social factors, NIA is committed to 
supporting basic behavioral and social research in aging. The NIA-
supported Health and Retirement Study remains the world's premier 
multidisciplinary source of data on the health and well-being of older 
Americans, linking objective and subjective measures of health with 
information about retirement, economic status, family structure, 
personality, as well as health behaviors and service utilization. Funds 
from the American Recovery and Reinvestment Act facilitated expansion 
of the study, including genotyping DNA samples from participants. In 
fiscal year 2016, research will be ongoing to take advantage of the 
newly available genetic data to advance understanding of how genetic, 
behavioral and psychosocial factors affect health and well-being. NIA 
remains an active participant in the trans-NIH Science of Behavior 
Change initiative and the Basic Behavioral and Social Science 
Opportunity Network.
    Personalized medicine is closer than ever to being realized for 
many aging-related diseases and conditions. One example involves AD--
approaches to systems biology identifying complex genetic and molecular 
networks, such as AMP, will enable identification of molecular 
signatures and networks underlying the various disease processes that 
lead to symptoms associated with AD. NIA is also partnering with the 
Patient-Centered Outcomes Research Institute (PCORI) to test an 
individually-tailored injurious falls prevention strategy that includes 
a ``fall care manager'' in community healthcare systems. Falls are a 
key cause of disability in older people. Multiple chronic health 
conditions are common among older adults and another NIA initiative 
supports research to identify behavioral interventions, targeted at 
older adults with multiple chronic conditions, with high potential 
impact on health outcomes.
    NIA also supports several innovative programs dedicated to training 
the next generation of aging researchers. These include the Paul Beeson 
Career Development Awards in Aging Research for outstanding clinician-
scientists and the Butler-Williams Scholars Program, a ``boot camp'' 
for emerging investigators in aging research to prepare them to compete 
successfully for grant funding.
    Despite the recent infusion of money targeted at ADRD research, 
which we greatly appreciate, NIA's current budget does not reflect the 
tremendous responsibility it has to meet the health research needs of a 
growing U.S. aging population. According to National Health Expenditure 
Data, in 2010 out of each healthcare dollar spent, 34 cents was spent 
on adults age 65 and older. Yet only 3.6 cents out of every dollar 
appropriated to NIH in 2010 went to support the work of NIA (NIH 
Almanac). With a continuation of support for ADRD research and an 
infusion of much needed support for all other aging research in fiscal 
year 2017, NIA can expand promising, recent research activities, such 
as:
  --Implement new prevention and treatment clinical trials, research 
        training initiatives, care interventions, and genetic research 
        studies developed to meet the goals of the National Plan to 
        Address Alzheimer's disease;
  --bolster trans-NIH initiatives developed by the NIH GeroScience 
        Interest Group to understand basic cellular and molecular 
        underpinnings of aging as a principal risk factor for chronic 
        disease and to explore common mechanisms governing 
        relationships between aging and chronic disease;
  --understand the impact of economic concerns on older adults by 
        examining work and retirement behavior, health and functional 
        ability, and policies that influence individual well-being; and
  --support personalized medicine initiatives that will better target 
        treatments and interventions to individuals who will most 
        benefit from them.
    NIA is poised to accelerate the scientific discoveries that we as a 
Nation are counting on. With millions of Americans facing the loss of 
their functional abilities, their independence and their lives to 
chronic diseases of aging, there is a pressing need for robust and 
sustained investment in the work of the NIA. In every community in 
America, healthcare providers depend upon NIA-funded discoveries to 
help their patients and caregivers lead healthier and more independent 
lives. In these same communities, parents are hoping NIA-funded 
discoveries will ensure that their children have a brighter future, 
free from the diseases and conditions of aging that plague our Nation 
today. We do not yet have the knowledge needed to predict, preempt and 
prevent the broad spectrum of diseases and conditions associated with 
aging. We do not yet have sufficient knowledge about disease processes 
to fully understand how best to prevent, diagnose and treat diseases 
and conditions of aging, nor do we have the knowledge needed about the 
complex relationships among biology, genetics, and behavioral and 
social factors related to aging. Bold, visionary and sustainable 
investments in the NIA will make it possible to achieve substantial and 
measurable gains in these areas sooner rather than later, and perhaps 
too late.
    We recognize the tremendous fiscal challenges facing our Nation and 
that there are many worthy, pressing priorities to support. However, we 
believe a commitment to the Nation's aging population by making bold, 
wise investments in programs will benefit them and future generations. 
Investing in NIA is one of the smartest investments Congress can make.

    [This statement was submitted by Kathryn Jedrziewski, PhD, Chair, 
Friends of the National Institute on Aging and Deputy Director, 
University of Pennsylvania Institute on Aging.]
                                 ______
                                 
  Prepared Statement of the Friends of the National Institute on Drug 
                                 Abuse
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to submit testimony to the Subcommittee in support of the 
National Institute on Drug Abuse (NIDA). The Friends of the National 
Institute on Drug Abuse is a coalition of over 150 scientific and 
professional societies, patient groups, and other organizations 
committed to preventing and treating substance use disorders as well as 
understanding their causes through the research agenda of the National 
Institute on Drug Abuse (NIDA).
    Recognizing that so many health research issues are inter-related, 
we request that the subcommittee provide at least $34.5 billion for the 
National Institutes of Health (NIH) and within that amount a 
proportionate increase for the National Institute on Drug Abuse, in 
your Fiscal 2017 Labor, Health and Human Services, Education and 
Related Agencies Appropriations bill. We also respectfully request the 
inclusion of the following NIDA specific report language.
    Opioid Misuse and Addiction.--The Committee is concerned about the 
escalating epidemic of prescription opioid and heroin use, addiction 
and overdose in the U.S. Nearly 130 people die each day in this country 
from opioid overdose, making it one of the most common causes of death 
for adolescents and young adults. The Committee appreciates the 
important role that research can and should play in the various Federal 
initiatives aimed at this crisis. The Committee urges NIDA to 1) 
continue funding research on medications to alleviate pain, including 
the development of those with reduced abuse liability; 2) as 
appropriate, work with private companies to fund innovative research 
into such medications; and 3) report on what we know regarding the 
transition from opioid analgesics to heroin abuse and addiction within 
affected populations.
    Adolescent Brain Development.--The Committee recognizes and 
supports the Adolescent Brain and Cognitive Development (ABCD) Study. 
We know that the brain continues to develop into the mid-twenties. 
However, we do not yet know enough about the dramatic brain development 
that takes place during adolescence and how the various experiences 
children are exposed to during this time (e.g., sports injuries, lack 
of sleep, marijuana or other substance use) interact with each other 
and a child's biology to affect brain development and, ultimately, 
social, behavioral, health and other outcomes. As part of the 
Collaborative Research on Addiction (CRAN), a trans-NIH consortium 
involving NIDA, NIAAA, and NCI, and in partnership with NICHD, NINDS, 
NIMH, NIMHD, and OBSSR, the ABCD study intends to address this 
knowledge gap. As the largest ever longitudinal brain-imaging study of 
youth, the ABCD study will follow approximately 10,000 U.S. children 
from ages 9-10 into early adulthood, who will provide behavioral, 
neuroimaging, genetic, and other health data throughout development. 
The ABCD study will yield critical insights into the foundational 
aspects of adolescence that shape life trajectories. The committee also 
recommends and recognizes that the cost of this comprehensive study 
should not inhibit investigator initiated studies or any potential 
special appropriation for its ongoing support.
    Marijuana Research.--The Committee is concerned that marijuana 
public policies in the States (medical marijuana, recreational use, 
etc.) are being changed without the benefit of scientific research to 
help guide those decisions. The Committee is also concerned that 
restrictions associated with Schedule 1 of the Controlled Substance Act 
effectively limit the amount or type of research that can be conducted 
on marijuana or its component chemicals. NIDA is encouraged to continue 
supporting a full range of research on the effects of marijuana and its 
components, including policy research focused on policy change and 
implementation across the country. The Committee also directs NIDA to 
provide a short report on the barriers to research that result from the 
classification of marijuana as a Schedule 1 substance.
    Raising Awareness and Engaging the Medical Community in Drug Abuse 
and Addiction Prevention and Treatment..--ducation is a critical 
component of any effort to curb drug use and addiction, and it must 
target every segment of society, including healthcare providers 
(doctors, nurses, dentists, and pharmacists), patients, and families. 
Through its NIDAMeD initiative, NIDA is advancing addiction awareness, 
prevention, and treatment in primary care practices through seven 
Centers of Excellence for Physician Information. Intended to serve as 
national models, these centers target physicians-in-training, including 
medical students and resident physicians in primary care specialties 
(e.g., internal medicine, family practice, and pediatrics). NIDA also 
developed, in partnership with the Office of National Drug Control 
Policy, two online continuing medical education courses on safe 
prescribing for pain and managing patients who abuse prescription 
opioids. These courses were viewed by over 200,000 individuals and 
completed for credit by over 100,000 clinicians combined. The Committee 
continues to be pleased with NIDAMed, and urges the Institute to 
continue its focus on activities to provide physicians and other 
medical professionals with the tools and skills needed to incorporate 
drug abuse screening and treatment into their clinical practices.
    Medications Development.--The Committee recognizes that new 
technologies are required for the development of next-generation 
pharmaceuticals. In the context of NIDA funding, chief among these are 
NIDA's current approaches to develop viable immunotherapeutic or 
biologic (e.g., bioengineered enzymes) approaches for treating 
addiction. The goal of this research is the development of safe and 
effective vaccines or antibodies that target specific addictive drugs, 
like nicotine, cocaine, and heroin, or drug combinations. The Committee 
is encouraged by this approach--if successful, immunotherapies, alone 
or in combination with other medications, behavioral treatments, or 
enzymatic approaches, stand to revolutionize how we treat, and 
ultimately prevent addiction.
    Drug Treatment in Justice System Settings.--The Committee 
understands that providing evidence-based treatment for substance use 
disorders offers the best alternative for interrupting the drug use/
criminal justice cycle for offenders with drug problems. Untreated 
substance using offenders are more likely to relapse into drug use and 
criminal behavior, jeopardizing public health and safety and taxing 
criminal justice system resources. Treatment has consistently been 
shown to reduce the costs associated with lost productivity, crime, and 
incarceration caused by drug use. This reality represents a significant 
opportunity to intervene with a high-risk population. In 2013 NIDA 
launched the Juvenile Justice Translational Research on Interventions 
for Adolescents in the Legal System (JJ-TRIALS) program to identify and 
test strategies for improving the delivery of evidence-based substance 
abuse and HIV prevention and treatment services for justice-involved 
youth. The JJ-TRIALS initiative will provide insight into the process 
by which juvenile justice and other service settings can successfully 
adopt and adapt existing evidence-based programs and strategies to 
improve treatment for at-risk youth. The Committee supports this 
important work and asks for a progress report in the next 
appropriations cycle.
    Electronic Cigarettes.--The Committee understands that electronic 
cigarettes (e-cigarettes) are increasingly popular among adolescents. 
Lack of regulation, easy availability, and a wide array of cartridge 
flavors may make them particularly appealing to this age group. In 
addition to the unknown health effects, early evidence suggests that e-
cigarette use may serve as an introductory product for youth who then 
go on to use other tobacco products, including conventional cigarettes, 
which are known to cause disease and lead to premature death. Early 
evidence also reveals that these devices are widely used as tools for 
smoking derivatives of marijuana (hash oil, ``shatter,'' etc.) The 
Committee requests that NIDA fund research on the use and consequences 
of these devices.
    Drug abuse is costly to Americans; it ruins lives, while tearing at 
the fabric of our society and taking a huge financial toll on our 
resources. Beyond the unacceptably high rates of morbidity and 
mortality, drug abuse is often implicated in family disintegration, 
loss of employment, failure in school, domestic violence, child abuse, 
and other crimes. Placing dollar figures on the problem; smoking, 
alcohol and illegal drug use results in an exorbitant economic cost on 
our Nation, estimated at over $600 billion annually. We know that many 
of these problems can be prevented entirely, and that the longer we can 
delay initiation of any use, the more successfully we mitigate future 
morbidity, mortality and economic burdens.
    Over the past three decades, NIDA-supported research has 
revolutionized our understanding of addiction as a chronic, often-
relapsing brain disease --this new knowledge has helped to correctly 
emphasize the fact that drug addiction is a serious public health issue 
that demands strategic solutions. By supporting research that reveals 
how drugs affect the brain and behavior and how multiple factors 
influence drug abuse and its consequences, scholars supported by NIDA 
continue to advance effective strategies to prevent people from ever 
using drugs and to treat them when they cannot stop.
    NIDA supports a comprehensive research portfolio that spans the 
continuum of basic neuroscience, behavior and genetics research through 
medications development and applied health services research and 
epidemiology. While supporting research on the positive effects of 
evidence-based prevention and treatment approaches, NIDA also 
recognizes the need to keep pace with emerging problems. We have seen 
encouraging trends--significant declines in a wide array of youth drug 
use--over the past several years that we think are due, at least in 
part, to NIDA's public education and awareness efforts. However, areas 
of significant concern include the recent increase in lethalities due 
to heroin and synthetic fentanyl, as well as the continued abuse of 
prescription opioids and the recent increase in availability of 
designer drugs and their deleterious effects. The need to increase our 
knowledge about the effects of marijuana is most important now that 
decisions are being made about its approval for medical use and/or its 
legalization. We support NIDA in its efforts to find successful 
approaches to these difficult problems.
    The Nation's previous investment in scientific research to further 
understand the effects of abused drugs on the body has increased our 
ability to prevent and treat addiction. As with other diseases, much 
more needs be done to improve prevention and treatment of these 
dangerous and costly diseases. Our knowledge of how drugs work in the 
brain, their health consequences, how to treat people already addicted, 
and what constitutes effective prevention strategies has increased 
dramatically due to support of this research. However, since the number 
of individuals continuing to be affected is still rising, we need to 
continue the work until this disease is both prevented and eliminated 
from society.
    We understand that the fiscal year 2017 budget cycle will involve 
setting priorities and accepting compromise, however, in the current 
climate we believe a focus on substance abuse and addiction, which 
according to the World Health Organization account for nearly 20 
percent of disabilities among 15-44 year olds, deserves to be 
prioritized accordingly. We look forward to working with you to make 
this a reality. Thank you for your support for the National Institute 
on Drug Abuse.
                                 ______
                                 
 Prepared Statement of the FSH Society on Facioscapulohumeral Muscular 
                               Dystrophy
Agency: National Institutes of Health (NIH).
Account: The NIH; National Institute of Arthritis and Musculoskeletal 
        and Skin Diseases (NIAMS), National Institute of Neurological 
        Disorders and Stroke (NINDS), Eunice Kennedy Shriver National, 
        Institute of Child Health and Human Development (NICHD), 
        National Human Genome Research Institute (NHGRI) and other 
        institutes.

Fiscal Year 2017 Report Language: The Committee strongly encourages the 
        NIH to accelerate research efforts and significantly increase 
        projects and funding on facioscapulohumeral muscular dystrophy 
        (FSHD). The Committee hopes and recognizes that scientific 
        opportunities and recent epigenetic breakthroughs in FSHD will 
        help NIH access therapies for this and many other grave 
        diseases such as cancer.

    Honorable Chairman Blunt, Ranking Member Murray, and distinguished 
members of the subcommittee, thank you for the opportunity to submit 
this testimony. It is an honor to have the opportunity to present the 
fiscal year 2017 request for NIH funding for research on 
facioscapulohumeral muscular dystrophy (FSHD) and update you on 
scientific opportunities. We thank this subcommittee for making 
research funding a national priority and for its strong investment in 
the NIH with the $2 billion funding increase in the fiscal year 2016 
Omnibus Appropriation bill.
    About FSHD, about our disease, my disease. FSHD, a heritable 
disease, is among the most common forms of muscular dystrophy with a 
prevalence of 1:8,000,\1\ affecting approximately 870,000 children and 
adults of both sexes worldwide. It can affect multiple generations and 
entire families. FSHD is characterized by the progressive loss of 
muscle strength. Muscle weakness typically starts at the face, shoulder 
girdle and upper arms, often progressing to the legs, torso and other 
muscles. The symptoms can develop at any age. The progression of FSHD 
is highly variable. FSHD has a high burden of disease and can cause 
significant disability and, in severely affected individuals, premature 
death, mainly through respiratory failure. Around 20 percent of 
affected individuals use a wheelchair or scooter. Besides muscle 
weakness, FSHD can also have the following manifestations: high-
frequency sensorineural hearing loss, respiratory insufficiency, 
abnormalities of blood vessels in the back of the eye, and non-
symptomatic cardiac arrhythmias.
---------------------------------------------------------------------------
    \1\ Deenen JC, et al, Population-based incidence and prevalence of 
FSHD. Neurology. 2014 Sep 16;83(12):1056-9. Epub 2014 Aug 13.
---------------------------------------------------------------------------
    The National Institutes of Health (NIH) is the principal worldwide 
source of funding of research on FSHD currently at the $8.398 million 
level fiscal year 2015 actual (and $12.616 million fiscal year 2016 
current), a fraction of the $77 million fiscal year 2015 actual it 
spent on all of the muscular dystrophies. For two decades, this 
subcommittee has supported the incremental growth in funding for FSHD 
research. I am pleased to report that this investment has produced 
remarkable results and remarkable advances in scientific understanding 
of human diseases.
    A partnership of Congress, NIH, patients and scientists has made 
truly outstanding progress in identifying areas in need of funding and 
in communicating these objectives to the public. Congress is 
responsible for this success by its sustaining support of the overall 
NIH budget, and specifically through the enactment of the Muscular 
Dystrophy Community Assistance, Research and Education Amendments of 
2001 (MD-CARE Act, Public Law 107-84). Several days ago, NIH leadership 
and staff that oversees muscular dystrophy published an editorial in 
Muscle & Nerve describing the work of the truly collaborative Muscular 
Dystrophy Coordinating Committee (MDCC), mandated by the MD CARE Act, 
which publicizes the 2015 NIH Action Plan for the Muscular Dystrophies 
as the roadmap for all funding, patient, family, and research 
communities.\2\ The 81 objectives of the Action Plan, released in 
November, are organized within 6 sections: mechanism, screening, 
treatments, trial readiness, access to care, infrastructure including 
workforce. I have been very involved in creating the MD CARE Act, 
remain of service to the MDCC, and helped draft, write and edit the 
first and revised Action Plans. NIH leadership, program and grant 
review staff have our highest respect and I echo Stephen I. Katz, M.D., 
Ph.D., chair of the MDCC, director of the NIAMS at the NIH when he says 
we can all use this plan ``to guide research, collaborations and 
strategies to extend and improve the quality of life of people 
suffering from these disorders.'' We are aware that MD Care Act does 
not set the amount of spending on FSHD or the other dystrophies at the 
NIH and we recognize that funding levels are determined in the 
appropriations process and the numbers of grant applications received 
and funded by the NIH on FSHD. We hope there are additional efforts and 
pathways that Congress can request and the NIH can enact to increase 
the amount of research funding on FSHD in the NIH portfolio that 
neither increases the NIH budget required nor takes money from another 
area of research and achieves more efficiency out of a non-growing 
research budget.
---------------------------------------------------------------------------
    \2\ Rieff HI, Katz SI et al. The Muscular Dystrophy Coordinating 
Committee Action Plan for the Muscular Dystrophies. Muscle Nerve. 2016 
Mar 21. [Epub ahead of print].
---------------------------------------------------------------------------
    As tiny as it is, the FSH Society continues to deliver huge results 
in improving our understanding of FSHD--and in turn helping scientists 
be more competitive at NIH with respect to the grant application and 
review process. As the Nation's most expert and largest FSHD research 
funding non-profit, the FSH Society's mission is to conduct research, 
increase awareness, understanding and education on FSHD. While we 
remain ever curious about how FSHD works, our goal is to improve 
health, reduce disability and illness and lengthen life for those 
living with FSHD. As of April 13, 2016, the FSH Society has provided 
approximately $6.97 million, since the inception of its research 
fellowships and grants program, in seed funds and grants to pioneering 
FSHD research areas and education worldwide and created an 
international collaborative network of patients and researchers. Recent 
advances in understanding the molecular genetics and cellular biology 
of FSHD have led to the identification of potential therapeutic 
targets. Impressive scientific progress was again achieved in 2015 in 
the basic molecular and clinical understanding of the disease largely 
due to cumulative Society funding of research. In 2015, the Society 
issued twelve new grants and fellowships, continued funding five 
ongoing grants, and issued three travel grants to facilitate travel for 
professionals working on FSHD. The Society also works with various 
research institutions doing clinical research on FSHD to help 
facilitate patient travel for evaluation and tissue and blood donation 
by covering patient travel and lodging expenses. Dollar for dollar the 
Society is one of the best investments one can make in FSHD research 
funding outside of NIH funding and we have been effective and 
successful stewards of the resources we have been given by our donors 
to provide individuals, data and new hypotheses of extraordinary 
quality that the NIH can fund research on FSHD.
    Quantum leaps in our understanding of FSHD. The past year and one-
half has brought forth exceptional if not remarkable contributions made 
by a very small but extremely dedicated tribe of researchers funded by 
the Society, NIH and other non-profits.
  --On September 25, 2014, researchers from United States, France, 
        Spain, Netherlands and United Kingdom narrow the focus 
        mechanistically opening the possibility of all types of FSHD 
        having an epigenetic basis.\3\
---------------------------------------------------------------------------
    \3\ Lemmers RJ, et al. Inter-individual differences in CpG 
methylation at D4Z4 correlate with clinical variability in FSHD1 and 
FSHD2. Hum Mol Genet. 2015 Feb 1;24(3):659-69. Epub 2014 Sep 25.
---------------------------------------------------------------------------
  --On March 29, 2015, different researchers involved with the NIH 
        Senator Paul A. Wellstone Cooperative Research Center using its 
        large collection of different FSHD patient samples and 
        different techniques arrive at the same answer that there is an 
        underlying principle of epigenetics defining asymptomatic or 
        non-manifesting and playing a role in disease severity.\4\
---------------------------------------------------------------------------
    \4\ Jones, TI, et al. Individual epigenetic status of the 
pathogenic D4Z4 macrosatellite correlates with disease in 
facioscapulohumeral muscular dystrophy. Clinical Epigenetics 2015, 72-
6, 29 March 2015.
---------------------------------------------------------------------------
  --On September 1, 2015, researchers from Fred Hutchinson Cancer 
        Research Center, Seattle, Rochester, New York and the 
        Netherlands funded by a NIH P01 program project describe the 
        role of siRNA-directed AGO/DICER-dependent epigenetic 
        repression (silencing the DUX4 retrogene with the D4Z4 region) 
        showing a pathway to therapeutically target FSHD.\5\
---------------------------------------------------------------------------
    \5\ Lim JW, et al. DICER/AGO-dependent epigenetic silencing of D4Z4 
repeats enhanced by exogenous siRNA suggests mechanisms and therapies 
for FSHD. Hum Mol Genet. 2015 Sep 1;24(17):4817-28.
---------------------------------------------------------------------------
  --On November 3, 2015, researchers at the University of Massachusetts 
        Medical School (UMMS) successfully used a derivation of the 
        CRISPR-based gene-editing method known as dCas9 to target and 
        silence the DNA sequence implicated in FSHD. For the very first 
        time a CRISPR-based system was been used to ameliorate 
        pathogenic gene expression in FSHD successfully in primary 
        human muscle cells.\6\
---------------------------------------------------------------------------
    \6\ Himeda CL, Jones, et al. CRISPR/dCas9-mediated Transcriptional 
Inhibition Ameliorates the Epigenetic Dysregulation at D4Z4 and 
Represses DUX4-fl in FSH Muscular Dystrophy. Mol Ther. 2016 
Mar;24(3):527-35. epub 2015 Nov 3.
---------------------------------------------------------------------------
  --On March 6, 2016 researchers at the University of Minnesota define 
        an important function of the C-terminal domain of DUX4, namely 
        to recruit the acetyltransferases p300 and CBP, which modify 
        chromatin in the vicinity of DUX4 binding.\7\
---------------------------------------------------------------------------
    \7\ Choi SH, et al. DUX4 recruits p300/CBP through its C-terminus 
and induces global H3K27 acetylation changes. Nucleic Acids Res. 2016 6 
Mar [Epub ahead of print].
---------------------------------------------------------------------------
    Many of these findings have their origins in seed funding from the 
FSH Society to researchers who have then used preliminary data to 
secure funding from the NIH. We are thrilled that our grantees and 
colleagues have data and publications that prove that the FSHD-causing 
DUX4-fl and cascading events can be turned off. Also in this last year 
in clinical and preclinical research multiple groundbreaking papers 
have emerged in whole body MRI, xenograph and transgenic/Cre-lox mouse 
models, improved diagnostic testing, biomarkers and clinical aspects of 
FSHD and the very first evidenced based guideline were written, 
compiled and distributed by the Centers for Disease Control, American 
Academy of Neurology and FSH Society.\3,8,9,10,11\ Despite this, the 
FSHD research and clinical enterprise is still starved for Federal 
funding from NIH!
---------------------------------------------------------------------------
    \8\ Tawil R, et al. Evidence-based guideline summary: Evaluation, 
diagnosis, and management of FSHD: Report of the Guideline Development, 
Dissemination, and Implementation Subcommittee of the American Academy 
of Neurology and the Practice Issues Review Panel of the American 
Association of Neuromuscular & Electrodiagnostic Medicine. Neurology. 
2015 Jul 28;85(4):357-64.
    \9\ Leung DG, et al. Whole-body magnetic resonance imaging 
evaluation of facioscapulohumeral muscular dystrophy. Muscle Nerve. 
2015 Oct;52(4):512-20. Epub 2015 Mar 31.
    \10\ Sakellariou P, Bloch R, et al. Neuromuscular electrical 
stimulation promotes development in mice of mature human muscle from 
immortalized human myoblasts. Skelet Muscle. 2016 Feb 27;6:4. 
eCollection 2015.
    \11\ Calandra P, et al. Allele-specific DNA hypomethylation 
characterises FSHD1 and FSHD2. J Med Genet. 2016 Feb 1. pii: jmedgenet-
2015-103436. [Epub ahead of print].
---------------------------------------------------------------------------
    We must keep moving forward. In October 2015 the FSH Society held 
its annual FSHD International Research Consortium meeting in Boston, 
Massachusetts. The meeting was funded in part by the NIH NICHD 
University of Massachusetts Medical School Wellstone center for FSHD. 
Over 100 researchers from around the world gathered to present latest 
data and discuss research strategies. Areas defined by the FSHD 
clinical and research community as priority areas are as follows:

                                TABLE 1.

_______________________________________________________________________
Genetics and epigenetics
    Priority 1:  Continued identification of the parameters that 
determine disease severity and progression, including identification of 
additional modifier and disease loci.
    Priority 2:  Improved diagnostic tests and tests to better predict 
onset and severity.
Mechanisms and targets
    Priority 3:  Determine the major mechanism(s) of muscle damage 
caused by DUX4 expression. DUX4 in muscle activates a diverse panel of 
pathways and mechanisms, which individually, or combined lead to muscle 
pathology.
    Priority 4:  Determine the relationship between DUX4 expression and 
disease onset and progression.
    Priority 5:  Determine how the expression of DUX4 in one muscle 
cell nucleus results in the spread of the pathology throughout the 
muscle.
Models
    Priority 6:  Continued development and validation of pre-clinical 
models to test specific pre-clinical goals.
Clinical and therapeutic studies
    Priority 7:  Validation of subjective and objective measurements of 
disease onset and progression. Quality of life, muscle function 
measurements and other physical biomarkers, molecular biomarkers, and 
imaging biomarkers all show tremendous promise. Individual and 
cooperative studies to identify, validate, and determine the best 
standard measurements are critical for trial preparedness in FSHD.
_______________________________________________________________________

    The detailed priorities stated for 2016, at the October 5-6, 2015, 
FSH Society FSHD IRC meetings can be found at: http://
www.fshsociety.org/international-research-consortium/. We need to be 
prepared for this new era in the science of FSHD. Many leading experts 
are now turning to work on FSHD because it represents the potential for 
great discoveries, insights into stem cells, transcriptional processes, 
new ways of thinking about disease of epigenetic etiology, and for 
treating diseases with epigenetic origin.
    NIH Funding for Muscular Dystrophy. Mr. Chairman, these major 
advances in scientific understanding and epidemiological surveillance 
are not free. They come at a cost. Since Congress passed the MD CARE 
Act in 2001, research funding at NIH for muscular dystrophy has 
increased 4-fold (from $21 million). While FSHD research funding has 
increased 16-fold fiscal year 2015 (from $0.5M) during this period, the 
level of funding is still too underpowered for FSHD given the 
remarkable discoveries in the past 6 years.

                                  FSHD RESEARCH DOLLARS & FSHD AS A PERCENTAGE OF TOTAL NIH MUSCULAR DYSTROPHY FUNDING
                                                                  [Dollars in millions]
--------------------------------------------------------------------------------------------------------------------------------------------------------
                   Fiscal Year                     2005    2006    2007    2008    2009    2010    2011    2012    2013    2014    2015    2016e   2017e
--------------------------------------------------------------------------------------------------------------------------------------------------------
All MD ($ millions).............................   $39.5   $39.9   $47.2     $56     $83     $86     $75     $75     $76     $78     $77     $80     $80
FSHD ($ millions)...............................    $2.0    $1.7      $3      $3      $5      $6      $6      $5      $5      $7      $8      $9      $9
FSHD (% total MD)...............................      5%      4%      5%      5%      6%      7%      8%      7%      7%      9%     10%     11%     11%
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sources: NIH/OD Budget Office & NIH OCPL & NIH RePORT RCDC (e = estimate).

    Despite the great success of the past 6 years in the science of 
FSHD brought about by Congress, NIH, non-profit funding agencies, 
patients, families and researchers we are gravely concerned that FSHD 
research is too under-represented in the NIH portfolio. Though in our 
story DUX4 is inappropriately expressed in the context of muscle only 
and is harmful in FSHD; there now are several papers in the last month 
showing DUX4 at work in other diseases and conditions--in the out layer 
of skin it is harmful to keratinocytes in another context of gene 
fusions it causes cells to divide uncontrollably and cause cancer (B 
cell acute lymphoblastic leukemia).\12,13\ The extraordinary depth and 
impact of discovery should soon allow a flood of new talent and higher 
quality and completive proposals to help NIH redress the imbalance of 
funding in the FSH muscular dystrophy portfolio by fostering 
opportunities for multidisciplinary research on FSHD commensurate with 
its prevalence and disease burden. We are concerned, very concerned 
that economy of scale is so different in particular for FSHD within the 
muscular dystrophy funding group. There are no quotas on peer-reviewed 
research above pay line at the NIH and given now that all the 
requisites are in place --funding for FSHD should increase rapidly at 
this time.
---------------------------------------------------------------------------
    \12\ Gannon OM, et al. DUX4 Is Derepressed in Late-Differentiating 
Keratinocytes in Conjunction with Loss of H3K9me3 Epigenetic 
Repression. J Invest Dermatol. 2016 Feb 9. pii: S0022-202X(16)00464-4. 
[Epub ahead of print].
    \13\ Yasuda T, et al. Recurrent DUX4 fusions in B cell acute 
lymphoblastic leukemia of adolescents and young adults. Nat Genet. 2016 
Mar 28. doi: 10.1038/ng.3535. [Epub ahead of print].
---------------------------------------------------------------------------
    There are 32 active projects NIH-wide totaling $12.616 million as 
of April 14, 2016 versus 26 on March 12, 2015 (source: NIH Research 
Portfolio Online Reporting Tools (RePORT) http://report.nih.gov keyword 
`FSHD or facioscapulohumeral or DUX4') the 32 projects cover 2 F32, 1 
K22, 1 K23, 1 R03, 4 R21, 15 R01, 1 P01, and 2 U54 grants. It was back 
in 2010, that the NIH Director Dr. Francis Collins said ``If we were 
thinking of a collection of the genome's greatest hits, this [FSHD] 
would go on the list.'' \14\ In the last year alone, incredible 
opportunities for public, private and non-profit entities engaged in 
FSHD research and clinical research have emerged. Oddly these 
discoveries clearly belonging to the leading edge of human genetics and 
our understanding the epigenome and treating epigenetic diseases are 
sitting somewhat idle. NIH needs to maximize research funding by 
capitalizing on the low hanging fruit that FSHD presents as a gateway 
to treating human epigenetic disease.
---------------------------------------------------------------------------
    \14\ Kolata, G., Reanimated `Junk' DNA Is Found to Cause Disease. 
New York Times, Science. Published online: August 19, 2010 http://
www.nytimes.com/2010/08/20/science/20gene.html.
---------------------------------------------------------------------------
    We request for fiscal year 2017, a doubling of the NIH FSHD 
research portfolio to at least $24 million. This will allow an 
expansion of basic research awards, expansion of post-doctoral and 
clinical training fellowships, dedicated centers to design and conduct 
clinical trials on FSHD and more U.S. DHHS NIH Senator Paul D. 
Wellstone Muscular Dystrophy Cooperative Research Centers. , and NIH 
has conveyed to researchers that it has a revised plan and an interest 
in funding research in FSHD and muscular dystrophy. Mr. Chairman, thank 
you for this opportunity to testify before your subcommittee.

    [This statement was submitted by Daniel Paul Perez, President & 
CEO, FSH Society on Facioscapulohumeral Muscular Dystrophy.]
                                 ______
                                 
      Prepared Statement of the GBS/CIDP Foundation International
    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the priorities of the 
community of individuals impacted by Guillain-Barre Syndrome (GBS), 
Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), variants and 
related conditions as you work to craft the fiscal year 2017 L-HHS 
Appropriations Bill.
            about gbs, cidp, variants and related conditions
Guillain-Barre Syndrome
    GBS is an inflammatory disorder of the peripheral nerves outside 
the brain and spinal cord.
    It's also known as Acute Inflammatory Demyelinating Polyneuropathy 
and Landry's Ascending Paralysis.
    The cause of GBS is unknown. We do know that about 50 percent of 
cases occur shortly after a microbial infection (viral or bacterial), 
some as simple and common as the flu or food poisoning. Some theories 
suggest an autoimmune trigger, in which the patient's defense system of 
antibodies and white blood cells are called into action against the 
body, damaging myelin (nerve covering or insulation), and leading to 
numbness and weakness.
    GBS in its early stages is unpredictable, so except in very mild 
cases, most newly diagnosed patients are hospitalized. Usually, a new 
case of GBS is admitted to ICU (Intensive Care) to monitor breathing 
and other body functions until the disease is stabilized. Plasma 
exchange (a blood ``cleansing'' procedure) and high dose intravenous 
immune globulins are often helpful to shorten the course of GBS. The 
acute phase of GBS typically varies in length from a few days to 
months, with over 90 percent of patients moving into the rehabilitative 
phase within four weeks. Patient care involves the coordinated efforts 
of a team such as a neurologist, physiatrist (rehabilitation 
physician), internist, family physician, physical therapist, 
occupational therapist, social worker, nurse, and psychologist or 
psychiatrist. Some patients require speech therapy if speech muscles 
have been affected.
    Recovery may occur over 6 months to 2 years or longer. A 
particularly frustrating consequence of GBS is long-term recurrences of 
fatigue and/or exhaustion as well as abnormal sensations including pain 
and muscle aches. These can be aggravated by `normal' activity and can 
be alleviated by pacing activity and rest.
Chronic Inflammatory Demyelinating Polyneuropathy
    CIDP is a rare disorder of the peripheral nerves characterized by 
gradually increasing weakness of the legs and, to a lesser extent, the 
arms.
    It is the gradual onset as well as the chronic nature of CIDP that 
differentiates it from GBS. Fortunately, CIDP is even rarer than GBS. 
The incidence of new cases is estimated to be between 1.5 and 3.6 in a 
million people (compare to GBS: 1-2 in 100,000).
    Like GBS, CIDP is caused by damage to the covering of the nerves, 
called myelin. It can start at any age and in both genders. Weakness 
occurs over two or more months.
    Unlike GBS, CIDP is not self-limiting (with an end to the acute 
phase). Left untreated, 30 percent of CIDP patients will progress to 
wheelchair dependence. Early recognition and treatment can avoid a 
significant amount of disability.
    Post-treatment life depends on whether the disease was caught early 
enough to benefit from treatment options. Patients respond in various 
ways. The gradual onset of CIDP can delay diagnosis by several months 
or even years, resulting in significant nerve damage that may take 
several courses of treatment before benefits are seen. The chronic 
nature of CIDP differentiates long-term care from GBS patients. 
Adjustments inside the home may need to be made to facilitate a return 
to normal life.
                          about the foundation
    The Foundation's vision is that every person afflicted with GBS, 
CIDP, or variants has convenient access to early and accurate 
diagnosis, appropriate and affordable treatments, and dependable 
support services.
    The Foundation's mission is to improve the quality of life for 
individuals and families across America affected by GBS, CIDP, and 
their variants by:
  --Providing a network for all patients, their caregivers and families 
        so that GBS or CIDP patients can depend on the Foundation for 
        support, and reliable up-to-date information.
  --Providing public and professional educational programs worldwide 
        designed to heighten awareness and improve the understanding 
        and treatment of GBS, CIDP and variants.
  --Expanding the Foundation's role in sponsoring research and engaging 
        in patient advocacy.
                              jim's story
    I had GBS in 1973. This is important because the subject matter, 
IVIG treatments, were not available in 1973 and I believe that because 
it was not available, my experience with GBS was many times worse than 
it needed to be. I was totally paralyzed and only my head was able to 
move side to side. When the disease hit me, I was a college student in 
St. John's University in NYC in my fourth year and a newlywed of 3 
months and I was also working 30 hours a week as a night manager in a 
busy Tire and Auto repair business. My wife and I were just beginning 
our lives together when GBS struck us down like a lightning bolt. My 
wife was also working full time and now the care of her totally 
paralyzed husband was in the hands of a 19 year woman who was asked to 
do things and make decisions that no 19 year old women should have to 
make. I never finished college due to the amount of medical bills the 
accumulated and this affected my working life for decades. Keeping in 
mind the year, 1973, ICU care was very different then it is now. She 
was only allowed to visit me in the ICU for five minutes every hour. 
The rest of the time, she spent in a tiny waiting room with other ICU 
patient's families. She was at the hospital before work, at lunchtime 
and in the evening totaling about forty minutes a day. Imagine the 
stress on this young lady. I spent five weeks in the ICU, totally 
paralyzed with a tracheotomy and with no movement and no ability to 
communicate in anyway at all. Any need that I had had to be guessed by 
the four person nursing staff who also had a dozen other very ill 
patients who were in the open room that held all of these patients. 
Nights were a nightmare. They were long mostly because I was not 
sleeping well, day or night. Minutes seemed like hours, and hours 
seemed like weeks. I was aware all of the time and it was like I was in 
a glass shell, unable to get out. The hospital staff tried, but no one 
could understand what it was like to be in that bed. One memorable 
evening, the tube that was connected to the MA-1 ventilator popped out 
of my neck and I was not getting any oxygen. Nobody saw that the 
bellows of the ventilator had dropped down. Someone had to see the 
situation or I was in big trouble. I had passed out from lack of air. 
Someone finally saw that it was not breathing for me. The ``crash 
cart'' finally got to me and I began to get some air. People started 
yelling ``why didn't the alarm sound'' There was an alarm that sounds 
if the machine failed for any reason. Two D cells powered the alarm and 
they were dead. Two D cells almost did me in.
    I firmly believe that if IVIG was available for me in 1973, I would 
have never been so paralyzed and in need of a ventilator. My life was 
in the hands of a hospital staff and machinery and humans who make 
mistakes. Time and time again, IVIG has arrested the progress of GBS 
patients and prevented a patient from needing a vent and putting their 
life in danger. GBS in and of itself generally does not cause a patient 
to die, it is poor care or a late diagnosis or preexisting conditions. 
IVIG is a lifesaver and huge factor in reducing the level of paralysis 
and the amount of time that a patient is in hospital and rehab. I wish 
that IVIG was available when I had GBS. Its availability would have a 
huge difference in my case.
               centers for disease control and prevention
    CIDP is a progressive condition with serious health impacts. 
Patients can end up almost completely paralyzed and on a ventilator. 
The key to limiting serious health impacts is an early and accurate 
diagnosis. The time it takes for a CIDP patient to begin therapy is 
linked to the length of therapy and the seriousness of the health 
impacts. An early diagnosis can mean the difference between a 3 month 
or 18 month hospital stay, or no hospitalization at all. For the 
Federal healthcare system, there is an economic incentive to ensure 
early and accurate diagnosis as longer hospitalizations equate to 
higher costs.
    CDC and NCCDPHP have resources that could be brought to bear to 
improve public awareness and recognition of CIDP and related 
conditions. In order to initiate new, potentially cost-saving programs, 
CDC requires meaningful funding increases to support crucial 
activities.
                     national institutes of health
    NIH hosts a modest research portfolio focused on GBS, CIDP, 
variants and related conditions. This research has led to important 
scientific breakthroughs and is well positioned to vastly improve our 
understanding of the mechanism behind these conditions. In fact, NINDS, 
NIAID, and the Office of Rare Diseases Research (ORDR) housed within 
NCATS have expressed interest in hosting a State-of-the-Science 
Conference on autoimmune peripheral neuropathies. This conference would 
allow intramural and extramural researchers to develop a roadmap that 
would lead research into these conditions into the next decade. While 
such a conference would not require additional appropriations, the 
Foundation urges you to provide NIH with meaningful funding increases 
to facilitate growth in the GBS, CIDP, and related conditions research 
portfolio.
    Thank you for your time and your consideration of the community's 
requests.
                                 ______
                                 
         Prepared Statement of the Genetics Society of America
    Thank you for the opportunity for the Genetics Society of America 
(GSA) to provide our perspective on the fiscal year 2017 appropriations 
for the National Institutes of Health (NIH). GSA recommends a minimum 
of $35 billion for NIH to continue its mission to further biomedical 
research.
    GSA is a professional scientific society with more than 5,500 
members from all 50 States working to deepen our understanding of the 
living world by advancing the field of genetics, from the molecular to 
the population level. Members of our community rely on support from the 
NIH to answer underlying biological questions that are the foundation 
for biomedical innovation. Whether termed foundational, fundamental, or 
basic research, these studies are critical to expanding our knowledge 
of the biological world around us. Indeed, the NIH recognized the 
importance of fundamental research in its agency-wide strategic plan 
\1\ and in a recent letter from Director Francis Collins and other NIH 
leaders published in Science magazine.\2\ Funding NIH at a minimum of 
$35 billion for fiscal year 2017 will allow the agency to increase its 
support for the fundamental research necessary to further biomedical 
breakthroughs.
---------------------------------------------------------------------------
    \1\ NIH-wide Strategic Plan http://www.nih.gov/sites/default/files/
about-nih/strategic-plan-fy2016-2020-508.pdf.
    \2\ Http://science.sciencemag.org/content/351/6280/1405.1.full.
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    Many of our members utilize model organisms in their research, 
which allow for extensive experimentation without the ethical 
implications of human subject research. Traditionally, the term ``model 
organism'' included systems such as fruit flies, roundworms, mice, 
yeast, and bacteria; but it now encompasses a growing collection of 
other systems including plants, zebrafish, frogs, and more--with new 
ones being developed regularly to study biological phenomena and 
disease States. Indeed, advances in technology have enhanced 
scientists' ability to use a diverse array of biological systems to 
advance understanding of the mechanisms of life.
    Fundamental research supported by the NIH has led to ground-
breaking discoveries in our field and beyond. For example, research 
into the mechanisms of bacterial immunity funded by NIH led to the 
development of CRISPR/Cas9, the breakthrough technology which has 
accelerated the potential for gene editing.\1\ As a result, researchers 
now have an unprecedented ability to study biological processes at the 
molecular level in a growing array of experimental systems, and a new 
universe for biotechnological applications is now open for exploration. 
In another example, ongoing studies in the genetics of mosquitoes are 
currently informing public health discussions around containing and 
ameliorating the threat of the Zika virus in U.S. The scientific 
evidence from these fundamental research projects created a body of 
evidence upon which officials can build more targeted studies to 
determine whether genetically engineered mosquitoes will impede the 
spread of the Zika virus.\3\
---------------------------------------------------------------------------
    \3\ Http://www.nytimes.com/2016/03/12/business/test-of-zika-
fighting-genetically-altered-mosquitoes-gets-tentative-fda-
approval.html.
---------------------------------------------------------------------------
    Because humans share much of their basic biology with all living 
systems, we believe that robust and expanded support for model 
organisms--from invertebrates and plants to microbes and mammals--is an 
essential part of this pursuit of foundational knowledge. One of the 
most effective ways to advance progress in biomedical research is to 
understand the fundamental biology of model systems. Time and time 
again, model organisms have led the way in advancing biological 
understanding to enable cures and treatments for human disease. Green 
fluorescent protein (GFP), a Nobel Prize-winning tool that allows 
scientists to observe biological processes in living animals that were 
once invisible to researchers was developed in worms. Model organisms 
are now routinely engineered to express GFP to study the activity of 
specific genes to understand cancer and other diseases.\1\ Similarly, 
the 2009 Nobel Prize for the discovery of the enzyme telomerase--which 
is critically important in cellular aging and integral to cancer cell 
proliferation--was first identified in the unicellular ciliate organism 
and yeast. Furthermore, several Nobel Prizes have been awarded for work 
in fruit flies, including for fundamental discoveries of the mechanisms 
of inheritance and embryonic development.
    Sustainable funding for the National Institutes of Health is 
critical to ensure that these types of investigator-initiated projects, 
which have implications for society at large, continue to be supported. 
An increase of $3.0 billion for fiscal year 2017 would enable NIH to 
fund more fundamental research projects while still providing increases 
to other critical portions of the agency's portfolio. If the percentage 
of the new funding used for R01 grants is the same as in prior years, 
NIH could fund more than 2,200 additional R01 grants--any number of 
which could yield the next biomedical breakthrough.
    A significant fraction of the GSA membership are trainees--
undergraduates, graduate students and postdoctoral scholars--who are 
concerned about the future of research funding and its implications for 
their careers. NIH has renewed its commitment to recruit and retain 
these early career scientists in order to cultivate an outstanding 
biomedical research workforce.\1\ The requested funding increase would 
ensure that undergraduate and graduate students and postdoctoral 
scholars advance to research careers, making strides in science and 
technology that will allow the U.S. to remain a world leader in STEM 
advances.
    Finally, we wish to emphasize the importance of sustainable support 
for research infrastructure. Biological databases, stock centers, and 
other shared research resources are essential for maintaining 
consistency across different research laboratories and are vital to 
scientists nationwide. For example, genomic databases speed innovation 
by providing accelerated access to well-curated data that can be used 
to validate new techniques. They also serve as searchable data 
repositories that allow scientists to connect their research findings 
and identify collaborators rapidly. Further, research databases 
function as a central place for data sharing, improving research 
transparency, and positively impacting research reproducibility. We 
believe that sustained public support for these community resources is 
essential and allows them to operate on an open access model, thus 
assuring that all researchers have the tools they need for discovery.
    We appreciate the opportunity to provide input into your 
deliberations about NIH appropriations. We are happy to provide any 
additional information about the impact of NIH funding on our community 
and the advancement of genetics research. Please contact GSA's 
Executive Director, Adam P. Fagen, PhD (AFagen@genetics-gsa.org) or 
GSA's Policy and Communications Manager, Chloe N. Poston, PhD 
(CPoston@genetics-gsa.org) with any questions.
                                 ______
                                 
     Prepared Statement of the Global Health Technologies Coalition
    Chairman Blunt, Ranking Member Murray, and members of the 
Committee, thank you for the opportunity to provide testimony on the 
fiscal year 2017 appropriations funding for the National Institutes of 
Health (NIH) and the Centers for Disease Control and Prevention (CDC). 
We appreciate your leadership in promoting the importance of 
international development, in particular global health. I am submitting 
this testimony on behalf of the Global Health Technologies Coalition 
(GHTC), a group of more than 25 nonprofit organizations working 
together to advance U.S. policies that can accelerate the development 
of new global health innovations--including new vaccines, drugs, 
diagnostics, microbicides, multipurpose prevention technologies, and 
other tools--to combat global health diseases and conditions.
    GHTC members strongly believe that in order to meet the world's 
most pressing global health needs, it is critical to invest in research 
today so that the most effective health solutions are available now and 
in the future. Sustainable investment in research and development (R&D) 
for a broad range of neglected diseases and health conditions is 
critical to tackling both endemic and emerging global health challenges 
that impact people around the world and at home in the United States. 
This need is particularly acute now, as the world is facing an 
increasing Zika epidemic and is still recovering from the 2014 Ebola 
outbreak--two diseases about which we knew little, and have no approved 
tools to diagnose, prevent, or treat.
    My testimony reflects the needs expressed by our member 
organizations, which work with a wide variety of partners to develop 
new and more effective lifesaving technologies, for the world's most 
pressing health issues. We strongly urge the Committee to continue its 
established support for global health R&D by:
  --Sustaining and supporting U.S. investment in global health research 
        and product development and fully funding the NIH at a level of 
        at least U.S.$34.5 billion, and providing robust funding for 
        the CDC, with $457 million for the CDC Center for Global 
        Health, and $629.49 million for the CDC National Center for 
        Emerging Zoonotic and Infectious Diseases (NCEZID).
  --Urging leaders at the NIH, CDC, the Food and Drug Administration, 
        and other entities within the U.S. Department of Health and 
        Human Services, like the Office of Global Affairs, the 
        Biomedical Advanced Research and Development Authority, and the 
        National Center for Advancing Translational Science (NCATS), to 
        join leaders of other U.S. agencies to develop a cross--U.S. 
        Government global health R&D strategy to ensure that U.S. 
        investments in global health research are efficient, 
        coordinated, and streamlined.
               critical need for new global health tools
    While we have made tremendous gains in global health over the past 
15 years, millions of people around the world are still threatened by 
HIV/AIDS, tuberculosis (TB), malaria, and other neglected diseases and 
health conditions. In 2014, TB killed 1.5 million people, surpassing 
deaths from HIV/AIDS. Sub-Saharan Africa saw 1.4 million new HIV 
infections. Half the global population remains at risk for malaria and 
drug-resistant strains are growing. Maternal mortality is 14 times 
greater in under-resourced regions than developed countries. One out of 
every 12 children in sub-Saharan Africa dies before the age of five, 
often from vaccine-preventable and other communicable diseases. These 
figures highlight the tremendous global health challenges that still 
remain and the need for sustained investment in global health research 
to deliver new tools to combat endemic and emerging threats.
    New tools and technologies are critical, both to address unmet 
global health needs and address challenges of drug resistance; outdated 
and toxic treatments; and difficulty administering current health 
technologies in poor, remote, and unstable settings. As seen with 
recent outbreaks of Ebola and Zika, we simply do not have the tools 
needed to prevent, diagnose, and treat many neglected diseases. While 
it is important to work to increase access to proven, existing drugs, 
vaccines, diagnostics, and other health tools, it is just as critical 
to invest in the development of next generation tools to fight existing 
and emerging disease threats. Particularly in our era of globalization 
where diseases know no borders, investments today in global health 
innovations for existing global health threats and new and emerging 
infections will mean millions of future lives saved--at home and around 
the world.
                research and u.s. global health efforts
    The United States is at the forefront of innovation in global 
health, with the NIH and CDC leading much of our global health 
research.
NIH
    The groundbreaking science conducted at the NIH has helped make the 
United States a global leader in medical research. Not only does NIH 
research lead to novel medical technologies for American patients, but 
it also fuels important discoveries and innovative applications of 
tools that help address both longstanding and emerging global health 
challenges.
    Within the NIH, the National Institute of Allergy and Infectious 
Diseases, the Office of AIDS Research, the Fogarty International 
Center, and NCATS all play critical roles in developing new health 
technologies that save lives around the world and at home in the United 
States. Recent activities have led to the development of new tools to 
combat neglected diseases, including vaccines for dengue fever and 
trachoma; new drugs to treat malaria and TB; and multiple projects to 
develop diagnostics, vaccines, and treatments for Ebola, including the 
development of ZMapp and the development and testing of Ebola vaccine 
candidates. NIH Director Dr. Francis Collins, recognizes the critical 
role the agency plays in global health R&D, and has named global health 
as one of the agency's top five priorities.
    For this important work to continue, the NIH needs adequate 
funding. We recognize and are grateful for Congress' work to bolster 
funding for the critical programs supported by NIH. However, Dr. 
Collins recently noted that the Bureau of Economic Analysis has 
calculated that due to rising costs of biomedical research expenses, 
the NIH has had a 23 percent drop in purchasing power since 2003. To 
deliver on the remarkable progress being made across the institutes, it 
is vital that we renew our commitment to health research and maintain 
steady support for the NIH.
    It is also important to stress the critical role that NCATS plays 
in translating basic research for neglected diseases into urgently 
needed tools and technologies. R&D conducted at NCATS has contributed 
to the development of early stage compounds to treat diseases including 
Chagas disease, schistosomiasis, giardia, and HIV/AIDS. We remain 
concerned that NCATS is the only NIH center limited by statute from 
supporting clinical trials beyond phase IIA. There is little risk of 
NCATS duplicating the global health activities of private industry, as 
this sector does not typically target neglected diseases due to limited 
commercial markets. We hope you will work to remove this statutory 
barrier and extend NCATS' ability to conduct trials through stage III--
the final pre-market stage where safety and efficacy of a treatment are 
tested in large groups of individuals.
CDC
    The CDC also makes significant contributions to global health 
research. The CDC's ability to respond to disease outbreaks, such as 
the current Zika outbreak and 2014 Ebola Virus Disease epidemic in West 
Africa, is essential to protecting the health of citizens both at home 
and abroad. The work of its scientists has led to major advancements 
against devastating diseases, including the eradication of smallpox and 
early identification of HIV/AIDS.
    Within the CDC, the Center for Global Health and NCEZID are 
critical to global health R&D and global health security efforts. 
Important work at NCEZID includes innovative technologies to provide a 
rapid diagnostic test for the Ebola virus; a new vaccine to improve 
rabies control; a new and more accurate diagnostic test for dengue 
virus; and coordination of the National Strategy for Combating 
Antibiotic Resistant Bacteria, focused on preventing, detecting, and 
controlling outbreaks of antibiotic resistant pathogens, such as drug-
resistant tuberculosis. Programs at CDC's Center for Global Health--
including the Global HIV/AIDS, Global Immunization, Parasitic Diseases 
and Malaria, Global Disease Detection and Emergency Response, and 
Global Public Health Capacity Development programs--have also yielded 
tremendous results in the development of new vaccines, drugs, 
microbicides, and other tools to combat HIV/AIDS, TB, malaria, and 
lesser known diseases like leishmaniasis, dengue fever, and 
schistosomiasis.
    In addition, the CDC works to implement the Global Health Security 
Agenda--a whole-of-government initiative that works to build capacity 
in 30 low- and middle-income countries to detect global health risks 
rapidly. We urge your support for this initiative alongside the vital 
work already ongoing at the Center for Global Health and NCEZID.
                 innovation as a smart economic choice
    Global health R&D brings lifesaving tools to those who need them 
most. However, the benefits of investing in these research efforts are 
much broader than preventing and treating disease. Global health R&D is 
also a smart economic investment in the United States, where it drives 
job creation, spurs business activity, and benefits academic 
institutions. Biomedical research, including global health, is a $100 
billion enterprise in the United States. Sixty-four cents of every U.S. 
dollar invested in global health R&D goes directly to U.S.-based 
researchers. As just one example of the many States positively impacted 
by global health R&D, the global health industry in Washington State 
includes 168 global health organizations, 54 percent of whom work on 
global health technology and devices. This industry directly accounts 
for $5.8 billion in output and provided 12,620 direct global health 
jobs in the State. In addition, investments in global health R&D today 
can help save significant money in the future. New therapies to treat 
drug-resistant TB, for example, have the potential to reduce the price 
of TB treatment by 90 percent and cut health system costs 
significantly.
    Smart investments in medical research in the past have yielded 
lifesaving breakthroughs for global health diseases, as well as 
important advances in diseases endemic to the United States. We must 
continue to build on those investments, and turn discoveries into new 
vaccines, drugs, tests, and other tools. Now more than ever, Congress 
must make smart budget decisions. Global health research that improves 
the lives of people around the world--while at the same time supporting 
U.S. interests, creating jobs, and spurring economic growth at home--is 
a win-win. On behalf of the members of the GHTC, I would like to extend 
my gratitude to the Committee for the opportunity to submit written 
testimony for the record.

    [This statement was submitted by Erin Will Morton, Coalition 
Director, Global Health Technologies Coalition.]
                                 ______
                                 
              Prepared Statement of God's Love We Deliver
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    God's Love We Deliver is part of a nationwide coalition, the Food 
is Medicine Coalition, of food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide 1.5 million 
medically tailored, home delivered meals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Karen Pearl, President & CEO, 
God's Love We Deliver.]
                                 ______
                                 
                Prepared Statement of the Harlem United
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Harlem United is part of the nationwide Food is Medicine Coalition 
of over 80 food and nutrition services providers, affiliates, and their 
supporters providing food and nutrition services to people living with 
HIV/AIDS (PLWHA) and other chronic illnesses. In Harlem and the South 
Bronx in New York City, we provide nearly 12,000 medically tailored, 
hot and nutritious meals to over 270 unique clients per year.
    As part of the Food is Medicine Coalition, Harlem United is 
committed to increasing awareness of the essential role that food and 
nutrition services (FNS) play in successfully treating HIV/AIDS and to 
expanding access to this indispensable intervention for people living 
with other severe illnesses.
Why Food and Nutrition Services (FNS) Matter for PLWHA
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. For example, proper nutrition is needed to increase 
absorption of medication, reduce side effects, and to maintain healthy 
body weight.
    Research has also identified HIV as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Additionally, several HIV medications can cause nausea and 
vomiting, and some can also affect lab results that test lipids and 
kidney and liver function. These compounding health effects reinforce 
the important role a nutrient-rich diet plays in patients' overall care 
plans.
    In addition, providing FNS at Harlem United facilitates connection 
to and engagement with the primary medical and dental care, housing, 
substance use treatment, and other services we provide, especially 
among vulnerable populations. In fact, over 50 percent of our FNS 
clients are actively engaged in other programs and services provided by 
Harlem United.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and FNS. MNT covers 
nutritional diagnostic, therapy, and counseling services focused on 
prevention, delay or management of diseases and conditions. MNT also 
involves an in-depth assessment, periodic reassessment and intervention 
provided by a licensed, Registered Dietitian Nutritionist (RDN) outside 
of a primary care visit.
    The range of FNS provided through the Ryan White program 
complements the needs of PLWHA at any stage of their illness. For those 
who are most mobile, there are congregate meals, such as what we 
provide to clients at our two Adult Day Health Care (ADHC) programs, as 
well as walk-in food pantries and voucher programs. For those whose 
disease has progressed, home-delivered meals and home-delivered grocery 
bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective, core medical service in 
the Ryan White Program. These services play a critical role in ensuring 
that PLWHA enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like FNS, are fundamental to making healthcare work 
for PLWHA. Support services for this population are not covered in any 
comprehensive way by Medicaid or other public insurance initiatives 
that have been expanded by the Affordable Care Act (ACA). As the HIV 
epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PLWHA remain connected to care and treatment.
Access to FNS and the Triple Aim
    Access to FNS is increasingly recognized as key to accomplishing 
the triple aim of national healthcare reform for PLWHA.
            Better Health Outcomes
    When clients receive effective FNS and become food secure, they are 
more likely to keep scheduled primary care visits, score higher on 
health functioning, are at lower risk for inpatient hospital stays, and 
are more likely to take their medications.\1\ Studies show both the 
health benefits of access to MNT and/or nutrition counseling for people 
with HIV infections and the resulting decreases in their healthcare 
costs.\2\ Compare these outcomes to PLWHA who are food insecure, who 
have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy \6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
            Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PLWHA. A recent study comparing participants in 
a medically-tailored FNS program to a control group within a local 
managed care organization found that average monthly healthcare costs 
for PLWHA fell 80 percent in the first 3 months after receiving FNS.\7\ 
If hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent, and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
            Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously, and manage their medical 
treatment more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PLWHA is fundamental to fulfilling the goals of 
the NHAS.
  --Reducing new HIV infections: PLWHA who are food insecure are 
        statistically significantly less likely to have undetectable 
        viral loads. Undetectable viral loads prevent transmission 96 
        percent of the time,\10\ thus FNS is key to prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --Increasing access to care and improving health outcomes for people 
        living with HIV: PLWHA who receive effective FNS are more 
        likely to keep scheduled primary care visits, score higher on 
        health functioning, are at lower risk for inpatient hospital 
        stays, and are more likely to take their medications.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --Reducing HIV-related disparities and health inequities: By 
        providing FNS to PLWHA who are in need largely because of 
        poverty, we improve health outcomes and reduce health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --Achieving a more coordinated national response to the HIV epidemic: 
        There remains a tremendous variation by State in coverage of 
        FNS, both inside and outside of Ryan White, making support for 
        Ryan White HIV Programs all the more needed. Ultimately, if we 
        are going to achieve a more coordinated, national response to 
        the HIV epidemic, as well as our quest to reduce healthcare 
        spending nationwide, FNS must be included in all healthcare 
        reform efforts, including Ryan White and the ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Committee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, is vital to lowering the number 
of new infections in the domestic HIV epidemic, and to ultimately 
reducing healthcare costs and preserving healthcare resources for the 
future.
    A client's diet has life and death consequences. When people are 
severely ill, good nutrition is one of the first things to deteriorate, 
making recovery and stabilization that much harder, if not impossible. 
Early and reliable access to medically-appropriate FNS helps PWH live 
healthy and productive lives, produces better overall health outcomes, 
and reduces healthcare costs. Along with our Food is Medicine Coalition 
colleagues, we appreciate the opportunity to offer this testimony 
regarding the fiscal year 2017 Appropriations process.
    Thank you.

    [This statement was submitted by Jacquelyn Kilmer, Esq., CEO, 
Harlem United.]
                                 ______
                                 
           Prepared Statement of the Harm Reduction Coalition
    The Harm Reduction Coalition appreciates the opportunity to submit 
this testimony to the Senate Appropriations Subcommittee on Labor, 
Health and Human Services, and Education, regarding opportunities to 
address the prescription opioid and heroin overdose epidemic. Harm 
Reduction Coalition recommends prioritizing funding needs under SAMHSA, 
HRSA and CDC towards three key strategies which address overdose risk 
and mortality: medication-assisted treatment, overdose education and 
naloxone distribution, and syringe exchange programs.
    Opioid overdose fatality is the leading cause of accidental death 
in the United States and has been declared an epidemic by the Centers 
for Disease Control and Prevention (CDC). According to CDC data, 
overdose deaths involving opioids--including prescription painkillers 
and heroin--claimed 28,647 lives in 2014. This figure represents a 14 
percent increase in age-adjusted overdose death rates since 2013. 
Increased mortality was driven by a dramatic rise in heroin overdose 
deaths, with heroin overdose death rates more than tripling since 2010, 
accompanied by a surge in deaths involving illicit fentanyl, a 
synthetic opioid increasingly combined with--or even sold as--heroin. 
These high rates of overdose will persist as long as the two most 
proven tools to prevent overdose deaths--medication-assisted treatment 
for opioid use disorders, and the overdose reversal drug naloxone--
remain starkly underutilized and difficult to access.
                     medication-assisted treatment
    Medication-assisted treatment (involving methadone, buprenorphine, 
or Vivitrol, accompanied by counseling and support) is the most 
effective means of facilitating recovery from opioid use disorders, and 
use of medication improves retention in treatment. Moreover, evidence 
shows that use of medication-assisted treatment reduces overdose by 50 
percent compared to treatment without medication. However, the majority 
of people with opioid use disorders do not have access to medication-
assisted treatment: 90 percent of U.S. counties do not have a methadone 
clinic, and only 32,000 doctors are waivered to prescribe 
buprenorphine, leaving 43 percent of U.S. counties without prescriber 
capacity.
              overdose education and naloxone distribution
    Overdose prevention education and training programs that distribute 
the FDA-approved, opioid rescue medication naloxone have been proven to 
significantly reduce mortality. When administered in a timely fashion, 
naloxone can reverse an opioid overdose; however, tragically it is not 
yet neither utilized broadly nor widely available in many parts of the 
country. In response to the opioid overdose epidemic, over 40 States 
and numerous communities and have taken action to make naloxone 
available within their jurisdictions. CDC recently reported that 
150,000 community members have been trained on overdose prevention and 
provided with naloxone over the last 20 years, and of those over 26,000 
successful overdose reversals have been reported by laypersons.\1\ 
However resources to support overdose education and naloxone 
distribution are still scarce. If naloxone was more accessible and 
overdose education and awareness efforts were expanded, countless lives 
could be saved.
---------------------------------------------------------------------------
    \1\ Wheeler E, Davidson PJ, Jones TS, Irwin KS. Community-based 
opioid overdose prevention programs providing naloxone--United States, 
2010. Morb Mortal Wkly Rep. 2012; 61(6):101-105.
---------------------------------------------------------------------------
    Harm Reduction Coalition believes that meaningful access to 
naloxone requires a four-pronged strategy to achieve a measurable 
impact on opioid overdose mortality:
    1.  Support for community-based overdose education and naloxone 
distribution (OEND) programs and initiatives training and equipping 
laypersons (family, friends, and people at risk of overdose) with 
naloxone
    2.  Promoting and incentivizing healthcare providers to prescribe 
naloxone to at-risk patients and their caregivers
    3.  Advancing innovative models for pharmacy access to naloxone 
through models including standing orders and collaborative practice 
agreements
    4.  Ensuring that first responders, including law enforcement 
officers, are trained and equipped with naloxone
    No single strategy will have a sufficiently broad population-level 
impact on opioid overdose mortality. However, the strongest available 
evidence suggests that direct support for increasing access to 
medication-assisted treatment and for community-based OEND programs 
must be a cornerstone of scale-up and expansion efforts.
                       syringe exchange programs
    Syringe exchange programs operate on the frontlines of the opioid 
and heroin crisis, and pioneered the use of naloxone outside of medical 
settings. Syringe exchange programs are effective outreach and 
engagement strategies that provide early intervention to people who 
inject drugs, linking them to healthcare and drug treatment. In recent 
years, new syringe exchange programs have emerged in several 
communities hard hit by the opioid and heroin epidemic, including in 
Indiana, Kentucky, Ohio, and West Virginia. These and other communities 
are grappling with the health and social consequences of increased 
injection drug use, including rising hepatitis C and hepatitis B 
infections and an HIV outbreak in Indiana.
    Syringe exchange programs operate on the frontlines of community-
based efforts to reach and assist people at risk of opioid overdose. 
These programs are highly effective in engaging and supporting people 
who use drugs and their communities on overdose education and naloxone 
distribution, and work to link people struggling with substance use 
disorders to effective treatment programs, including medication-
assisted treatment. In fiscal year 2016, Congress modified provisions 
to allow more flexibility in use of Federal funding to support syringe 
exchange programs in communities experiencing or at risk of an increase 
in hepatitis C cases or an HIV outbreak. Congress maintained a 
restriction prohibiting use of Federal funds for the purchase of 
syringes, but allowed for Federal funding to support counseling, 
education, outreach and other services. Harm Reduction Coalition 
advocated for and supports the revised Federal funding policy.
    HHS recently released implementation guidance on use of Federal 
funds to support aspects of syringe exchange programs allowable under 
the provisions of the fiscal year 2016 Omnibus, and operating in 
accordance with State and local law. Harm Reduction Coalition's work 
with these new and emerging syringe exchange programs in high-need 
areas has convinced us that Congress should appropriate funding in 
fiscal year 2017 to ensure that these programs have resources to 
prevent disease transmission, provide overdose education and naloxone 
distribution, and connect people who use drugs to treatment and 
healthcare.
                  recommendations for fiscal year 2017
    Harm Reduction Coalition recommends that the Subcommittee consider 
the following investments:
Substance Abuse and Mental Health Services Administration (SAMHSA)
    Grants to Prevent Prescription Drug/Opioid Overdose Related Deaths 
(Center for Substance Abuse Prevention, Programs of Regional and 
National Significance). Harm Reduction Coalition proposes an increase 
of $8 million over fiscal year 2016 levels to provide support to 
additional States for this critical overdose prevention program.

------------------------------------------------------------------------
                   Fiscal Year
-------------------------------------------------     Harm Reduction
                             2017 President's        Coalition request
      2016 Enacted               request
------------------------------------------------------------------------
         $12,000,000              $12,000,000        $20,000,000 (+$8
                                                             million)
------------------------------------------------------------------------

Health Resources and Services Administration (HRSA)
    Rural Opioid Overdose Reversal Grant Program (ROOR--Office of Rural 
Health Policy). These funds would support rural communities in 
addressing opioid misuse and overdose through education and prevention, 
training of healthcare professionals, emergency transport, treatment 
referrals and care coordination, and naloxone purchase.

------------------------------------------------------------------------
                   Fiscal Year
-------------------------------------------------     Harm Reduction
                             2017 President's        Coalition request
      2016 Enacted               request
------------------------------------------------------------------------
                 N/A              $10,000,000             $10,000,000
------------------------------------------------------------------------

Centers for Disease Control and Prevention (CDC)
    Grants to Support Syringe Exchange Programs (Division of Viral 
Hepatitis). Harm Reduction Coalition proposes additional funding on top 
of any increases to core Division of Viral Hepatitis for targeted 
support to syringe exchange programs.
    Proposed language:
    Grants may be awarded to State, local and Tribal governments and 
community-based organizations to support syringe exchange programs. 
Funds may be used to carry out programs, including through providing 
outreach, counseling, health education, case management, syringe 
disposal, and other program components in accordance with allowable use 
of funds. Funds may also be used to provide technical assistance, 
including training and capacity-building, to assist the development and 
implementation of syringe exchange programs. At least 15 percent of 
grants shall be made to syringe exchange programs that have been in 
operation for less than 3 years.

------------------------------------------------------------------------
                   Fiscal Year
-------------------------------------------------     Harm Reduction
                             2017 President's        Coalition request
      2016 Enacted               request
------------------------------------------------------------------------
                 N/A                      N/A             $15,000,000
------------------------------------------------------------------------

    Harm Reduction Coalition supports the following Administration 
requests addressing medication-assisted treatment under SAMHSA:
  --$50.1 million (+$25.1 million over fiscal year 2016) for 
        Medication-Assisted Treatment for Prescription Drug and Opioid 
        Addiction (MAT PDOA--Center for Substance Abuse Treatment, 
        Programs of Regional and National Significance)
  --$10 million for Buprenorphine-Prescribing Authority Demonstration 
        (Center for Substance Abuse Treatment, Programs of Regional and 
        National Significance)
    In addition, Harm Reduction Coalition strongly supports the 
Administration's request for $1 billion over fiscal year 2017 and 
fiscal year 2018 to expand access to treatment for opioid use 
disorders. This represents a critical investment in treatment capacity 
at a pivotal moment in the opioid epidemic. While the Administration 
requested these monies as mandatory funding, Harm Reduction Coalition 
does not have a position on whether these funds should be discretionary 
or mandatory. However, we agree with the Administration that a 
substantive and targeted investment is critical at this juncture, and 
endorse the proposed approach to allocate the bulk of these funds 
through new State Targeted Response Cooperative Agreements, with the 
remaining dollars supporting workforce development and cohort 
monitoring and evaluation of medication-assisted treatment expansion 
and outcomes.
    We thank you again for your consideration of our testimony and for 
the subcommittee's previous support for these priorities in fiscal year 
2016. Please do not hesitate to contact us if you have any questions.

    [This statement was submitted by Daniel Raymond, Policy Director, 
Harm Reduction Coalition.]
                                 ______
                                 
  Prepared Statement of the Health Professions and Nursing Education 
                               Coalition
    The members of the Health Professions and Nursing Education 
Coalition (HPNEC) are pleased to submit this statement for the record 
recommending $524 million in fiscal year 2017 for the health 
professions education and training programs authorized under Titles VII 
and VIII of the Public Health Service Act and administered through the 
Health Resources and Services Administration (HRSA). Additionally, 
because HRSA has been administering the Behavioral Health Workforce 
Education and Training (BHWET) Program, we also support the President's 
fiscal year 2017 budget proposal of shifting funds previously 
appropriated to the Substance Abuse and Mental Health Services 
Administration to HRSA.
    HPNEC is an alliance of national organizations dedicated to 
ensuring the healthcare workforce is trained to meet the needs of the 
country's growing, aging, and diverse population. Titles VII and VIII 
are the only federally-funded programs that seek to improve the supply, 
distribution, and diversity of the health professions workforce, with a 
focus on primary care and interdisciplinary training. By providing 
educational and training opportunities to aspiring and practicing 
health professionals, the programs also play a critical role in helping 
the workforce adapt to meet the Nation's changing healthcare needs. 
Titles VII and VIII are structured to allow grantees to test 
educational innovations, respond to changing delivery systems and 
models of care, and address timely topics in their communities. By 
assessing the needs of the communities they serve, Titles VII and VIII 
are well positioned to fill gaps in the workforce and increase access 
to care for all populations. Further, the programs emphasize 
interprofessional education and training, bringing together knowledge 
and skills across disciplines to provide effective, efficient and 
coordinated care.
    HPNEC recognizes the Subcommittee faces difficult decisions in a 
constrained budget environment; therefore, we are grateful the 
Subcommittee recognized that these programs are a high priority and 
continued its commitment to programs supporting healthcare workforce 
development in the fiscal year 2016 omnibus spending package. The 
Nation faces a shortage of health professionals, which will be 
exacerbated by increasing demand for healthcare services. Failure to 
fully fund the Title VII and Title VIII programs would jeopardize 
activities to fill these vacancies and to prepare the next generation 
of health professionals.
    The Title VII and Title VIII programs can be considered in seven 
general categories:
  --The Primary Care Medicine and Oral Health Training programs support 
        education and training of primary care professionals to improve 
        access and quality of healthcare in underserved areas. 
        According to HRSA, approximately 20 percent of Americans live 
        in rural or urban areas designated as health professional 
        shortage areas (HPSA). The primary care medical and oral health 
        training grants are also used to develop curricula and test 
        training methods to transform healthcare practice and delivery, 
        including innovations in the primary care team's management of 
        chronic disease, patient-centered models of care, and 
        transitioning across healthcare settings. The General 
        Pediatrics, General Internal Medicine, and Family Medicine 
        programs provide critical funding for primary care physician 
        training in community-based settings and support a range of 
        initiatives, including medical student and residency training, 
        faculty development, and the development of academic 
        administrative units. The Rural Physician Training Grants focus 
        on increasing the number of medical school graduates practicing 
        in rural communities. The primary care cluster also provides 
        grants for Physician Assistant programs to encourage and 
        prepare students for primary care practice in rural and urban 
        Health Professional Shortage Areas. The General Dentistry, 
        Pediatric Dentistry, Dental Public Health, and Dental Hygiene 
        programs provide grants to dental schools, dental hygiene 
        schools, and hospitals to create or expand primary care dental 
        training.
  --Because much of the Nation's healthcare is delivered in remote 
        areas, the Interdisciplinary, Community-Based Linkages cluster 
        supports community-based training of health professionals. 
        These programs are designed to encourage health professionals 
        to return to such settings after completing their training and 
        to encourage collaboration between two or more disciplines. The 
        Clinical Training in Interprofessional Practice program 
        supports interdisciplinary training opportunities that prepare 
        providers to deliver coordinated, efficient, and high-quality 
        care. The Area Health Education Centers (AHECs) offer clinical 
        training opportunities to health professions and nursing 
        students in rural and other underserved communities by 
        extending the resources of academic health centers to these 
        areas. AHECs improve health by leading the Nation in the 
        recruitment, training, and retention of a diverse health 
        workforce for underserved communities. By leveraging State and 
        local matching funds to form networks of health-related 
        institutions, AHECs also provide education services to 
        students, faculty, and practitioners. The final fiscal year 
        2016 omnibus spending package combined the Title VIII 
        Comprehensive Geriatric Education program, which establishes 
        traineeships for individuals who are preparing for advanced 
        education in geriatric nursing, with the Title VII geriatrics 
        programs, including the Geriatrics Education Centers programs, 
        which support interprofessional geriatrics education and 
        training for geriatrics specialists and non-specialists, 
        Geriatric Training for Physicians, Dentists, and Behavioral/
        Mental Health Professionals programs, which increase the supply 
        of geriatrics faculty and re-train faculty in geriatrics, and 
        the Geriatric Academic Career Awards (GACA) program, which 
        promote the development of academic clinician educators who 
        provide clinical training in geriatrics. Individually, these 
        programs are all designed to bolster the number and quality of 
        healthcare providers caring for the rapidly growing number of 
        older adults and to expand geriatrics training to all 
        healthcare professionals. The newly combined program--the 
        Geriatrics Workforce Enhancement program (GWEP)-- seeks to 
        improve integration of geriatrics with primary care across 
        health settings and disciplines. However, due to the nature of 
        the program consolidation, it is not yet clear if or how all of 
        the previous activities will be supported in the new program. 
        Specifically, we are concerned that the GACAs may not continue 
        to play their important role in the new GWEP structure. The 
        Graduate Psychology Education (GPE) program is the Nation's 
        only Federal program dedicated solely to the education and 
        training of doctoral-level psychologists. GPE supports the 
        interprofessional training of doctoral-level psychology 
        students in providing supervised mental and behavioral health 
        services to underserved populations (i.e. older adults, 
        children, chronically ill, and victims of abuse and trauma, 
        including returning military personnel and their families) in 
        rural and urban communities. The Mental and Behavioral Health 
        Education and Training Grant Program supports the training of 
        psychologists, social workers, and child and adolescent 
        professionals. These programs together work to close the gap in 
        access to quality mental and behavioral healthcare services by 
        increasing the number of qualified mental health clinicians.
  --The Minority and Disadvantaged Health Professionals Training 
        cluster helps improve healthcare access in underserved areas 
        and the representation of minority and disadvantaged 
        individuals in the health professions. Diversifying the 
        healthcare workforce is a central focus of the programs, making 
        them a key player in mitigating racial, ethnic, and socio-
        economic health disparities. Further, the programs emphasize 
        cultural competency for all health professionals, an important 
        role as the Nation's population is growing and becoming 
        increasingly diverse. Minority Centers of Excellence support 
        increased research on minority health, establish educational 
        pipelines, and provide clinical experiences in community-based 
        health facilities. The Health Careers Opportunity Program helps 
        to improve the development of a competitive applicant pool 
        through partnerships with local educational and community 
        organizations and extends the healthcareers pipeline to the K-
        12 level. The Faculty Loan Repayment and Faculty Fellowship 
        programs provide incentives for schools to recruit 
        underrepresented minority faculty. The Scholarships for 
        Disadvantaged Students supports students from disadvantaged 
        backgrounds who are eligible and enrolled as full-time health 
        professions students.
  --The Health Professions Workforce Information and Analysis program 
        provides grants to institutions to collect and analyze data to 
        advise future decisionmaking on the health professions and 
        nursing programs. The Health Professions Research and Health 
        Professions Data programs have developed valuable, policy-
        relevant studies on the distribution and training of health 
        professionals. The National Center for Workforce Analysis 
        performs research and analysis on health workforce issues, 
        including supply and demand, to help inform both public and 
        private decisionmaking.
  --The Public Health Workforce Development programs help increase the 
        number of individuals trained in public health, identify the 
        causes of health problems, and respond to such issues as 
        managed care, new disease strains, food supply, and 
        bioterrorism. The Public Health Traineeships and Public Health 
        Training Centers seek to alleviate the critical shortage of 
        public health professionals by providing up-to-date training 
        for current and future public health workers, particularly in 
        underserved areas. Preventive Medicine Residencies, which do 
        not receive funding through Medicare GME, provide training in 
        the only medical specialty that teaches both clinical and 
        population medicine to improve community health. This cluster 
        also includes a focus on loan repayment as an incentive for 
        health professionals to practice in disciplines and settings 
        experiencing shortages. The Pediatric Subspecialty Loan 
        Repayment Program offers loan repayment for pediatric medical 
        subspecialists, pediatric surgical specialists, and child and 
        adolescent mental and behavioral health specialists, in 
        exchange for service in underserved areas.
  --The Nursing Workforce Development programs under Title VIII provide 
        support for nurses and nursing students across the entire 
        education spectrum improve the access to, and quality of, 
        healthcare in underserved areas. These programs provide the 
        largest source of Federal funding for nursing education, 
        providing loans, scholarships, traineeships, and programmatic 
        support that supports nurses and nursing students as well as 
        numerous academic nursing institutions and healthcare 
        facilities. At the same time, the need for high-quality nursing 
        services is expected to grow, particularly in rural and 
        underserved areas. The Advanced Nursing Education program 
        awards grants to train a variety of nurses with advanced 
        education, including clinical nurse specialists, nurse 
        practitioners, certified nurse-midwives, certified registered 
        nurse anesthetists, public health nurses, nurse educators, and 
        nurse administrators. Nursing Workforce Diversity grants help 
        to recruit and retain students from minority and disadvantaged 
        backgrounds to the nursing profession through scholarships, 
        stipends, and other retention activities. Graduate nursing 
        students are provided reimbursement for tuition and program 
        costs through the Advanced Education Nursing Traineeships and 
        Nurse Anesthetist Traineeships. The Nurse Education, Practice, 
        Quality, and Retention program helps schools of nursing, 
        academic health centers, nurse-managed health centers, State 
        and local governments, and other healthcare facilities to 
        develop programs that provide nursing education, promote best 
        practices, and enhance nurse retention. The Loan Repayment and 
        Scholarship Program repays up to 85 percent of nursing student 
        loans and offers full-time and part-time nursing students the 
        opportunity to apply for scholarship funds in exchange for 2 
        years of practice in a designated critical shortage facility. 
        The Comprehensive Geriatric Education grants support the 
        education of registered nurses and nursing professionals who 
        will provide direct care to older Americans, develop and 
        disseminate geriatric curricula, train faculty members, and 
        provide continuing education. The Nurse Faculty Loan program 
        supports graduate students pursing the opportunity to become 
        nursing faculty members through loan repayment in exchange for 
        service as nursing faculty.
  --The loan programs under Student Financial Assistance support 
        financially disadvantaged health professions students. The 
        NURSE Corps supports undergraduate and graduate nursing 
        students with a preference for those with the greatest 
        financial need. The Primary Care Loan (PCL) program provides 
        loans in return for dedicated service in primary care. The 
        Health Professional Student Loan (HPSL) program provides loans 
        for financially needy health professions students based on 
        institutional determination. These programs are funded out of 
        each institution's revolving fund and do not receive Federal 
        appropriations. The Loans for Disadvantaged Students program 
        provides grants to institutions to make loans to disadvantaged 
        students.
    Title VII and Title VIII programs guide individuals to high-demand 
health professions jobs, helping individuals reach their goals and 
communities fill their health needs. Further, numerous studies 
demonstrate that the Title VII and Title VIII programs graduate more 
minority and disadvantaged students and prepare providers that are more 
likely to serve in Community Health Centers (CHC) and the National 
Health Service Corps (NHSC). The multi-year nature of health 
professions education and training, coupled with provider shortages 
across many disciplines and in many communities, necessitate a strong, 
continued, and reliable commitment to the Title VII and Title VIII 
programs.
    While HPNEC members understand the budget limitations facing the 
Subcommittee, we respectfully urge support for $524 million for the 
Title VII and VIII programs in fiscal year 2017, and providing BHWET 
funding directly to HRSA. We look forward to working with the 
Subcommittee to prioritize the health professions programs in fiscal 
year 2017 and into the future.
                                 ______
                                 
            Prepared Statement of Helen Keller International
    Mr. Chairman, thank you for this opportunity to provide testimony 
to the Subcommittee on behalf of Helen Keller International's 
ChildSight program. My name is Kathy Spahn, and I serve as the 
President and Chief Executive Officer of Helen Keller International 
(HKI). I am requesting that this Subcommittee recommend in its fiscal 
year 2017 Appropriations report that the Department of Education 
provide funding for programs that identify and provide prescription 
eyeglasses to children from low income families whose educational 
performance and future vocational success may be hindered because of 
poor vision.
    It is HKI's hope that with the continued support of the Department 
of Education and private donors we can deliver free vision screenings 
and eyeglasses to thousands of economically disadvantaged children who 
have extremely limited access to immediate and affordable vision care.
                              childsight
    Established in 1994, ChildSight tackles the common problem of 
refractive error among children and adolescent students in underserved 
communities in the United States. More commonly known as 
nearsightedness, farsightedness, and astigmatism, refractive error 
affects one in four children and adolescents nationwide.
    The mission of ChildSight is to improve the vision and academic 
potential of economically disadvantaged children. Research has 
established a clear link between vision and learning. Most learning 
platforms--books, computer screens, blackboards and classroom 
presentations--require clear vision in order for a child to interact, 
assimilate information and respond. Yet in thousands of classrooms, 
millions of children are unable to make the most of their education 
simply because they cannot see well. This is especially tragic since 
most cases of poor vision are due to refractive error and are easily 
corrected.
    If not detected and treated promptly, refractive error and other 
eye conditions can lead to long term visual deficiencies and 
developmental problems. Students must have clear, healthy eyesight in 
order to fully focus on schoolwork and classroom lessons or the 
opportunity to gain a valuable education is severely diminished. Adults 
whose visual impairment denied them the chance to gain core academic 
skills are at a disadvantage in seeking employment and achieving 
economic independence.
    In most cases, the solution is simple: the provision of correctly 
prescribed eyeglasses. ChildSight helps students directly by going 
into the schools to conduct vision screenings, identifying children 
with refractive error and providing prescription eyeglasses to address 
this need, all free of charge. In so doing, ChildSight ``brings 
education into focusTM'' for children who would otherwise be 
left with untreated vision problems--and lost opportunities.
    Millions of students do not get the care they need due to limited 
access to vision screening and the prohibitive cost of a pair of 
prescription eyeglasses. ChildSight targets these communities and 
serves at-risk children by providing free on-site screening, free 
eyeglasses and follow-up care so that students can focus in the 
classroom in order to achieve their potential for future academic and 
vocational success.
    ChildSight is distinguished by its high clinical standards and its 
efforts to educate children and their families about the importance of 
corrected vision and the availability of related healthcare resources 
in their community. ChildSight provides direct access to vision 
screening and refraction by a licensed optometrist who prescribes the 
necessary lenses for each child.
    ChildSight goes one step further. Students identified with 
potentially severe eye conditions beyond basic refractive error are 
referred to our partnering ophthalmologists for a full eye exam and 
follow-up treatment as needed. This final step ensures that children 
who need further assessment and care will be able to receive it.
    ChildSight also addresses the needs of out of school youth. 
Services are offered to runaway and homeless youth, in partnership with 
organizations like Covenant House and the Ali Forney Center in New 
York, and for high school dropouts seeking to pass the General 
Educational Development (GED) test. By addressing the eye care needs of 
vulnerable youth, ChildSight helps to reintegrate these young people 
into the educational system and enables them to seek and maintain 
employment.
                            positive results
    Since its inception, ChildSight has screened over 1.7 million 
children and delivered over 243,000 pairs of free eyeglasses to 
children in need, with support from this Subcommittee, the Department 
of Education and private donations. We have seen the positive results 
of the ChildSight program.
    Teachers we have surveyed throughout the country report that a 
majority of students who had their vision corrected with ChildSight 
eyeglasses exhibited significant improvement in the completion of 
schoolwork and homework; increased class participation and a reduction 
in disruptive behavior; and improvement in grades, self-confidence and 
self-perception as reported by the teachers.
                       public/private undertaking
    ChildSight is truly a public/private endeavor. The program's 
success is due in large part to the dedication and commitment of our 
partner physicians, educators, community activists and business people 
in each of our local sites. With their support and the contributions of 
foundations and corporations, we continue to seek the 
institutionalization and long term sustainability of our programs. 
Government funding is also crucial to achieving long term 
sustainability and expanding access. For example, a recent grant from 
the City of New York has supported the integration of ChildSight eye 
health services into a package of social and health services offered at 
designated Community School locations in the Bronx.
    The endorsement and support of the Department of Education have 
played an integral role in our ability to leverage committed support 
from the private sector. ChildSight has received significant long term 
funding from foundations including The Community Foundation for Greater 
New Haven, Lavelle Fund for the Blind, Mt. Sinai Health Care 
Foundation, The New York Community Trust, Children's Aid Society, The 
Rose Hills Foundation, Victoria Foundation, The Healthcare Foundation 
of New Jersey, and Reader's Digest Partners for Sight Foundation.
    Local healthcare professionals, such as optometrists, pediatric 
ophthalmologists and opticians, at our program sites are members of the 
ChildSight team who help us meet the vision care needs of the students 
we serve. ChildSight contracts with ophthalmic clinics and optical 
shops selected according to their strong professional credentials. The 
services of these community professionals are either donated or 
provided at a reduced, reasonable rates.
                               conclusion
    ChildSight provides an invaluable--and often life changing--
service to local youth in a pragmatic and cost-effective manner. Of 
particular concern is the need to reach at-risk children and provide 
them free screening, free eyeglasses and free follow-up care.
    I ask this Subcommittee to recommend in its fiscal year 2017 
Committee report that the United States Department of Education support 
programs that provide vision care for children from economically 
disadvantaged families. These Department of Education funds will 
support ongoing programs and will provide vision screening and 
prescription eyeglasses for such children.
    Corrective treatment eye treatment is needed to overcome the 
economic, social and transportation barriers that prevent many children 
from economically disadvantaged families from obtaining the vision care 
they need. Students with corrected vision can focus in the classroom in 
order to achieve their potential for academic and vocational success
    As our founding board member Helen Keller said: We are never really 
happy until we try to brighten the lives of others.

    [This statement was submitted by Kathy Spahn, President and Chief 
Executive Officer, Helen Keller International.]
                                 ______
                                 
     Prepared Statement of the Hepatitis Appropriations Partnership
    The Hepatitis Appropriations Partnership (HAP) is a national 
coalition based in Washington, DC. The coalition includes community-
based organizations, public health and provider associations, national 
hepatitis and HIV organizations, and diagnostic, pharmaceutical and 
biotechnology companies. HAP works with policy makers and public health 
officials to increase Federal support for hepatitis prevention, 
testing, education, research and treatment. On behalf of HAP, we urge 
your support for increased funding for Federal hepatitis programs in 
the fiscal year 2017 Labor-Health-Education Appropriations bill, and 
thank you for your consideration of the following critical funding 
needs for hepatitis programs in fiscal year 2017:

------------------------------------------------------------------------
        Agency                  Program            HAP Funding Request
------------------------------------------------------------------------
Centers for Disease     Division of Viral        $62.8 million
 Control and             Hepatitis
 Prevention
------------------------------------------------------------------------

    According to the Centers for Disease Control and Prevention (CDC), 
hepatitis mortality rates have increased substantially in the United 
States over the past decade. In fact, for nearly 10 years, deaths from 
HCV have surpassed deaths from HIV and the CDC now reports that deaths 
associated with HCV now surpass deaths associated with all 59 other 
notifiable infectious diseases combined. Addressing HIV co-infection 
rates, as high as 25 percent for HCV and 10 percent for HBV, remains a 
significant challenge. Until more is done to address hepatitis it will 
remain the leading non-AIDS cause of death in people living with HIV. 
Further, HBV and HCV are the leading causes of liver cancer--one of the 
most lethal, expensive, and fastest growing cancers in America. As 
CDC's 2016 Annual Report to the Nation on the Status of Cancer show, 
while overall incidences of, and deaths from, cancer have declined, 
liver cancer is an exception. Both cases of and deaths from liver 
cancer are on the rise. While HBV and HCV are completely preventable 
and treatable, as many as 5.3 million people in the U.S. live with HBV 
and/or HCV and 50-65 percent of them remain undiagnosed, leaving them 
vulnerable for progression to liver disease, cancer, and ultimately 
death. However, as indicated in the April 2016 report from the National 
Academies of the Sciences, Eliminating the Public Health Problem of 
Hepatitis B and C in the United States, elimination of hepatitis in the 
United States is feasible, but only if we dedicate the necessary 
resources and address the underlying barriers.
    Although most people living with HCV, who also have the greatest 
risk for HCV-related morbidity and mortality, are baby boomers--those 
born between 1945 through 1965--hepatitis transmission among young 
people has skyrocketed in recent years. Just last year, in Scott 
County, Indiana, an outbreak of nearly 185 cases of HIV, of which more 
than 90 percent were already infected with HCV, demonstrated the danger 
of a public health infrastructure lacking in the basic resources 
necessary to stop the spread of completely preventable infections. 
Between 2010 and 2013 there was a significant increase in new HBV and 
HCV infections, with HCV rising by 150 percent. States like Indiana, 
Kentucky, West Virginia, Washington and 25 others have reported 
increases in HCV, while at least Kentucky, Tennessee and West Virginia 
have seen increases in HBV. Increases in both HBV and HCV in those 
areas are tied to increases in injection drug use.
    In addition to the above concerns, mother-to-child transmission of 
hepatitis remains a challenge, again despite the availability of 
prevention tools. Although hepatitis B vaccination coverage among 
newborns has increased, it remains below the Healthy People 2020 goals. 
Approximately 24,000 infants are born to mothers living with HBV, 
resulting in as many as 1000 perinatal transmissions per year. 
Additionally, the ongoing HCV epidemic among young people who inject 
drugs has led to increases, in some areas, of mother-to-child 
transmission of HCV. Elimination of mother-to-child transmission is 
possible, with increased vaccination for HBV and early detection and 
treatment of new hepatitis infections.
    Even with these challenges, the availability of effective new 
curative treatments for HCV, and an effective vaccine and good 
treatments to control HBV, brings the elimination of HCV and HBV in the 
United States within our reach, setting the stage for an enormous new 
public health victory. But not without increased investments in 
comprehensive, national hepatitis prevention, screening, linkage to 
care, education and surveillance programs. The CDC's 2010 professional 
judgment (PJ) budget provided the need estimate of $170.3 million 
annually from fiscal year 2014-fiscal year 2017 to comprehensively 
address HBV and HCV. HAP's request of $62.8 million recognizes the 
current budgetary limitations while also balancing the very urgent need 
to accomplish the goals of the Action Plan for the Prevention, Care, & 
Treatment of Viral Hepatitis (Viral Hepatitis Action Plan), to 
implement the United States Preventive Services Task Force (USPSTF) HBV 
and HCV screening recommendations, and to ultimately end the epidemics. 
HAP recommends that these funds be used on the following priority 
areas, allocated in proportion to HBV and HCV burden, using available 
epidemiological data.
Screening and Linkage to Care
    The Viral Hepatitis Action Plan established a goal of increasing 
the proportion of persons who are aware of their hepatitis infection to 
66 percent for both HBV and HCV. Full implementation of the CDC and 
USPSTF recommendations for HBV and HCV testing and linkage to care by 
State Medicaid programs, Medicare, and private health systems and 
providers are necessary to accomplish these goals. As studies have 
shown, identifying and treating a person living with hepatitis early, 
before the disease progresses, as opposed to at later stages both 
averts advanced liver disease and is cost effective: treating a person 
living with HCV before there is liver scarring gains, or saves, more 
than $187,000 per person per year. Increased resources would enable DVH 
to:
  --Work to advance testing in private clinical settings, public health 
        settings, and other settings to increase the number of persons 
        diagnosed with HBV and HCV infection and linked to lifesaving 
        care earlier in their infection
  --Explore opportunities for utilizing electronic health records to 
        monitor implementation of CDC/USPSTF recommendations
Surveillance
    As testing and linkage to care activities increase and improve, 
strengthening local and State capacity to execute hepatitis monitoring 
and surveillance activities takes on an even greater importance. The 
CDC currently funds only 5 State health departments and 2 local health 
departments to conduct minimal surveillance in their jurisdictions. CDC 
also provides funds to State and local health departments, the 
cornerstone implementers of national public health policies, to 
coordinate prevention and surveillance efforts via the Viral Hepatitis 
Prevention Coordinator Program (VHPC). The VHPC program is the only 
national program dedicated to the prevention and control of the 
hepatitis epidemics. This program provides funding to support a 
coordinator position in each jurisdiction, though not enough for a full 
time position, and leaves little to no money for the provision of 
public health services, such as surveillance, public education and 
access to prevention services like testing and hepatitis A and B 
vaccinations, which must be cobbled together from other sources year-
to-year. Hepatitis disproportionately impacts several communities, 
particularly people who inject drugs (PWID)--as demonstrated by the 
Indiana outbreak, men who have sex with men, persons living with HIV, 
African immigrants and African Americans, Asian immigrants and Asian 
Americans, Pacific Islanders, Latinos, tribal communities, veterans, 
and residents of rural and remote areas with limited access to medical 
treatment or culturally and linguistically-appropriate services. 
Surveillance is needed in order to adequately address the epidemics in 
these populations. Increasing funding would allow DVH to:
  --Establish a regional health training and technical assistance 
        center to support detection and investigations of new HBV and 
        HCV cases, including mother to child HCV transmission; promote 
        implementation of prevention practices among State/local health 
        departments, substance use disorder treatment programs, 
        correctional organizations, and nongovernmental organizations
  --Support the development model projects for the elimination of HCV 
        transmission and related mortality throughout an indicated area
  --Increase the number of funded sites to increase surveillance in 
        those jurisdictions hardest hit by the hepatitis epidemics.
Addressing the Emerging Hepatitis C Epidemic Among Young Persons at 
        Risk
    HCV prevalence among PWIDs is as high as 70 percent, and between 
20-30 percent of people who inject drugs acquires HCV each year. This 
trend is largely due to the prescription opiate epidemic and the 
transition many young people have made from using opiate pills to 
injecting heroin. This increase, and the ongoing outbreaks in several 
States, makes the need to enhance and expand these prevention efforts 
all the more urgent and underscore the need to prioritize immediate 
support in the field, strengthening health department and community 
responses that target youth and young adults, specifically persons who 
injection drugs, persons under 30 years old, and persons living in 
rural areas. Increased funding would enable DVH to:
  --Investigate networks of transmission in order to improve 
        implementation and evaluation of prevention services
  --Promote HBV vaccinations, and HBV and HCV screening in settings 
        that reach and provide services for populations at highest risk 
        for transmission
  --In addition to HBV and HCV testing, DVH would assure implementation 
        of prevention services to stop HBV and HCV transmission, 
        including counseling, locally supported syringe services 
        programs, treatment for substance use disorders, and linkage to 
        care treatment for people living with HBV and HCV
Elimination of Mother-to-Child Transmission of Hepatitis B
    Due in part to the success of the Perinatal Hepatitis B Coordinator 
program at CDC's National Center for Immunization and Respiratory 
Diseases (NCIRD), great strides have been made to reduce HBV among 
newborns and youth. However, between 800 to 1000 perinatal HBV 
transmissions still occur each year in the U.S. With increased 
resources, DVH would:
  --Monitor and improve implementation of vaccination of all infants 
        within three days of birth through continued collaborations 
        with birthing hospitals
  --Continue to work with State epidemiologists to implement revised 
        State and local reporting criteria for pregnant women and their 
        newborns living with HCV
  --Consider routine testing HCV testing for women of child bearing age 
        to identify young women living with HCV who would benefit from 
        treatment, and to provide preventive services to their newborns
    As the National Academies of the Sciences and the World Health 
Organization has recognized, prevention and elimination of hepatitis is 
a feasible goal and should be a public health priority. It is certainly 
possible in the United States. We have the tools to accomplish this 
goal and we hope the fiscal year 2017 Labor HHS bill will reflect this 
priority through the allocation of significant resources to rein in the 
current epidemics and begin to identify those who are already living 
with HBV and HCV.
    As you contemplate the fiscal year 2017 Labor, Health and Human 
Services, Education and Related Agencies appropriations bill, we ask 
that you consider these critical funding needs. We thank the Chairman, 
Ranking Member and members of the Subcommittee, for their thoughtful 
consideration of our recommendations. Our response to the viral 
hepatitis epidemics in the United States defines us as a society, as 
public health agencies, and as individuals living in this country. 
There is no time to waste in our Nation's fight against these 
epidemics.

    [This statement was submitted by Mariah Johnson, Coordinator, 
Hepatitis Appropriations Partnership.]
                                 ______
                                 
            Prepared Statement of the Hepatitis B Foundation
    The Hepatitis B Foundation appreciates the opportunity to submit 
testimony to the U.S. Senate Appropriations Subcommittee on Labor, 
Health and Human Services, and Education, and Related Agencies (LHHS) 
regarding the fiscal year 2017 Appropriations bill. The Hepatitis B 
Foundation is the Nation's leading 501(c)(3) nonprofit organization 
dedicated to finding a cure for hepatitis B and improving the lives of 
those affected worldwide through research, education and patient 
advocacy. To further expand its reach and impact, the HBF established 
and co-chairs `Hep B United,' a national coalition of 30 community-
based multi-sectoral coalitions and national organizations with a reach 
to more than 4 million high-risk individuals---working across 14 States 
and 24 cities to address and eliminate hepatitis B in the United 
States. We are concerned funding to combat chronic viral hepatitis in 
the United States continues to be severely inadequate, and does not 
come close to reflecting the burden of disease, with as many as 5.7 
million people living with chronic hepatitis B and C, and highly 
alarming rates of new infections. We therefore urge the Subcommittee to 
address the issue across several agencies and programs within its 
jurisdiction in order to help meet the goal of developing new and 
better treatments, to find a cure, and to reduce the incidence and 
transmission of the hepatitis B virus. Specifically, we urge the 
subcommittee to increase appropriations as follows:
  --Health Resources and Services Administration Bureau of Primary 
        Health Care: + $3 million. This funding is necessary to 
        demonstrate, test, and validate the most effective protocols to 
        eliminate the perinatal transmission of hepatitis B.
  --Centers for Disease Control and Prevention: +$28.8 million. This 
        will permit a more comprehensive response to control the spread 
        of acute and chronic hepatitis B infection through increased 
        surveillance, testing, education, and linkage to care and 
        treatment.
  --National Institutes of Health: + $2.4 billion in total including 
        +$49 million for hepatitis B research. This will permit a 
        doubling of NIH research funding focused on finding a cure for 
        hepatitis B in a trans-Institute initiative guided by a 
        professional judgement budget. NIH funding for hepatitis B has 
        actually decreased by almost 16 percent since fiscal year 2011. 
        These additional resources will put us on a path to find a 
        cure. The Hepatitis B Foundation joins with the Ad Hoc Group 
        for Biomedical Research and requests at least $34.5 billion for 
        the NIH in fiscal year 2017.
Scope of the Epidemics
    In the United States, CDC estimates that as many as 5.7 million 
people are living with chronic hepatitis B virus (HBV) and hepatitis B 
C virus (HCV) infection, and at least half of persons living with HBV 
or HCV do not know they are infected.\1\ However, these are likely 
conservative prevalence estimates as state surveillance systems are 
inconsistent and underfunded. HBV and HCV are silent infections, often 
asymptomatic, and without early diagnosis or intervention, can lead to 
serious liver diseases and liver cancer. There is a safe and highly 
effective vaccine and treatments to prevent and control HBV, and 
revolutionary curative treatments for HCV. Strategies to increase 
testing, vaccination, treatment and linkages to care, can dramatically 
reduce disease and premature deaths due to chronic viral hepatitis.
---------------------------------------------------------------------------
    \1\ Http://www.cdc.gov/hepatitis/abc/index.htm.
---------------------------------------------------------------------------
Hepatitis B and Liver Cancer
    In the U.S., it is estimated that over 2 million Americans are 
living with chronic HBV infection, but only 25 percent are aware of 
their infection and less than 10%of infected individuals are able to 
access care and receive treatment.\2\ Chronic HBV infection disparately 
impacts and represents serious public health inequities for racial and 
ethnic communities in the U.S. For example, Asian Americans and Pacific 
Islanders make up 5 percent of the total U.S. population, yet account 
for more than 50 percent of Americans living with chronic HBV.\3\ 
Additionally, a CDC assessment found significant increases in acute HBV 
infections in the Appalachian region (Kentucky, Tennessee, and West 
Virginia) among non-Hispanic whites, persons aged 30-39 years, and 
injection drug users. This represents an increased incidence of 114 
percent in acute HBV infections during 2009-2013 in these States.\4\
---------------------------------------------------------------------------
    \2\ Cohen C, H. S., McMahon BJ, Block JM, Brosgart CL, Gish RG, 
London WT, Block TM. (2011). Is chronic hepatitis B being undertreated 
in the United States? Journal of Viral Hepatitis, 18, 377-383.
    \3\ Http://www.cdc.gov/knowhepatitisb.
    \4\ 4 http://www.cdc.gov/mmwr/volumes/65/wr/
mm6503a2.htm?s_cid=mm6503a2_e.

    Left untreated, 1 in 4 of those with chronic HBV infection will die 
prematurely from liver failure and/or liver cancer. The CDC 2016 Annual 
Report to the Nation on the Status of Cancer found that unlike other 
cancers, liver cancer incidence and death rates are rising. In the 
U.S., liver cancer is the second deadliest cancer with a 5-year 
survival rate of only 10 percent.\5\ This underscores the urgent need 
for hepatitis B screening to identify new and chronic infections, and 
furthermore, with the HBV vaccine (the first ``anti-cancer'' vaccine, 
according to the FDA) that has been available for over 20 years, 
preventing hepatitis B infections can prevent primary liver cancer. 
According to the CDC, hepatitis B vaccination coverage is low among 
adults; the 2013 National Health Interview Survey data indicated that 
coverage with at least 3 doses of HBV vaccine was 32.6 percent for 
adults aged 19-49 years, the group at highest risk for new 
infections.\6\
---------------------------------------------------------------------------
    \5\ Http://www.cdc.gov/cancer/dcpc/research/articles/arn_7512.htm.
    \6\ Http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm.
---------------------------------------------------------------------------
Elimination of Perinatal Hepatitis B Transmission
    The transmission of HBV from mother to child, or perinatal 
transmission, during birth is the most common route of transmission 
worldwide. Despite prevention efforts, approximately 800 to 1,000 
babies are born each year in the U.S. and develop a chronic HBV 
infection.\7\ Without intervention, babies exposed to the hepatitis B 
virus during delivery have a 90 percent risk of developing a chronic 
infection, and 25 percent of infants chronically infected will die 
prematurely from HBV-related complications. Effective post-exposure 
prophylaxis comprised of the HBV vaccine and HBV immune globulin, can 
prevent mother-to-child transmission with a success rate of more than 
95 percent.\8\
---------------------------------------------------------------------------
    \7\ Https://blog.aids.gov/wp-content/uploads/
Perinatal_HBV_Report_FINAL_12-21-15-508.pdf.
    \8\ Ibid.
---------------------------------------------------------------------------
    The Hepatitis B Foundation believes that the elimination of 
perinatal HBV transmission is within reach if resources are dedicated 
to strengthening surveillance and referral systems and enhancing 
prevention efforts. We are pleased that after 4 years of urgings from 
the Committee, the Bureau of Primary Health Care has finally agreed to 
look an evaluation of intervention strategies to eliminate the 
perinatal transmission of hepatitis B in HRSA funded healthcare 
settings. However, a full evaluation of intervention strategies will 
require the training of healthcare professionals, followed by service 
delivery, data collection, and evaluation and we urge that the Bureau's 
funding plans accommodate these components and this necessary sequence 
of activities in order to accommodate a full evaluation of the 
recommended intervention strategies.
Strengthening Surveillance and State/Local Capacity
    A strong national surveillance system is critical towards 
understanding the true burden of disease, monitoring trends, outbreaks, 
and tracking progress in public health interventions. The current state 
of surveillance, especially to track chronic HBV infections, is sorely 
lacking and masks the true state of the epidemic in the U.S. Currently, 
the CDC funds merely five States and two large cities to conduct 
enhanced chronic viral hepatitis surveillance. CDC also provides a 
small amount of funding to State and local health departments through 
the Viral Hepatitis Prevention Coordinator Program (VHPC).\9\ The VHPC 
program, which funds a prevention coordinator position, is the only 
dedicated effort at a State and local level to coordinate viral 
hepatitis prevention activities. This position is severely underfunded 
and rarely enough to address HBV or HCV full time. Both are inadequate 
efforts and resources to address these large-scale epidemics and 
alarming new infections. In order to effectively combat chronic viral 
hepatitis in the U.S., we must increase State, local, and territorial 
capacity to address these epidemics and strengthen coordination, 
including surveillance systems, across the country.
---------------------------------------------------------------------------
    \9\ Http://www.cdc.gov/hepatitis/partners/vhcp.htm.
---------------------------------------------------------------------------
Research for a Cure
    We depend upon the NIH to fund research that will lead to new and 
more effective interventions to treat people with HBV and liver cancer. 
The Hepatitis B Foundation joins with the Ad Hoc Group for Biomedical 
Research and requests at least $34.5 billion for the NIH in fiscal year 
2017. We thank the Committee for their continued investment in the NIH, 
and specifically for the robust $32.1 billion of funding in fiscal year 
2016. Sustaining predictable increases for NIH is essential for 
development of life changing cures, pioneering treatments, and 
innovative prevention strategies.
    Additional funding could make transformational advances in research 
leading to curative treatments for HBV. In view of the fact that an 
estimated 2.2 million Americans are chronically infected with HBV, and 
on average more than 10 people die each day from the disease, it is 
incredibly disappointing that funding for HBV research at NIH has 
declined by almost 16 percent since fiscal year 2011. And yet, despite 
this decline in investment, there is the greatest momentum for 
discovery. For the first time it is now possible to study the entire 
hepatitis B virus life cycle and therefore identify targeted 
vulnerabilities that can be exploited to cure this deadly disease. In 
order to take advantage of this new scientific opportunity, funding for 
HBV research should be doubled with the goal of discovering more 
effective treatments and finding a complete cure. In addition, the 
Hepatitis B Foundation requests a stronger focus on liver cancer at the 
National Cancer Institute and urges the funding of a series of 
Specialized Programs of Research Excellence (SPOREs) focused on liver 
cancer. While SPOREs currently exist for every other major cancer, none 
currently exist that are focused on liver cancer.
Summary
    We are at a critical point in public health research and 
understanding to eliminate chronic HBV in the U.S. and reduce incidence 
and deaths from liver cancer. We strongly urge the Subcommittee to take 
this opportunity and increase the appropriation for HRSA's Bureau of 
Primary Health Care (+$3 million); the CDC Division of Viral Hepatitis 
(+$28.8 million); and for NIH (+$2.4 billion including +$ 49 million 
for hepatitis B research). We thank Chairman Blunt, Ranking Member 
Murray, and members of the Subcommittee for their thoughtful 
consideration of our request.

    [This statement was submitted Kate Moraras, Senior Program 
Director, Hepatitis B Foundation.]
                                 ______
                                 
            Prepared Statement of Heritage Health & Housing
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Heritage Health & Housing is part of a nationwide coalition, the 
Food is Medicine Coalition, of over 80 food and nutrition services 
providers, affiliates and their supporters across the country that 
provide food and nutrition services to people living with HIV/AIDS 
(PWH) and other chronic illnesses. In our service area, we provide 
20,000 congregate meals and 12,000 home delivered annually. 
Collectively, the Food is Medicine Coalition is committed to increasing 
awareness of the essential role that food and nutrition services (FNS) 
play in successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Sonia Grant, Program Director, 
Food and Nutrition Services Program, Heritage Health and Housing.]
                                 ______
                                 
           Prepared Statement of the HIV Medicine Association
    The HIV Medicine Association (HIVMA) of the Infectious Diseases 
Society of America (IDSA) represents more than 5,000 physicians, 
scientists and other healthcare professionals who practice on the 
frontlines of the HIV/AIDS pandemic. Our members provide medical care 
and treatment to people with HIV/AIDS in the U.S. and globally, lead 
HIV prevention programs and conduct research that has led to the 
development of effective HIV prevention and treatment options. As you 
work on the fiscal year 2017 appropriations process, we urge you to 
invest in the medical research supported by the National Institutes of 
Health (NIH), sustain robust funding for the Ryan White Program at the 
Health Resources and Services and Administration (HRSA) and support 
adequate funding for the Centers for Disease Control and Prevention's 
(CDC) HIV and STD prevention programs.
    Early access to effective HIV treatment helps patients with HIV 
live healthy and productive lives and is cost effective.\1\ Treatment 
not only saves the lives of individuals with HIV but directly benefits 
public health by reducing HIV transmission risk to near zero.\2\ 
However, despite our remarkable progress in HIV prevention, diagnosis 
and treatment, the HIV/AIDS epidemic is far from over. HIV/AIDS 
continues to pose a serious disease burden and public health threat in 
the United States with more than 1.2 million people living with HIV 
infection. Almost 1 in 8 (12.8 percent) individuals living with HIV are 
not aware of their HIV infection and there are an estimated 50,000 new 
infections occurring annually in the U.S. In our country, HIV infection 
disproportionately impacts racial and ethnic minority communities and 
low income people who depend on public services for their life-saving 
healthcare and treatment. The rate of new HIV infection in African 
Americans is 8 times that of whites.\3\ Globally, there are more than 
35.3 million people living with HIV, the great majority of them in Sub-
Saharan Africa.
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    \1\ Kitahata, Gange, Abraham, et al. Effect of early versus 
deferred antiretroviral therapy for HIV on survival. New Engl J Med 
2009;360:1815-26.
    \2\ Cohen, Myron S., et al. Prevention of HIV-1 Infection with 
Early Antiretroviral Therapy. 2011 New England Journal of Medicine 493-
505: V365, no 6, http://www.nejm.org/doi/full/10.1056/NEJMoa1105243.
    \3\ CDC Fact Sheet, February, 2014, accessed online at: http://
www.cdc.gov/hiv/risk/racialethnic/aa/facts/index.html.
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    The funding requests in our testimony largely reflect the consensus 
of the Federal AIDS Policy Partnership (FAPP), a coalition of HIV 
organizations from across the country, and are estimated to be the 
amounts necessary to mount an effective response to the domestic HIV 
epidemic and meet the need in communities across the country.
NIH--Office of AIDS Research (OAR)
    HIVMA strongly supports an overall fiscal year 2017 budget request 
level of at least $34.5 billion for the NIH, and urges that at least 
$3.45 billion be allocated to the NIH Office of AIDS Research. This 
level of funding is vital to sustain the pace of research that will 
improve the health and quality of life for millions of people in the 
U.S. and in the developing world. Flat funding of HIV/AIDS research 
since fiscal year 2015 threatens to slow progress toward a vaccine and 
a cure, erode our capacity to sustain our Nation's historic worldwide 
leadership in HIV/AIDS research and innovation, and discourage the next 
generation of scientists from entering the field.
    Our past investment in HIV/AIDS research paid off in dramatic 
reductions in mortality from AIDS of nearly 80 percent in the U.S. and 
in other countries where treatment is available. This research also 
helped reduce the mother to child HIV transmission rate from 25 percent 
to less than 1 percent in the U.S. and to very low levels in other 
countries where treatment is available. Sustained investments in NIH 
funding are also essential to train the next generation of scientists 
and prepare them to make tomorrow's HIV discoveries.
    The NIH-Wide Strategic Plan \4\ identifies criteria for setting the 
NIH's research priorities, including consideration of the value of 
permanently eradicating a disease--noting that biomedical research 
stands at another such pivotal moment today: the very real possibility 
of entirely eliminating HIV/AIDS. The plan also notes that such an 
investment makes good economic sense: every new case of HIV diagnosed 
in the United States translates into a lifetime cost of approximately 
$350,000 for treatment with antiretroviral drugs. Getting to zero new 
cases of HIV/AIDS would save our Nation an estimated $17.5 billion 
annually.\5\ Congress should ensure our Nation does not delay vital 
HIV/AIDS research progress.
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    \4\ NIH-Wide Strategic Plan, fiscal years 2016-2020: Turning 
Discovery Into Health, (December, 2015).
    \5\ Ibid, p. 32.
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HRSA--HIV/AIDS Bureau (HAB)
    At this critical time in the HIV/AIDS epidemic, when research has 
confirmed that early access to HIV care and treatment not only saves 
lives but prevents new infections by reducing the risk of transmission 
to near zero for patients who are virally suppressed and keeps patients 
engaged and working, it is essential to maintain overall funding levels 
for the Ryan White Program. Increasing access to and successful 
engagement in effective, comprehensive HIV care and treatment is the 
only way to lead the Nation to an AIDS-free generation and reduce the 
devastating costs of--including lives lost to--HIV infection. The Ryan 
White Program annually serves more than half a million individuals 
living with HIV in the U.S., providing the care and treatment that 
allows them to live close to a normal lifespan. HIVMA urges an 
allocation of $225.1 million, or a $20 million increase, for Ryan White 
Part C programs in fiscal year 2017. Part C-funded HIV medical clinics 
currently struggle to meet the demand of increasing patient caseloads. 
The expert, comprehensive HIV care model or ``medical home'' that is 
supported by the Ryan White Program has been highly successful at 
achieving positive clinical outcomes with a complex patient population. 
Patients with HIV who receive Ryan White services are more likely to be 
prescribed HIV treatment and to be virally suppressed.\6\ We also know 
that the annual healthcare costs for HIV patients who are not able to 
achieve viral suppression (often due to delayed diagnosis and care) are 
nearly 2.5 times that of healthier HIV patients.\7\
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    \6\ Bradley, H., et al. Ryan White HIV/AIDS Program Assistance and 
HIV Treatment Outcomes in the United States. CROI 2015. Abstract: 1064. 
Accessed online at: http://www.croiconference.org/sessions/ryan-white-
hivaids-program-assistance-and-hiv-treatment-outcomes-united-states.
    \7\ Based on data from Gilman BH, Green, JC. Understanding the 
variation in costs among HIV primary care providers. AIDS 
Care.2008:20;1050--6.
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    While the Affordable Care Act (ACA) provides important new 
healthcare coverage options for many patients, most health insurers 
fail to support the comprehensive care and treatment necessary for many 
patients to manage HIV infection. High cost sharing, benefit gaps and 
limited state uptake of the Medicaid expansion, especially in the 
South, necessitate an essential and ongoing role for the Ryan White 
Program to avoid life-threatening and costly disruptions in care.
    HIVMA does not support the proposal to consolidate Ryan White Part 
D funding into Part C. Ryan White Part C and D programs both provide 
comprehensive, effective care and treatment for women, infants, 
children and youth living with HIV/AIDS. Part D programs have 
cultivated special expertise for engaging and retaining women, 
including pregnant women, HIV-exposed infants, and young people in 
care. The programs provide services tailored to women and young people 
and in some communities, Part D-funded programs are the main providers 
of HIV care and treatment.
    Additionally, we support the President's request to increase by $9 
million the Special Projects of National Significance in order to 
increase hepatitis C virus (HCV) testing, and care and treatment for 
people living with HIV who are co-infected with HCV.
CDC--National Center for HIV/AIDS, Viral Hepatitis, STD, and TB 
        Prevention (NCHHSTP)
    HIVMA appreciates the much needed increase of $5 million proposed 
in the President's fiscal year 2017 budget for the CDC's NCHHSTP, to be 
directed to viral hepatitis--however, an increase on the order of $30 
million would more adequately meet the urgent need to ramp up the 
national response to the burgeoning viral hepatitis epidemic which has 
been fueled by injection drug use in the wake of the opioid and heroin 
addiction crisis. We also support sustained funding for HIV and STD 
prevention and surveillance, plus the Division of Adolescent School 
Health (DASH). We are also especially concerned about flat funding of 
CDC's global HIV programs, and request an increase of at least $3.3 
million for a total of $132 million, which includes resources for the 
agency's essential role in implementing PEPFAR programs in developing 
nations.
Policy Riders--Continue Progress on Federal Funding for Syringe 
        Exchange Programs
    HIVMA applauds the subcommittee's work in advancing report language 
that allows for the judicious use of Federal funding for syringe 
exchange programs (SEPs) as an important prevention and public health 
intervention. We support the continuation of this policy. SEPs are 
associated with decreases in HIV and viral hepatitis incidence, and 
provide an important point of healthcare access, including initiation 
of HIV and viral hepatitis education, counseling and testing, linkage 
to care, and entry into substance use treatment. SEPs also benefit 
community safety by reducing the number of improperly disposed syringes 
as well as reducing needle stick injuries to law enforcement officers 
and other first responders.
Conclusion
    We are at serious risk of losing ground against the HIV pandemic if 
we fail to prioritize HIV public health, treatment and research 
programs. HIV remains the leading infectious killer worldwide, and we 
must fully leverage and invest in HIV prevention, care and treatment 
and research to save the lives of millions who are infected or at risk 
of infection here in the U.S. and around the globe, and ultimately to 
end the HIV/AIDS epidemic.
                                 ______
                                 
   Prepared Statement of The Humane Society of the United States and 
                    Humane Society Legislative Fund
    On behalf of The Humane Society of the United States (HSUS) and the 
Humane Society Legislative Fund (HSLF), we appreciate the opportunity 
to provide testimony on our top NIH funding priorities for the House 
Labor, Health and Human Services, Education and Related Agencies 
Appropriations Subcommittee in fiscal year 2017.
               retirement of federally-owned chimpanzees
                  by the national institutes of health
    The HSUS and HSLF would like to thank the committee for all their 
hard work to ensure that the National Institutes of Health (NIH) 
retires government-owned chimpanzees from laboratories to sanctuary. 
Since their announcement in June of 2013, when the NIH laid out their 
plans to retire all but 50 government-owned chimpanzees to sanctuary, 
the agency has decided to retire all chimpanzees--including the group 
of 50 reserve chimpanzees. There are currently approximately 300 
chimpanzees cared for by the government who need to be moved from 
laboratories to the National Chimpanzee Sanctuary.
    Chimpanzees should be moved as quickly as possible to sanctuary, 
since it is in their best interest for their welfare as well as good 
for taxpayers. At Chimp Haven, the National Chimpanzee Sanctuary, 
chimpanzees are the sole focus of the facility and its staff. There, 
chimpanzees receive the very best care possible, including access to 
expansive outdoor habitats, large social groups and regular and varying 
enrichment. Accredited sanctuaries provide the highest welfare 
standards for chimps at a lower cost to taxpayers than housing 
chimpanzees in barren labs. It is estimated that transferring the 
government-owned chimpanzees who are slated for retirement from the 
laboratories where they are currently housed to the national sanctuary 
would save taxpayer dollars for care and maintenance costs. For these 
reasons, it is imperative that the NIH move the remaining government-
owned chimpanzees to sanctuary as soon as possible.
    To facilitate this transfer, the National Chimpanzee Sanctuary will 
need to expand, which will be a significant expense for the sanctuary. 
There is no doubt that relief of this financial strain would expedite 
the faster movement of the chimpanzees to sanctuary.
    We respectfully request that the Subcommittee continue to work with 
the NIH to ensure the remainder of the government-owned chimpanzees 
housed in laboratories are sent to sanctuary in a timely manner.
        the national center for advancing translational sciences
    The National Center for Advancing Translational Sciences (NCATS) is 
one of 27 Institutes and Centers (ICs) at the NIH. Established to 
transform and accelerate the translational research process, NCATS is 
all about getting more treatments to more patients more quickly. The 
Center complements other NIH ICs, the private sector and the nonprofit 
community; rather than concentrating on specific diseases, NCATS 
focuses on what is common among them. The Congress awarded $53,000,000 
over the president's budget for fiscal year 2016.
    Translation is the process of turning observations in the 
laboratory, clinic and community into interventions that improve the 
health of individuals and the public--from diagnostics and therapeutics 
to medical procedures and behavioral changes.
    Translational science is the field of investigation focused on 
understanding the scientific and operational principles underlying each 
step of the translational process.
Bridging the Gap
    Several thousand genetic diseases affect humans, of which only 
about 500 have any treatment. A novel drug, device or other 
intervention can take about 14 years and cost $2 billion or more to 
develop, and about 95 percent never make it past clinical trials. Even 
when a new drug or other intervention is developed and shown to be 
effective in clinical trials, many years may pass before all patients 
who could benefit from it are identified and treated.
    Here are some areas the animal protection community and industry 
have supported:
  --Tissue Chip for Drug Screening (Tissue Chip) Initiative.--This 
        partnership with the Defense Advanced Research Projects Agency 
        and the Food and Drug Administration (FDA) is designed to 
        develop 3-D human tissue chips that model the structure and 
        function of human organs, such as the lung, liver and heart, 
        and then combine these chips into an integrated system that can 
        mimic complex functions of the human body.
  --Toxicology in the 21st Century (Tox21) Initiative.--Tox21 is a 
        collaborative effort among NIH--including NCATS and the 
        National Toxicology Program at the National Institute of 
        Environmental Health Sciences--the Environmental Protection 
        Agency and the FDA. Through Tox21, researchers are testing 
        10,000 drugs and environmental chemicals for their potential to 
        affect molecules and cells in ways that can cause health 
        problems. The compounds undergo testing in NCATS' high-speed 
        robotic screening system.
    We respectfully request the Subcommittee request an update from 
NCATS on the plans for translational work to ultimately eliminate the 
use of animals in chemical testing and drug development.
    We appreciate the opportunity to share our views for the Labor, 
Health and Human Services, Education and Related Agencies 
Appropriations Act for fiscal year 2017.
                                 ______
                                 
    Prepared Statement of the Infectious Diseases Society of America
    On behalf of the Infectious Diseases Society of America (IDSA), I 
offer testimony in support of the U.S. Department of Health and Human 
Services (HHS) agencies and programs that contribute to the prevention, 
detection and treatment of infectious diseases (ID). IDSA represents 
more than 10,000 physicians and scientists dedicated to promoting 
health through excellence in ID research, education, prevention, and 
patient care. IDSA urges the Subcommittee to provide necessary fiscal 
year 2017 funding for public health and biomedical research activities 
that ultimately save lives, contain healthcare costs and promote 
economic growth. More specifically, IDSA encourages the Subcommittee to 
provide $7.8 billion for the Centers for Disease Control and Prevention 
(CDC) and $34.5 billion for the National Institutes of Health (NIH). 
IDSA also asks that the Subcommittee act swiftly to provide the $1.9 
billion requested by the administration to prevent and respond to the 
Zika virus.
    Our community of infectious diseases professionals is particularly 
concerned by the growing public health crisis of antimicrobial 
resistance (AR). We witness firsthand the impact that AR has on 
individuals. As a result, we have aggressively advocated for the 
creation and implementation of a comprehensive Federal response. IDSA 
applauds Congress, and in particular the many champions on this 
Subcommittee, for appropriating approximately $380 million in new 
funding during the fiscal year 2016 cycle to begin implementation of 
the National Action Plan for Combating Antibiotic-Resistant Bacteria 
(Action Plan). The Action Plan details and coordinates prevention, 
surveillance, antibiotic stewardship, as wells as research and 
development (R&D) activities across Federal agencies --as recommended 
by the President's Council of Advisors on Science and Technology 
(PCAST) in their September 2014 Report to the President on Combating 
Antibiotic Resistance.
    We know that the Federal response to antimicrobial resistance must 
be sustained in order to stem the tide that already results in over two 
million infections and 23,000 deaths each year. In March 2016, the 
Presidential Advisory Council on Combating Antibiotic-Resistant 
Bacteria (PACCARB) released a draft of its Initial Assessments of the 
National Action Plan for Combating Antibiotic-Resistant Bacteria. The 
report states that ``Combating AMR [antimicrobial resistance] requires 
an adequate resource base to slow down, control, and hopefully reverse 
the problem. Simply stated, the USG [U.S. Government] must commit 
sufficient resources to solving the problem with funding continued over 
a long period of time.'' The president's budget for fiscal year 2017 
requests the resources necessary to continue implementation of the 
Action Plan. IDSA urges the Subcommittee to provide the funding 
increase requested for the CDC Antibiotic Resistance Solutions 
Initiative. We ask that the final fiscal year 2017 Labor-HHS-Education 
Appropriations bill also support the Action Plan activities carried out 
by the NIH, Biomedical Advanced Research and Development Authority 
(BARDA) and the Agency for Healthcare Research and Quality (AHRQ).
    The Zika virus is another serious public health threat that is of 
considerable interest to our members. We are witnessing the first 
widespread transmission of the Zika virus in the Americas. While the 
mosquito-borne virus generally causes mild illness or no symptoms, it 
has been linked to birth defects in infants born to mothers who were 
infected during pregnancy. The Federal Government now has a window of 
opportunity to help contain the Zika virus in Zika-endemic countries, 
as well as to enhance State/local prevention and response efforts, 
increase epidemiology and surveillance capacity, and support R&D for 
vaccines, diagnostics and therapeutics. We ask that Congress 
immediately fund the president's request to combat the Zika virus. As a 
temporary measure, the Obama administration recently repurposed $600 
million to address the Zika Virus. However, these funds will need to be 
replaced and are insufficient to provide the necessary response.
               centers for disease control and prevention
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
    The NCEZID leads CDC efforts to address antibiotic resistance as 
well as helps confront emerging public health threats such as the Zika 
virus.
    We ask that NCEZID be provided the $629.5 million requested by the 
Obama administration, including $200 million for continuation of the 
Antibiotic Resistance Solutions Initiative, which was initiated with 
fiscal year 2016 support from this Subcommittee. The requested fiscal 
year 2017 funding would allow CDC to expand fiscal year 2016 
Healthcare-Associated Infections (HAI)/AR prevention efforts from 25 
States to up to 50 States, six large cities, and Puerto Rico. CDC plans 
to award the majority of the fiscal year 2017 increased AR funding to 
States. The CDC projects that over 5 years the initiative will lead to 
a 60 percent decline in health-care associated carbapenem-resistant 
Enterobacteriaceae (CRE), 50 percent reduction in Clostridium 
difficile, 50 percent decline in bloodstream methicillin-resistant 
Staphylococcus aureus (MRSA), 35 percent decline in health-care 
associated multidrug-resistant Pseudomonas spp., and 25 percent 
reduction in multidrug-resistant Salmonella infections, eclipsing the 
costs of the program.
    IDSA also supports the proposed budget of $21 million for the 
National Healthcare Safety Network (NHSN) to increase the number of 
participating healthcare facilities from 19,000 to as many as 20,000 by 
the end of fiscal year 2017, as well as to increase the number of sites 
reporting antibiotic use data from 130 in 30 States to 750 in all 50 
States. Information provided to the NHSN is critical for evaluating the 
success of interventions designed to reduce inappropriate antibiotic 
use and limit the development of resistance.
    IDSA recommends that at least $30 million be allocated for the 
Advanced Molecular Detection (AMD) initiative in fiscal year 2017. This 
funding will allow CDC to more rapidly determine where emerging 
diseases come from, whether microbes are resistant to antibiotics, and 
how microbes are moving through a population. During the 2014/2015 
Ebola outbreak, AMD methods were utilized to determine whether the 
virus was changing as it spread through different populations, which 
facilitated appropriate responses.
Global Health Security
    IDSA supports CDC continued efforts to implement the Global Health 
Security Agenda, which would accelerate the efforts of the U.S. and 
partner nations to prevent, detect and slow the spread of infectious 
diseases across borders. We ask that you provide the Global Health 
Security initiative with at least the funding requested in the fiscal 
year 2017 PBR.
    CDC plays a central role in responding to new outbreaks such as of 
Ebola virus disease in 2014/2015 and Zika virus infections in 2015/
2016. The spread of Zika virus through South America, Central America, 
the Caribbean and now into the U.S. is the latest example of the fact 
that infectious diseases respect no national borders and that CDC must 
be appropriately funded to maintain readiness to be ahead of new 
crises. The requested funding will build response and prevention in the 
U.S. and territories as well as international surveillance and public 
health capacity. The request expands the Field Epidemiology Training 
Program, laboratory testing, healthcare provider training, and 
surveillance and control in countries at highest risk. The requested 
resources will also accelerate R&D of medical countermeasures, 
including vaccines and diagnostics, which will be a necessary to combat 
the Zika virus.
    IDSA also urges the Subcommittee to include $132 million for the 
CDC Global AIDS Program, which plays a unique role in building 
sustainability by funding physicians, epidemiologists, and public 
health advisors in countries hit hardest by the AIDS epidemic.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 
        (NCHHSTP)
    Despite a misperception as a disease of the past, tuberculosis now 
causes more deaths than any other single infectious disease agent, with 
9.6 million new illnesses and 1.5 million deaths in 2014. Approximately 
480,000 of those cases were caused by multidrug-resistant (MDR) 
tuberculosis, including 9.7 percent that were extensively drug-
resistant (XDR). In December, 2015, the Obama administration released 
the National Action Plan to Combat Multi-Drug Resistant (MDR) 
Tuberculosis, a comprehensive plan to address drug-resistant TB in the 
U.S. and abroad and accelerate MDR-TB R&D. In order to fund the plan 
and put the U.S. back on the path towards TB elimination, IDSA 
recommends a budget of $243 million in fiscal year 2017 for the CDC 
Division of Tuberculosis Elimination.
    IDSA recommends an increase of $30 million for NCHHSTP to enhance 
the response to the viral hepatitis epidemic that has been fueled by 
injection drug use associated with opioid addiction. Sustained funding 
of $157.3 million is also necessary for HIV and STD prevention and 
surveillance activities.
National Center for Immunization and Respiratory Diseases
    Immunizations are among the most cost-effective clinical preventive 
services. However, national adult immunization rates remain low for 
most routinely recommended vaccines. Each year in the U.S., tens of 
thousands of adults die from illnesses that are preventable through 
vaccination. Additionally, vaccine-preventable diseases and related 
complications result in billions of dollars annually in direct and 
indirect healthcare costs. IDSA asks that the CDC Immunization Grant 
Program (Section 317) be funded at least at the fiscal year 2016 level 
of $611 million.
    IDSA recommends that the Subcommittee provide at least the $188 
million proposed in the PBR for CDC efforts to control influenza. CDC 
plays a critical role in seasonal and pandemic influenza preparedness 
and response, including conducting surveillance activities that inform 
response efforts and providing public communications regarding 
influenza prevention and treatment.
                     national institutes of health
National Institute of Allergy and Infectious Diseases (NIAID)
    Within NIH, NIAID should be funded at least at $4.716 billion as 
requested in the fiscal year 2017 PBR. Further, we believe that NIAID 
should be provided an increase that is proportionate to any increase 
provided to the NIH as a whole. The NIAID plays a leading role in 
research for new rapid ID diagnostics, vaccines and therapeutics. The 
January 2015 IDSA report, Better Tests, Better Care: The Promise of 
Next Generation Diagnostics explains that advances in biomedical 
research over the last few decades have created the potential for 
increasingly simple, fast and reliable diagnostic tests for infectious 
diseases. By allowing physicians to quickly distinguish between 
bacterial and viral infections, better diagnostics can lead to faster 
and more appropriate treatments for patients, help preserve the utility 
of our existing drugs, and aid in identifying individuals to 
participate in clinical trials. Last year, NIAID awarded more than $11 
million in first-year funding for research to develop diagnostics to 
rapidly detect antibiotic-resistant bacteria. NIAID also recently 
announced awards of approximately $5 million for non-traditional 
alternatives to antibiotics. These efforts as well as research on new 
antimicrobials and vaccines are set to ramp up with the $100 million 
increase made last year. We ask that the Subcommittee continue this 
work in fiscal year 2017.
    The Antibacterial Resistance Leadership Group (ARLG), led by 
researchers at Duke University and the University of California San 
Francisco, is an example of extramural research to address AR made 
possible by NIAID. The ARLG manages a clinical research agenda to 
increase knowledge of antibacterial resistance. The ARLG has supported 
early clinical research on new antibacterials as well as on diagnostics 
that rapidly identify resistant bacteria. Continued operation of the 
ARLG depends on support from the NIAID.
Office of AIDS Research
    Federal investments in HIV/AIDS research have led to much longer 
lives for those living in countries where treatment is available. 
Continued investment in HIV/AIDS research through NIH is critically 
important. We urge the Subcommittee to provide at least $3.45 billion 
for the Office of AIDS Research (OAR). The level-funding of HIV/AIDS 
research since 2015 threatens work towards a vaccine as well as 
discourages individuals from entering the field.
           assistant secretary for preparedness and response
Biomedical Advanced Research and Development Authority
    BARDA is a critical initiator of public-private collaborations for 
antibiotic, diagnostic and vaccine R&D. PCAST has identified BARDA as 
best positioned to elicit private investments necessary to address 
antibiotic resistance. IDSA recommends that the Subcommittee provide 
$607 million for BARDA in fiscal year 2017. Such funding is necessary 
to allow BARDA to pursue additional work on antibiotic development 
while maintaining its strong focus on other medical countermeasures to 
address biothreats.
    We also request that in any final version of fiscal year 2017 
appropriations language, you strongly urge BARDA to include TB in their 
new and emerging infectious disease efforts and invest in the 
development of new TB diagnostics, drugs and vaccines as part of the 
CARB initiative and the Emerging Infectious Diseases program at BARDA.
               center for medicare and medicaid services
    Despite the significant and vital contributions ID physicians make 
to patient care, research and public health, their work continues to be 
undervalued. Over 90 percent of the care provided by ID physicians is 
considered evaluation and management (E&M). Current E&M codes fail to 
reflect the increasing complexity of E&M work. ID physicians often care 
for patients with chronic illnesses, including HIV, hepatitis C, and 
recurrent infections. Such care involves preventing complications and 
exploring complicated diagnostic and therapeutic pathways. ID 
physicians also conduct significant post-visit work, such as care 
coordination, patient counseling and other necessary follow up.
    New research is needed to better identify and quantify the inputs 
that accurately capture the elements of complex medical decisionmaking. 
Such studies should take into account the evolving healthcare delivery 
models with growing reliance on team-based care, and should consider 
patient risk-adjustment as a component to determining complexity. 
Research activities should include the direct involvement of physicians 
who primarily provide cognitive care. We urge the Subcommittee to 
include report language in the fiscal year 2017 funding bill asking 
that ``CMS undertake research necessary to develop new E&M codes and 
accompanying documentation requirements that more precisely describe 
the cognitive work in these physician-patient encounters, and that the 
results of such research be made publicly available no later than 2 
years after the passage of this Act.''
               agency for healthcare research and quality
    IDSA supports the $12 million requested in the president's budget 
for fiscal year 2017 for research to develop methods and approaches for 
combating antibiotic resistance and conducting antibiotic stewardship 
in multiple healthcare settings, with a focus on long-term and 
ambulatory care settings.
    Once again, thank you for the opportunity to submit this statement 
on behalf of the Nation's ID physicians and scientists. We rely on 
strong Federal partnerships to keep Americans healthy and urge you to 
support these efforts. Please forward any questions to Jonathan Nurse 
at jnurse@idsociety.org.
                                 ______
                                 
      Prepared Statement of the Institute of Makers of Explosives
           interest of the institute of makers of explosives
    The Institute of Makers of Explosives (IME) was founded in 1913 to 
provide accurate information and comprehensive recommendations 
concerning the safety and security of the commercial explosives 
industry. Our mission is to promote safety, and the protection of 
users, the public and environment, and to encourage the adoption of 
uniform rules and regulations in the manufacture, transportation, 
storage, handling, use and disposal of explosive materials used in 
blasting and other essential operations.
    IME represents the U.S. manufacturers and distributors of 
commercial explosive materials and oxidizers as well as other companies 
that that provide related services. Millions of metric tons of high 
explosives, blasting agents, and oxidizers are consumed annually in the 
U.S. Of this, IME member companies produce over 98 percent of the high 
explosives and a great majority of the blasting agents and oxidizers. 
These products are used in every State and are distributed worldwide.
    IME also publishes industry best practice standards in its Safety 
Library Publications (SLPs). These standards have been incorporated in 
Federal and State regulations and are used internationally. In 
addition, IME publishes a number of guidance documents on various 
subjects, such as our Safety and Security Guidelines for Ammonium 
Nitrate \1\ and has produced several DVDs, including a DVD and Leader's 
Guide for first responders detailing the proper response to 
transportation incidents involving explosive materials.\2\ The SLPs are 
regularly reviewed and updated by the Institute and represent the most 
current, reliable and expert recommendations on explosives management 
available to the industry.
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    \1\ Safety and Security Guidelines for Ammonium Nitrate; IME, 
International Association of Fire Chiefs (IAFC), International 
Association of Explosive Engineers (ISEE), and the National Stone, Sand 
& Gravel Association (NSSGA), (2013).
    \2\ Responding to Highway Incidents Involving Commercial 
Explosives, IME and Department of Transportation (2013).
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    In addition, IME has developed a comprehensive quantitative risk 
assessment (QRA) software program, IMESAFR. The program is a windows-
based computer model for assessing the risk from a variety of 
commercial explosives activities as an alternative to determining safe 
setback distances based on decades old quantity-distance tables. 
IMESAFR is a state-of-the-art, tool that, will prove invaluable to the 
commercial explosives industry in our continuing mission to ensure the 
health, safety and security of present and future generations of 
explosive managers, the public and the environment.
                                comments
    The following comments reflect our commitment to worker and public 
safety.
Occupational Safety & Health Administration (OSHA)
    IME would like to express our thanks to the Committee for including 
in the fiscal year 2016 conference report the following language:

    ``The Committee understands that, as a result of Executive Order 
        13650, Improving Chemical Safety and Security, OSHA is 
        considering options to ensure the safety of ammonium nitrate 
        handling and storage. The Committee also understands that there 
        is no record thus far of an accidental detonation of ammonium 
        nitrate in a situation where a storage facility has been 
        compliant with OSHA's existing regulations at 29 CFR 
        1910.109(i). The existing regulations are based on standards of 
        the National Fire Protection Association. Before any new 
        regulations are proposed for the storage of solid ammonium 
        nitrate, the Secretary shall submit a report to the Committees 
        on Appropriations of the House Representatives and the Senate; 
        the Senate Health, Education, Labor and Pensions Committee; and 
        the House Committee on Education and the Workforce that 
        identifies any provisions of OSHA's current 29 CFR 1910.109(i) 
        regulations under consideration for update and that evaluates 
        the costs and benefits of such changes.''
    We regret to inform you that despite this clear direction, OSHA has 
determined to include the option of regulating AN within the scope of 
its recently proposed rulemaking, ``Process Safety Management and 
Prevention of Major Chemical Accidents (RIN: 1218-AC83).'' 
Consequently, we urge the Subcommittee to retain this language in the 
committee report for the fiscal year 2017 Labor, Health and Human 
Services, and Education appropriations bill.
    This language was necessitated by section 6(c) of Executive Order 
13650, which among other things, instructed OSHA to determine if 
Process Safety Management (PSM) can and should be expanded to cover AN. 
IME supports the continued reliance on the Sec. 1910.109(i) standard, 
and updating this standard to match current industry best practices. 
The updates include; (1) a prohibition on the use of wooden storage 
bins, (2) an instruction that fires involving AN should not be fought 
(our recommendation against fighting AN fires is aimed at offsite first 
responders, not to trained, in-house fire brigades that respond to 
emergencies in accordance with facility emergency action plans), and 
(3) a requirement that facilities prepare written emergency response 
plans and share these plans with the local emergency responder 
community. These recommendations are included in the previously 
mentioned IME Safety & Security Guidelines for Ammonium Nitrate (2013), 
and are largely consistent with the 2016 National Fire Protection 
Association (NFPA) 400 standard.
    Current Sec. 1910.109(i) rules have proven very effective. Since 
the standard was promulgated in 1971, there has not been an accidental 
detonation of AN at any facility compliant with this regulation. A 45-
year record of safety is, in our opinion, a good reason to strengthen 
the regulations, rather than impose the PSM standard on the industry.
    Not only do the current regulations work, applying PSM in our 
opinion, is inappropriate and is not likely to increase safety in 
proportion with greatly increased compliance efforts that would be 
required. The PSM program was developed to prevent the release of 
highly dangerous chemicals like those released in the catastrophic 
accident in Bhopal, India, and AN is simply not a highly dangerous 
chemical. The ``technical'' grade of AN used in the explosives industry 
has the same chemical composition as the ``fertilizer'' grade of AN 
used in the agricultural sector, only the density of the prill is 
different. AN, in either form, is not a volatile or self-reactive 
chemical requiring constant diligence in its handling. Rather, it is a 
stable, relatively benign substance when it is managed properly--and 
proper management of AN is simple, well understood, and easily 
accomplished. AN does not pose a threat of an accidental release of 
energy or fumes unless subjected to substantial and sustained heat 
(e.g., fire), contamination, or shock from high impact projectiles.
    Considering that most IME members are small businesses, as defined 
by the Small Business Administration, the workload requirements 
associated with a PSM standard would fall hard on the industry. The PSM 
standard requires employers to complete 14 hazard assessment actions 
related to chemical processes, and completing these steps would likely 
require hiring additional employees or contractors. IME expects that 
these process hazard analyses (``PHAs'') will conclude that compliance 
with the current standard at 29 C.F.R. 1910.109(i) will be sufficient 
to ensure that AN is safely stored and managed. Just to be clear, AN is 
also subject to a number of other ATF, EPA, DHS, and DOT safety and 
security regulations. Updating the current regulations will provide 
clear and actionable steps that can be taken to ensure safety of 
workers and the public, without the substantial and reoccurring 
financial burden that compliance with PSM would require.
Mine Safety & Health Administration
    The fiscal year 2017 budget request for MSHA contains two 
initiatives that we support.
            Safety Alliances
    IME is in advanced stages of discussion to formally enter into a 
voluntary alliance with MSHA to promote safety across the commercial 
explosives sector. MSHA's Alliance Program enables organizations, like 
IME, that are committed to mine safety and health to collaborate with 
MSHA to prevent injuries and illnesses in the workplace. Through the 
program, MSHA and its allies work together to reach out to, educate, 
and lead the Nation's mine operators and miners in improving and 
advancing mine safety and health. Alliances are formed by MSHA senior 
headquarters staff after initial discussions with an organization 
interested in collaborating with MSHA. While the safety statistics 
classified under Explosives and Breaking Agents by MSHA are exemplary, 
IME believes that safety should never take a rest. We look forward to 
reaching an agreement to work with MSHA to promote safety across the 
entire commercial explosives industry.
            Rules to Live By
    IME recognizes that advancement in technology allows our membership 
to access training resources on their own schedule and across multiple 
platforms. In 2015, IME rolled out a new website that will adjust to 
the users' device allowing IME members and non-members to access our 
safety materials wherever and whenever they choose and on the device of 
their choice. For this reason, we applaud MSHA for innovative 
initiatives like ``Rules to Live By'' where the agency is using 
multiple platforms to promote safety. By putting knowledge and best 
practices literally at users' fingertips, both IME and MSHA can add a 
level of safety by directly empowering employees with the knowledge and 
understanding they need to stay safe. We are hopeful that the Committee 
will support MSHA's continuing efforts to increase workers' knowledge 
base of safety through this initiative in fiscal year 2017.
    Thank you for your attention to these requests.

    [This statement was submitted by John Boling, Director of 
Government Affairs, Institute of Makers of Explosives.]
                                 ______
                                 
      Prepared Statement of the Interstitial Cystitis Association
            summary of recommendations for fiscal year 2017
_______________________________________________________________________

  --Provide $1 million for the IC Education and Awareness Program and 
        the IC Epidemiology Study at the Centers for Disease Control 
        and Prevention (CDC)
  --Provide $7.8 billion for CDC
  --Provide $34.5 billion for the National Institutes of Heatlh (NIH) 
        and Proportional Increases Across all Institutes and Centers
  --Support NIH Research on IC, Including the Multidisciplinary 
        Approach to the Study of Chronic Pelvic Pain (MAPP) Research 
        Network
_______________________________________________________________________

    Thank you for the opportunity to present the views of the 
Interstitial Cystitis Association (ICA) regarding interstitial cystitis 
(IC) public awareness and research. ICA was founded in 1984 and is the 
only nonprofit organization dedicated to improving the lives of those 
affected by IC. The Association provides an important avenue for 
advocacy, research, and education. Since its founding, ICA has acted as 
a voice for those living with IC, enabling support groups and 
empowering patients. ICA advocates for the expansion of the IC 
knowledge-base and the development of new treatments. ICA also works to 
educate patients, healthcare providers, and the public at large about 
IC.
    IC is a condition that consists of recurring pelvic pain, pressure, 
or discomfort in the bladder and pelvic region. It is often associated 
with urinary frequency and urgency. This condition may also be referred 
to as painful bladder syndrome (PBS), bladder pain syndrome (BPS), and 
chronic pelvic pain (CPP). It is estimated that as many as 12 million 
Americans have IC symptoms. Approximately two-thirds of these patients 
are women, though this condition does severely impact the lives of as 
many as 4 million men. IC has been seen in children and many adults 
with IC report having experienced urinary problems during childhood. 
However, little is known about IC in children, and information on 
statistics, diagnostic tools and treatments specific to children with 
IC is limited.
    The exact cause of IC is unknown and there are few treatment 
options available. There is no diagnostic test for IC and diagnosis is 
made only after excluding other urinary/bladder conditions. It is not 
uncommon for patients to experience one or more years delay between the 
onset of symptoms and a diagnosis of IC. This is exacerbated when 
healthcare providers are not properly educated about IC.
    The effects of IC are pervasive and insidious, damaging work life, 
psychological well-being, personal relationships, and general health. 
The impact of IC on quality of life is equally as severe as rheumatoid 
arthritis and end-stage renal disease. Health-related quality of life 
in women with IC is worse than in women with endometriosis, vulvodynia, 
and overactive bladder. IC patients have significantly more sleep 
dysfunction, and higher rates of depression, anxiety, and sexual 
dysfunction.
    Some studies suggest that certain conditions occur more commonly in 
people with IC than in the general population. These conditions include 
allergies, irritable bowel syndrome, endometriosis, vulvodynia, 
fibromyalgia, and migraine headaches. Chronic fatigue syndrome, pelvic 
floor dysfunction, and Sjogren's syndrome have also been reported.
    As prescription drug abuse and issues of opioid addiction present 
challenges for many areas of the country, Congress and Federal agencies 
are working to craft policies to address emerging problems. When 
Congress faces a crisis there is a tendency to create blunt and broad 
solutions as opposed to nuanced and thoughtful solutions. To date, the 
focus of the government has been on reducing and limiting access to 
pain medication.
    The Food and Drug Administration, CDC, and other Federal agencies 
have all released guidance or requested community feedback on standards 
and guidelines for pain management therapies. A comprehensive National 
Pain Management Strategy was also released in late March.
    We need to raise awareness on Capitol Hill that many Americans rely 
on unobstructed access to pain medications to manage chronic pain. 
Further, we need to combat perceptions and prejudices that lead to 
stigma and make it harder for physicians to prescribe needed 
medications or manage chronic pain with treatment plans. Basically, as 
new standards are set the chronic pain community should not be painted 
with the same broad brush and new policies should accommodate patients 
impacted by chronic pain while also addressing societal issues.
             ic public awareness and education through cdc
    ICA recommends a specific appropriation of $1 million in fiscal 
year 2017 for the CDC IC Program. This will allow CDC to fund the 
Education and Awareness Program, per ongoing congressional intent, as 
well as the IC Epidemiology Study.
    In December 2014, CDC switched the focus of the IC program from 
education and awareness to an epidemiology study. The IC community is 
concerned that eliminating education and awareness activities is 
detrimental to patients and their families. The CDC IC Education and 
Awareness Program is the only Federal program dedicated to improving 
public and provider awareness of this devastating disease, reducing the 
time to diagnosis for patients, and disseminating information on pain 
management and IC treatment options. ICA urges Congress to provide 
funding for IC education and awareness in fiscal year 2017.
    The IC Education and Awareness program has utilized opportunities 
with charitable organizations to leverage funds and maximize public 
outreach. Such outreach includes public service announcements in major 
markets and the Internet, as well as a billboard campaign along major 
highways across the country. The IC program has also made information 
on IC available to patients and the public though videos, booklets, 
publications, presentations, educational kits, websites, self-
management tools, webinars, blogs, and social media communities such as 
Facebook, YouTube, and Twitter. For healthcare providers, this program 
has included the development of a continuing medical education module, 
targeted mailings, and exhibits at national medical conferences.
    The CDC IC Education and Awareness Program also provided patient 
support that empowers patients to self-advocate for their care. Many 
physicians are hesitant to treat IC patients because of the time it 
takes to treat the condition and the lack of answers available. 
Further, IC patients may try numerous potential therapies, including 
alternative and complementary medicine, before finding an approach that 
works for them. For this reason, it is especially critical for the IC 
program to provide patients with information about what they can do to 
manage this painful condition and lead a normal life.
         ic research through the national institutes of health
    ICA recommends a funding level of $34.5 billion for NIH in fiscal 
year 2017. ICA also recommends continued support for IC research 
including the MAPP Study administered by NIDDK.
    The National Institutes of Health (NIH) maintains a robust research 
portfolio on IC with the National Institute of Diabetes and Digestive 
and Kidney Diseases (NIDDK) serving as the primary Institute for IC 
research. Research currently underway holds great promise to improving 
our understanding of IC and developing better treatments and a cure. 
The NIDDK Multidisciplinary Approach to the Study of Chronic Pelvic 
Pain (MAPP) Research Network studies the underlying causes of chronic 
urological pain syndromes, including epidemiology. The MAPP Study has 
expanded in its second phase to include cross-cutting researchers and 
researchers are currently identifying different phenotypes of the 
disease. Phenotype information will allow physicians to prescribe 
treatments with more specificity. Research on chronic pain that is 
significant to the community is also supported by the National 
Institute of Neurological Disorders and Stroke (NINDS) as well as the 
National Center for Complementary and Integrative Health (NCCIH). 
Additionally, the NIH investigator-initiated research portfolio 
continues to be an important mechanism for IC researchers to create new 
avenues for interdisciplinary research.
    Thank you for the opportunity to present the views of the 
interstitial cystitis community.

    [This statement was submitted by Lee Claassen, Executive Director, 
Interstitial Cystitis Association.]
                                 ______
                                 
    Prepared Statement of the Leaders Engaged on Alzheimer's Disease
    Dear Chairmen Cochran and Blunt and Ranking Members Mikulski and 
Murray: We thank Congress for recognizing and responding decisively in 
fiscal year 2016 to the challenges of Alzheimer's disease and related 
dementias (including vascular, Lewy body and frontotemporal dementia). 
We applaud your determination to seize the enormous opportunities for 
America if we invest in the science, care and support required to 
overcome these challenges and for recognizing the consequences if we 
fail to act. Doing so is a national priority, an economic and budgetary 
necessity, a health and moral imperative.
    We urge that you build upon recent developments and include the 
resources necessary to support dementia and aging research within the 
fiscal year 2017 budget. Specifically, we urge you to move with all 
alacrity to commit at least 1 percent of the cost of treating persons 
living with dementia to research supported by the National Institutes 
of Health (NIH) and to move us substantially closer to this goal in 
fiscal year 2017. Today, this amount would be approximately $2 billion, 
the minimum annual amount of public research funding leading dementia 
researchers have recommended must be committed to maximize the 
likelihood of achieving the Nation's goal of preventing and effectively 
treating dementia by 2025.
    As you assemble the fiscal year 2017 Labor, Health and Human 
Services, Education and Related Agencies Appropriations Act, we urge 
that you include:
  --A minimum increase of $400 million in Alzheimer's disease and 
        related dementias research at the NIH over the fiscal year 2016 
        enacted level. Such an increase would result in an NIH-wide 
        dementia research budget of about $1.336 billion in fiscal year 
        2017. If similar commitments are made over the following 2 
        years, we will meet and exceed the $2 billion target by fiscal 
        year 2019.
  --A minimum increase of $500 million over the fiscal year 2016 
        enacted level for aging research across the NIH, in addition to 
        the funding for dementia. This increase will ensure that the 
        NIH and NIA have the resources they need, not only to address 
        dementia, but also the many other age-related chronic diseases.
  --A minimum increase of $25 million in the budgets for dementia care 
        and services programs over the fiscal year 2016 enacted levels 
        at the Administration for Community Living, Health Resources 
        and Services Administration, the Centers for Disease Control 
        and Prevention, and the Department of Justice.
    There are few more compelling or complex issues to confront our 
aging society than dementia, now and over the coming decades. These 
conditions impose enormous costs to our Nation's health and prosperity, 
costs that are skyrocketing.\1\ Due to NIA's Health and Retirement 
Study (HRS), we now know that the healthcare costs of caring for people 
with dementia in the United States are comparable to, if not greater 
than, those for heart disease and cancer.\2\ A recent analysis of HRS 
data revealed that, in the last 5 years of life, total healthcare 
spending for people with dementia was more than a quarter-million 
dollars per person, some 57 percent greater than costs associated with 
death from other diseases, including cancer and heart disease.\3\ 
Today, more than five million Americansi \4\ have dementia at an annual 
cost to our economy exceeding $200 billion.\5\ Alzheimer's disease 
contributes to the deaths of approximately 500,000 Americans each year, 
making it the third leading cause of death in the United States.\6\ If 
the current trajectory persists, at least 13 million Americans will 
have dementia in 2050 and total costs of care are projected to exceed 
(inflation adjusted 2014 dollars) $1 trillion annually.\7\ The Federal 
Government, through Medicare and Medicaid payments, shoulders an 
estimated 70 percent of all such direct care costs.
---------------------------------------------------------------------------
    \1\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
    \2\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
    \3\ Http://annals.org/article.aspx?articleid=2466364#.
    \4\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan2014.pdf.
    \5\ Http://www.nejm.org/doi/full/10.1056/NEJMsa1204629.
    \6\ Http://www.neurology.org/content/early/2014/03/05/
WNL.0000000000000240.
    \7\ Http://www.alz.org/trajectory.
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    The choice before our Nation is not whether to pay for dementia--we 
are paying dearly. The question is whether we will emulate the 
investment strategies that have led to remarkable progress in fighting 
other leading causes of death such as cancer, HIV/AIDS and heart 
disease and achieve similar breakthroughs, or spend trillions to care 
for tens of millions of people. A modernized and more robust research 
portfolio can help America prevent this catastrophe and move us closer 
to achieving our national goal of preventing and effectively treating 
dementia by 2025.\8\
---------------------------------------------------------------------------
    \8\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf.
---------------------------------------------------------------------------
    Due to leadership and direction from Congress, HHS continues to 
increase prioritization of Alzheimer's disease and related dementias. 
The publicly appointed members of the Advisory Council on Alzheimer's 
Research, Care, and Services have generated their most thoughtful and 
catalytic recommendations for the annual update to the National Plan to 
Address Alzheimer's Disease. There is heightened focus on improving 
care for people with advanced dementia.\9\ The Food and Drug 
Administration is encouraging new research avenues and clarifying 
regulatory approval pathways. Your committee and NIH have moved 
mountains to create additional resources, public-private partnerships, 
and a culture of urgency. Across the NIH, institutes are supporting 
promising Alzheimer's disease and related dementias research to: 
understand genetic risk factors; \10\ address health disparities among 
women,\11\ African Americans,\12\ Hispanics,\13\ and persons with 
intellectual disabilities; \14\ and pursue cutting-edge trials aimed at 
preventing or substantially slowing disease progression by 
administering treatments much earlier in the disease process.\15\ In 
fiscal year 2017, the NIA plans to increase its research focus on 
dementia epidemiology, health disparities, and caregiving.\16\
---------------------------------------------------------------------------
    \9\ Http://aspe.hhs.gov/daltcp/napa/012615/Mtg15-Slides4.pdf.
    \10\ Http://www.nia.nih.gov/alzheimers/publication/2012-2013-
alzheimers-disease-progress-report/genetics-alzheimers-disease.
    \11\ Http://www.alz.org/downloads/facts_figures_2014.pdf.
    \12\ Http://www.usagainstalzheimers.org/sites/default/files/
USA2_AAN_CostsReport.pdf.
    \13\ Http://www.nhcoa.org/wp-content/uploads/2013/05/NHCOA-
Alzheimers-Executive-Summary.pdf and http://
www.usagainstalzheimers.org/sites/all/themes/alzheimers_networks/files/
LatinosAgainstAlzheimers_Issue_Brief.pdf.
    \14\ Http://aadmd.org/sites/default/files/NTG_Thinker_Report.pdf.
    \15\ Http://www.nia.nih.gov/alzheimers/publication/2012-2013-
alzheimers-disease-progress-report/advancing-discovery-
alzheimers#priorities.
    \16\ Https://www.nia.nih.gov/about/budget/2016/fiscal-year-2017-
budget.
---------------------------------------------------------------------------
    As urgently as resources are needed to enable scientific 
breakthroughs, millions of Americans already living with dementia 
deserve equal commitments to programs to protect and enhance their 
quality of life. New funding is essential to sustain core Older 
Americans Act services and develop and disseminate evidence-based 
services instrumental to achieving the national plan's goals to enhance 
care quality, efficiency and expand supports.\17\ These programs 
provide needed respite to family caregivers and training in best 
practices to meet the many challenges of providing care to persons with 
dementia. Until an effective prevention, disease-modifying treatment or 
cure comes to market, families rely on these programs to protect their 
own well- being while helping their loved ones remain independent, in 
the community while delaying placement in institutional settings.
---------------------------------------------------------------------------
    \17\ Http://aspe.hhs.gov/daltcp/napa/NatlPlan2014.pdf.
---------------------------------------------------------------------------
    Thank you for considering our views and for your commitment to 
overcoming Alzheimer's disease and related dementias. Please contact 
Ian Kremer, executive director of Leaders Engaged on Alzheimer's 
Disease (the LEAD Coalition),\18\ ikremer@leadcoalition.org, with 
questions or for additional information.
---------------------------------------------------------------------------
    \18\ Http://www.leadcoalition.org Leaders Engaged on Alzheimer's 
Disease (the LEAD Coalition) is a diverse national coalition of member 
organizations including patient advocacy and voluntary health non-
profits, philanthropies and foundations, trade and professional 
associations, academic research and clinical institutions, and home and 
residential care providers, and biotechnology and pharmaceutical 
companies. The LEAD Coalition works collaboratively to focus the 
Nation's strategic attention on Alzheimer's disease and related 
dementias--including vascular, Lewy body or frontotemporal dementia--
and to accelerate transformational progress in detection and diagnosis, 
care and support, and research leading to prevention, effective 
treatment and eventual cure. One or more participants may have a 
financial interest in the subjects addressed.
---------------------------------------------------------------------------
    Sincerely,

Abe's Garden
ACT on Alzheimer's
ActivistsAgainstAlzheimer's
African American Network Against Alzheimer's
Ageless Alliance
AgeneBio
Aging and Memory Disorder Programs, Howard University
Allergan
Alliance for Aging Research
Alliance for Patient Access
Alzheimer's & Dementia Alliance of Wisconsin
Alzheimer's Drug Discovery Foundation
Alzheimer's Greater Los Angeles
Alzheimers North Carolina
Alzheimer's Orange County
Alzheimer's Tennessee
AMDA--The Society for Post-Acute and Long-Term Care Medicine
American Academy of Neurology
American Association for Long Term Care Nursing
American Association of Nurse Assessment Coordination
American Federation for Aging Research (AFAR)
American Geriatrics Society
ARGENTUMExpanding Senior Living
Association of Population Centers
Laura D. Baker, PhD (Wake Forest School of Medicine*)
Banner Alzheimer's Institute
David M. Bass, PhD (Benjamin Rose Institute on Aging*)
Beating Alzheimer's by Embracing Science
Benjamin Rose Institute on Aging
Biogen Idec
Soo Borson MD (University of Washington Schools of Medicine and 
Nursing*)
James Brewer, M.D., Ph.D. (UC San Diego and Alzheimer's Disease 
Cooperative Study*)
BrightFocus Alzheimer's Disease Research
Christopher M. Callahan, MD (Indiana University Center for Aging 
Research*)
Caregiver Action Network
CaringKind
Center for Alzheimer Research and Treatment, Harvard Medical School
Center for BrainHealth at The University of Texas at Dallas
Center for Elder Care and Advanced Illness, Altarum Institute
Sandra Bond Chapman, PhD (Center for BrainHealth at The University of 
Texas at Dallas*)
ClergyAgainstAlzheimer's
Cleveland Clinic Foundation
CorTechs Labs
Jeffrey Cummings, MD, ScD (Cleveland Clinic Lou Ruvo Center for Brain 
Health*)
Cure Alzheimer's Fund
CurePSP
Darrell K. Royal Fund for Alzheimer's Research
Dementia Friendly America
Department of Neurology, Washington University School of Medicine
Rachelle S. Doody, MD, PhD (Baylor College of Medicine*)
Gary Epstein-Lubow, MD (Alpert Medical School of Brown University*)
Fujirebio
Sam Gandy, MD, PhD (Icahn School of Medicine at Mount Sinai*)
Joseph E. Gaugler, Ph.D. (School of Nursing, Center on Aging, 
University of Minnesota*)
General Electric Healthcare
Daniel R. George, Ph.D, M.Sc (Penn State College of Medicine*)
Georgetown University Medical Center Memory Disorders Program
Gerontological Society of America
Laura N. Gitlin, PhD (Johns Hopkins School of Medicine*)
Global Coalition on Aging
Lisa P. Gwyther, MSW, LCSW (Duke University Medical Center*)
David Holtzman, MD (Washington University School of Medicine, 
Department of Neurology*)
Home Instead Senior Care
Huffington Center on Aging
Indiana University Center for Aging Research
Janssen R&D
Kathy Jedrziewski, PhD (University of Pennsylvania*)
Katherine S. Judge, PhD (Cleveland State University*)
Keep Memory Alive
Diana R Kerwin, MD (Texas Alzheimer's and Memory Disorders*)
Walter A. Kukull, PhD (School of Public Health, University of 
Washington*)
LatinosAgainstAlzheimer's
Latino Alzheimer's and Memory Disorders Alliance
Lewy Body Dementia Association
LuMind Research Down Syndrome Foundation
Lundbeck
Mary Mittelman, DrPH (New York University Medical Center*)
David G. Morgan, PhD (USF Health Byrd Alzheimer's Institute*)
Mount Sinai Center for Cognitive Health
National Alliance for Caregiving
National Asian Pacific Center on Aging
National Association of Nutrition and Aging Services Programs
National Certification Council for Activity Professionals
National Committee to Preserve Social Security and Medicare
National Council for Behavioral Health
National Down Syndrome Society
National Hispanic Council On Aging (NHCOA)
National Task Group on Intellectual Disabilities and Dementia Practices
Neurotechnology Industry Organization
New York Academy of Sciences
NFL Neurological Center
NYU Alzheimer's Disease Center
NYU Langone Center on Cognitive Neurology
Thomas O. Obisesan, MD, MPH (Howard University Hospital*)
OWL-The Voice of Women 40+
Patient Engagement Program, a subsidiary of CurePSP
Pat Summitt Foundation
Piramal Imaging S.A.
Planetree
Population Association of America
Prevent Alzheimer's Disease 2020
Eric Reiman, MD (Banner Alzheimer's Institute*)
Research!America
ResearchersAgainstAlzheimer's
Stephen Salloway, M.D., M.S. (The Warren Alpert Medical School of Brown 
University*)
Second Wind Dreams, Inc./Virtual Dementia Tour
Reisa A. Sperling, MD, MMSc (Center for Alzheimer Research and 
Treatment, Harvard Medical School*)
Rudolph Tanzi, PhD (Department of Neurology, MGH/Harvard Medical 
School*)
The Association for Frontotemporal Degeneration
The Evangelical Lutheran Good Samaritan Society
The Youth Movement Against Alzheimer's
Geoffrey Tremont, Ph.D., ABPP-CN (Alpert Medical School of Brown 
University*)
R. Scott Turner, MD, PhD (Georgetown University Memory Disorders 
Program*)
UsAgainstAlzheimer's, LEAD Coalition co-convener
USF Health Byrd Alzheimer's Institute Volunteers of America, LEAD 
Coalition co-convener
Nancy Wilson, MA LCSW (Baylor College of Medicine*)
WomenAgainstAlzheimer's
                      
\*\ Affiliations of individual researchers are for identification 
purposes only and do not necessarily represent the endorsement of the 
affiliated institution.
                                 ______
                                 
          Prepared Statement of the Lower Elwha Klallam Tribe
    The Lower Elwha Klallam Tribe supports the President's fiscal year 
2017 budget proposal for a ``Department-wide Tribal Health and Well-
Being Coordinated Budget for the Department of Health and Human 
Services''. The Affordable Care Act mandated the integration of medical 
and mental health disciplines at parity and is supported by the fiscal 
year 2017 proposed budget. This plan would be inclusive of the 
Substance Abuse and Mental Health Services Administration (SAMHSA), 
Administration for Children and Families (ACF), Health Resources and 
Services Administration (HRSA), Centers for Disease Control and 
Prevention (CDC) and the Indian Health Service (IHS appropriations not 
included in this Appropriations Subcommittee).
    The Lower Elwha Klallam Tribal Health Department operates a multi-
disciplinary, ambulatory health department with 9 programs and 81 
personnel. We provide services to Lower Elwha Klallam Tribal members, 
other federally recognized American Indians/Alaskan Natives and people 
residing in the greater Clallam County area. As a Tribally operated 
facility, we provide direct patient care services that include medical, 
dental, mental health, substance abuse, community health, prevention 
health, integrative services, purchased/referred care and 
administration. We submit the following appropriations requests:
       substance abuse and mental health services administration
$30 million--Tribal Behavioral Health Grants
    We have a critical need to address the mental health and chemical 
dependency epidemic in our community. The proposed funding of $30 
million, as part of the Generation Indigenous initiative, in the Mental 
Health ($15 million) and Substance Abuse Prevention ($15 million) 
appropriations line items is appreciated but will not have a real 
impact on the unmet need that increases daily in Indian Country. For 
the Lower Elwha youth, substance abuse and suicide prevention efforts, 
we find that there is no budget equity and performance measures value 
when Tribes have to compete with each other for critically needed 
funding to address the widespread status of substance abuse and mental 
health needs of our citizens. Tribal communities have a historical and 
escalating need that is uncommon to the rest of the population and 
requires additional resources to effectively treat the overwhelming 
need. The Lower Elwha Klallam Tribe continues to see the effects of 
heroin and opioid abuse in all ages at alarming, epidemic rates within 
Clallam County.
    The Lower Elwha Klallam Tribe subsidizes 3rd party funds in 
attempts to adequately address the treatment and long term needs of our 
patient population with addiction and behavioral disorders. We realize 
the need for trauma informed, long-term, American Indian/Alaskan Native 
treatment facilities to assist those caught in the cycle of addictions. 
Instead of ignoring the rising heroine and opioid epidemic, we are in 
support of a budget that will allow the Tribes to facilitate culturally 
relevant, trauma informed treatment services to our patients so that 
they can continue their journey of wellness far surpassing the current 
30-45 day in-patient treatment process that public insurance does not 
adequately authorize or reimburse.
    In the United States, we do not approach the treatment of other 
chronic diseases like cancer in this fashion. The Tribe is requesting 
that the payment and reimbursement model for chemical dependency in-
patient and mental health services be critically scrutinized. We urge 
Congress to fund the integration plan to financially support our 
efforts in developing a Native best practice treatment and payment 
system utilizing trauma informed care targeted at our families and 
communities. There are additional funding areas and payment models that 
need to be addressed and worked on for the overall health of American 
Indians and Alaska Native citizens residing throughout the United 
States.
                administration for children and families
+$20 Million--Increasing Tribal Access to Promoting Safe and Stable 
        Families (PSSF)
    The fiscal year 2017 budget requests a $20 million increase in the 
discretionary PSSF appropriations from the fiscal year 2016 enacted 
level to increase the capacity of Tribes to administer child welfare 
services. American Indian and Alaska Native children are 
disproportionately represented at two times their population in State 
child welfare systems nationally. Among individual State foster care 
systems they are overrepresented at as much as 10 times their 
population rate. This proposal aims to address this disproportionality 
by investing in Tribal child welfare systems and, in turn, providing 
culturally appropriate services to Tribal families.
    Many Tribes lack infrastructure and stable funding. The Fostering 
Connections to Success and Increasing Adoptions Act of 2008 allowed 
Tribes to directly administer Title IV-E programs, but many Tribes need 
to build their child welfare programs before they are able to consider 
developing a program meeting the requirements of Title IV-E. With this 
increase, total funding reserved for formula grants for Tribes would be 
$31 million, including $22 million discretionary and $9 million 
mandatory. Also, the fiscal year 2017 budget includes a proposal to 
improve access to PSSF funding for Tribal grantees by eliminating the 
current statutory threshold of $10,000 to receive a grant. It will be 
replaced with a minimum grant award of $10,000 for all Tribes with 
approved plans, combined with a hold harmless provision that guarantees 
that currently funded Tribes receive not less than their current award, 
so as not to unintentionally undermine the capacity of currently funded 
grantees. This proposal allows access to critically important funding 
for preventive services for all Tribes that wish to participate in the 
program and assures greater stability and predictability in funding 
year-to-year.
+$2.75 Million--Tribal Court Improvement--Tribal Court Improvement 
        Grants Assist Tribal Courts to:
  --Conduct assessments of how Tribal courts handle child welfare 
        proceedings
  --Make improvements to court processes to provide for the safety, 
        permanency, and well-being of children as set forth in the 
        Adoption and Safe Families Act (ASFA) and increase and improve 
        engagement of the entire family in court processes relating to 
        child welfare, family preservation, family reunification, and 
        adoption
  --Ensure children's safety, permanency, and well-being needs are met 
        in a timely and complete manner (through better collection and 
        analysis of data)
  --Provide training for judges, attorneys, and legal personnel in 
        child welfare cases
    This increase will allow ACF to fund a total of 25 Tribal court 
improvement grants. The expansion of the Tribal Court Improvement 
Program would continue to strengthen the Tribal court's capacity to 
exercise jurisdiction in Indian Child Welfare Act cases and to 
adjudicate child welfare cases in Tribal court.
                                closing
    There are additional funding areas and payment models that need to 
be addressed and worked on for the overall health of American Indians 
and Alaska Native citizens residing throughout the United States. The 
support of the Congress and the Administration with these efforts is 
greatly appreciated.

    [This statement was submitted by Hon. Frances G. Charles, 
Chairwoman, Lower Elwha Klallam Tribe.]
                                 ______
                                 
                  Prepared Statement of Mama's Kitchen
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Mama's Kitchen is part of a nationwide coalition, the Food is 
Medicine Coalition, of over 80 food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide 450,000 medically 
tailored, home delivered meals annually. Collectively, the Food is 
Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NI-IAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Alberto Cortes, Executive 
Director, Mama's Kitchen .]
                                 ______
                                 
                      Prepared Statement of Manna
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    MANNA is part of a nationwide coalition, the Food is Medicine 
Coalition, of over 80 food and nutrition services providers, affiliates 
and their supporters across the country that provide food and nutrition 
services to people living with HIV/AIDS (PWH) and other chronic 
illnesses. In our service area, encompassing the Greater Philadelphia 
and Southern New Jersey region, we provide nearly 1 million medically 
tailored, home delivered meals annually. Over 18,000 people have 
benefited from the 12 million meals that MANNA has delivered over our 
26 year history. Collectively, the Food is Medicine Coalition is 
committed to increasing awareness of the essential role that food and 
nutrition services (FNS) play in successfully treating HIV/AIDS and to 
expanding access to this indispensable intervention for people living 
with other severe illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in the first 3 months after receiving FNS.\7\ 
If hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Sue Daugherty, RD, LDN, Chief 
Executive Officer, Metropolitan Area Neighborhood Nutrition Alliance.]
                                 ______
                                 
                Prepared Statement of the March of Dimes

       MARCH OF DIMES: FISCAL YEAR 2017 FEDERAL FUNDING PRIORITIES
                          (Dollars in thousands)
------------------------------------------------------------------------
                                                            Fiscal year
                         Program                           2017 request
------------------------------------------------------------------------
National Institutes of Health (total)...................      34,500,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
National Institute of Child Health and Development......       1,441,000
National Human Genome Research Institute................         558,000
National Institute on Minority Health and Disparities...         302,000
National Institute of Environmental Health Sciences.....         732,200
National Children's Study Alternative...................         165,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Centers for Disease Control and Prevention (total)......       7,800,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
National Center for Birth Defects and Developmental              143,068
 Disabilities...........................................
Birth Defects Research and Surveillance.................          20,045
Folic Acid Campaign.....................................           3,323
Section 317 Immunization Program........................         650,000
Polio Eradication.......................................         174,000
Safe Motherhood Initiative..............................          46,000
Preterm Birth...........................................           2,000
National Center for Health Statistics...................         170,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Health Resources and Services Administration (total)....       7,480,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Title V Maternal and Child Health Block Grant...........         650,000
SPRANS- Infant Mortality and Preterm Birth..............           3,000
Heritable Disorders.....................................          18,000
Universal Newborn Hearing...............................          18,660
Healthy Start...........................................         103,500
Children's Hospitals Graduate Medical Education.........         300,000
rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Agency for Healthcare Research and Quality (total)......         364,000
------------------------------------------------------------------------

                        about the march of dimes
    The March of Dimes, a unique collaboration of scientists, 
clinicians, parents, members of the business community, and other 
volunteers representing every State, the District of Columbia and 
Puerto Rico, appreciates this opportunity to submit testimony for the 
record on fiscal year 2017 appropriations for the Department of Health 
and Human Services (HHS). For over 75 years, the March of Dimes has 
promoted maternal and child health through activities such as funding 
research and field trials for the eradication of polio, promoting 
newborn screening, and educating medical professionals and the public 
about best practices for healthy pregnancy. Today, the March of Dimes 
works to improve the health of women, infants and children by 
preventing birth defects, premature birth, and infant mortality through 
research, community services, education, and advocacy. The March of 
Dimes recommends the following funding levels for programs and 
initiatives that are essential investments in maternal and child 
health.
                               zika virus
    Our Nation faces an unprecedented challenge in the form of a 
mosquito-borne virus that causes devastating birth defects. It is 
imperative that Congress provide resources immediately to address the 
full span of activities necessary to track, treat, and ultimately 
prevent Zika infections. This includes a wide range of activities 
throughout HHS agencies, including vaccine research at the National 
Institutes of Health (NIH), vector control, diagnostic testing, public 
education, and birth defects surveillance at the Centers for Disease 
Control and Prevention (CDC), and much more. Only a robust, multi-
faceted response will prevent the virus from gaining a foothold in the 
United States. The March of Dimes calls upon the Committee to do 
everything in its power to protect pregnant women and their infants 
from this deadly virus.
Eunice Kennedy Shriver National Institute of Child Health and Human 
        Development
    The March of Dimes recommends at least $34.5 billion for NIH and 
$1.441 billion for the Eunice Kennedy Shriver National Institute of 
Child Health and Human Development (NICHD) in fiscal year 2017. This 
funding will allow NICHD to sustain vital research on preterm birth and 
related issues through extramural grants, Maternal-Fetal Medicine 
Units, the Neonatal Research Network and the intramural research 
program. This funding would also allow NICHD to continue investments in 
transdisciplinary research to identify the causes of preterm birth, as 
recommended in the Director's 2012 Scientific Vision for the next 
decade, the Institute of Medicine 2006 report on preterm birth, and the 
2008 Surgeon General's Conference on the Prevention of Preterm Birth. 
The March of Dimes fully supports NICHD's pursuit of transdisciplinary 
science, which facilitates the exchange of scientific ideas and leads 
to novel approaches to understanding complex health issues--and how to 
treat or prevent them. NIH's work in transdisciplinary research is 
complemented by the March of Dimes commitment to invest $75 million 
over 10 years in transdisciplinary research to unravel the causes of 
preterm birth.
Title V Maternal and Child Health Block Grant Program
    The March of Dimes recommends funding the Title V Maternal and 
Child Health Block Grant Program at $650 million. More than half of 
pregnant women and more than a third of infants and children benefit 
from maternal and child health block grant programs.
    The March of Dimes also recommends Congress specify that $3 million 
within the Title V Special Projects of Regional and National 
Significance account be used to support current preterm birth and 
infant mortality initiatives, as authorized in the PREEMIE Act, and to 
support the expansion of its initiatives nationwide. The PREEMIE 
Reauthorization Act renewed preterm birth-related demonstration 
projects, which are aimed at improving education, treatment and 
outcomes for babies born preterm. This funding will support the 
Collaborative Improvement & Innovation Network (CoIIN) to Reduce Infant 
Mortality, which assists States focusing on a range of interventions 
proven to reduce preterm birth and improve maternal and child health.
Safe Motherhood Initiative
    Preterm birth is a serious health problem that costs the United 
States more than $26 billion annually. Alarmingly, one in 10 infants in 
the United States is born preterm. Prematurity is the leading cause of 
neonatal mortality and the second leading cause of infant mortality.
    In 2013, Congress passed the PREEMIE Reauthorization Act (Public 
Law 113-55), which renews our Nation's commitment to giving every baby 
a healthy start. The mission of the Safe Motherhood Initiative at the 
Centers for Disease Control and Prevention's (CDC) National Center for 
Chronic Disease Prevention and Health Promotion is to promote optimal 
reproductive and infant health. The March of Dimes recommends funding 
of $46 million for the Safe Motherhood program and strongly urges 
maintenance of the preterm birth sub-line at $2 million, as 
reauthorized in the PREEMIE Reauthorization Act, to retain and buttress 
current preterm birth research within the CDC.
National Center on Birth Defects and Developmental Disabilities
    According to the CDC, an estimated 120,000 infants in the United 
States are born with major structural birth defects each year. While 
birth defects are a leading cause of infant mortality, the causes of 
more than 70 percent of birth defects remain unknown. Federal 
investments are sorely needed to support research to discover the 
causes of all birth defects, and for the development of effective 
interventions to prevent them or reduce their prevalence.
    The National Center on Birth Defects and Developmental Disabilities 
(NCBDDD) is the lead Federal agency tasked with supporting vital 
surveillance, research, and prevention activities aimed at birth 
defects and developmental disabilities. Given the center's expertise, 
NCBDDD staff are playing a vital role in the international and domestic 
response to the Zika virus. Currently, about 12 percent of the NCBDDD's 
staff are deployed to the CDC's Emergency Operations Center, while many 
other staff are providing technical assistance while maintaining 
ongoing NCBDDD activities.
    For fiscal year 2017, the March of Dimes recommends funding of 
$143.068 million for the NCBDDD. We also request at least $20.045 
million to support birth defects research and surveillance, and $3.323 
million to support folic acid education.
    Birth defects research and surveillance activities have been 
severely curtailed due to funding cuts, slowing the pace of research 
identifying the causes of birth defects, and decreasing the ability to 
track birth defects. Specifically, budgetary constraints have led to 
the elimination of two Centers for Birth Defects Research and 
Prevention. Expertise from the previously funded Centers in Texas and 
Utah (including knowledge regarding medications used during pregnancy, 
environmental exposures of concern, maternal infections, and birth 
defects risk among Hispanics) is no longer contributing to the study, 
and 25 percent fewer families are participating in CDC birth defects 
research. Birth defects surveillance programs funded by NCBDDD have 
gone from 28 in 2004 to 14 in 2016, with a 40 percent (800,000) 
reduction in the number of live births monitored by States. This 
reduction in surveillance, study, and scope will mean fewer treatments, 
fewer reductions in birth defects, and ultimately higher healthcare 
costs for families and the government. These cuts also have major 
implications for our Nation's ability to track birth defects caused by 
the Zika virus. We urge Congress in the strongest terms to bolster 
funding for NCBDDD, and particularly for birth defects surveillance.
Immunization Programs
    The March of Dimes is also committed to ensuring that mothers and 
children are protected from vaccine-preventable diseases, and strongly 
urges the committee to reject proposed cuts to the Section 317 
Immunization program included in the President's fiscal year 2017 
budget. The March of Dimes recommends funding of $650 million for the 
Section 317 Immunization program and $174 million for the continuing 
effort to eradicate polio worldwide.
Newborn Screening
    Newborn screening detects conditions in newborns that, if left 
untreated, can cause disability, developmental delays, intellectual 
disabilities, serious illnesses, or even death. If diagnosed early, 
many of these disorders can be managed successfully. The March of Dimes 
urges funding of $18 million for the Health Resources and Services 
Administration's heritable disorders program, which plays a critical 
role in assisting States in the adoption of additional screenings, 
educating providers and consumers, and ensuring coordinated follow-up 
care.
    Also funded by this program is the work of the Advisory Committee 
on Heritable Disorders in Newborns and Children (ACHDNC), which 
provides recommendations to the HHS Secretary for conditions to be 
included in the Recommended Uniform Screening Panel (RUSP). This year, 
the ACHDNC added two new conditions to the RUSP, bring the total number 
of recommended screens to 34. Additional funding for the heritable 
disorders program is crucial to ensure States have adequate funds and 
technical assistance to implement screening tests for these new 
additions to the RUSP.
                               conclusion
    March of Dimes volunteers and staff representing every State, the 
District of Columbia and Puerto Rico look forward to working with 
appropriators and all of Congress to secure the resources needed to 
improve the health of the Nation's mothers, infants and children.
                                 ______
                                 
              Prepared Statement of The Marfan Foundation
 the foundation's fiscal year 2017 l-hhs appropriations recommendations
  --$7.8 billion in program level funding for the Centers for Disease 
        Control and Prevention (CDC), which includes budget authority, 
        the Prevention and Public Health Fund, Public Health and Social 
        Services Emergency Fund, and PHS Evaluation transfers.
    --A proportional fiscal year 2017 funding increase for CDC's 
            National Center on Birth Defects and Developmental 
            Disabilities (NCBDDD).
  --At least $34.5 billion in program level funding for the National 
        Institutes of Health (NIH).
    --Proportional funding increases for NIH's National Heart, Lung, 
            and Blood Institute (NHLBI); National Institute of 
            Arthritis and Musculoskeletal and Skin Diseases (NIAMS); 
            National Eye Institute (NEI); and National Center for 
            Advancing Translational Sciences (NCATS).
    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the priorities of the 
heritable connective tissue disorders community as you work to craft 
the fiscal year 2017 L-HHS Appropriations Bill.
    about marfan syndrome and heritable connective tissue disorders
Marfan Syndrome
    Marfan syndrome is a genetic disorder that affects the body's 
connective tissue. Connective tissue holds all the body's cells, organs 
and tissue together. It also plays an important role in helping the 
body grow and develop properly.
                        the patient perspective
    Krystal Kamire--My journey with Marfan syndrome has been a long and 
complicated one. I was first tested when I was 19. At that time, the 
tests were inconclusive. I have some of the features of Marfan 
syndrome, such as pectus carinatum (pigeon chest), and was very tall 
and thin, but my measurements were borderline. I had no known family 
history, and I hadn't developed any serious heart problems. They told 
me this is not uncommon because I was still young and many people don't 
begin to have problems until they are older. The doctors couldn't 
confirm that I had Marfan syndrome, but they also couldn't confirm that 
I didn't have it. So here I was in limbo, and limbo was where I stayed 
for a long time.
    It's not easy to tell a doctor that you might have Marfan syndrome 
and have them take you seriously. Honestly, they probably didn't know 
much more about the condition than I did. Because I wasn't having any 
luck with doctors, I did the only other thing I could think of: I 
googled it. That's how I found The Marfan Foundation's website. I 
signed up to request more information and within a week I had a packet 
in the mail. But then the most surprising thing happened. I received a 
phone call from a woman with a local chapter of The Marfan Foundation 
who reached out to me to help. It might not seem like much, a simple 
phone call, but it was one of the most influential things to happen to 
me. I wasn't alone. It is profound to have that realization. I signed 
up to become a member that very day.
    About a year later, I received an email about a meeting in Seattle 
to form a NW Washington group. That meeting changed my life. I was able 
to look around the room and see other people with this condition and, 
once again, saw that I wasn't alone. I met Dr. Byers, my geneticist, 
that day. There also was a wonderful woman from the Foundation who told 
me about the Annual Family Conference. She said that they had a medical 
clinic that allowed you to see the best Marfan specialists in the 
country for free. I knew then that if I wanted a definite answer, I 
wouldn't find any better way to get it.
    I can honestly say that, if I hadn't received a scholarship to 
attend the conference, at 33 years old, I still might not have a 
diagnosis today. Much more important than that, at the conference I 
found a community. I met so many people who were like me and, for once, 
I wasn't the tallest person in the room. And I wasn't the only person 
who had a pigeon chest. I wasn't the only woman scared to have 
children. I wasn't the only person there to find answers. I wasn't 
alone. That, more than anything, is the biggest gift that that this 
organization has given to me. From now on, I'm not alone. When you 
spend your whole life trying to pretend that everything is okay because 
no one will understand, to meet so many people who know exactly what 
you are going through is life-changing. I found a family within The 
Marfan Foundation. I know that I can reach out to them at any time and 
someone will reach back out to me. Just like that first phone call that 
surprised me so much. I could not begin to express my gratitude to The 
Marfan Foundation. I only hope that, through this amazing organization, 
I am able to help someone the way that they have helped me.
               centers for disease control and prevention
    People with Marfan syndrome are born with it, but features of the 
disorder are not always present right away. Some people have a lot of 
Marfan features at birth or as young children--including serious 
conditions like aortic enlargement. Others have fewer features when 
they are young and don't develop aortic enlargement or other signs of 
Marfan syndrome until they are adults. Some features of Marfan 
syndrome, like those affecting the heart and blood vessels, bones or 
joints, can get worse over time.
    This makes it very important for people with Marfan syndrome and 
related disorders to receive accurate, early diagnosis and treatment. 
Without it, they can be at risk for potentially life-threatening 
complications. The earlier some treatments are started, the better the 
outcomes are likely to be.
    Knowing the signs of Marfan syndrome can save lives. Our community 
of experts estimates that nearly half the people who have Marfan 
syndrome don't know it. CDC and NCBDDD have critical programs that can 
help improve awareness and recognition of warning signs, which can save 
lives. Some of these programs include CDC's Million Hearts Campaign and 
NCBDDD's newborn screening activities.
    Additionally, we support the establishment of a new sports 
screening program to fund awareness in high schools around the country 
and prevent Marfan syndrome-related thoracic aortic aneurysm and 
dissection, which claims the lives of young athletes across the country 
each year. A contemporary example of this need is Isaiah Austin, who 
was diagnosed with Marfan syndrome just five days before he was 
supposed to take part in the NBA Draft. Had it not been for the intense 
testing each potential draftee undergoes as part of the process, Isaiah 
may never have been diagnosed. He story might have ended by him 
collapsing on national television or years before while he was playing 
basketball in college. He is a prime example that more needs to be 
done. Meaningful funding increases will allow CDC to establish this new 
activity.
                     national institutes of health
    NIH has worked closely with the Foundation to investigate the 
mechanisms of these conditions. In recent decades, this research has 
yielded significant scientific breakthroughs that have the potential to 
improve the lives of affected individuals. In order to ensure that the 
heritable connective tissue disorders research portfolios can continue 
to expand and advance, NIH requires meaningful funding increases to 
invest in emerging and promising activities.
National Heart Lung and Blood Institute (NHLBI)
    First and foremost, the Foundation applauds NHLBI for the 
completion of the first clinical trial for Marfan syndrome and for its 
10 year support of the GenTAC (Genetically Triggered Thoracic Aortic 
Aneurysms and Cardiovascular Conditions) registry. To date, the 
registry has produced numerous publications with data derived from over 
3750 subjects. The research derived from this registry covers a wide 
scope of issues, including surgery, gene discovery, drug therapies 
outcomes and imaging needs of the community.
NEI
    Ectopia lentis, dislocation of the lens, occurs in up to 60 percent 
of patients with Marfan syndrome. The central positioning of the lens 
depends on the zonule of Zinn, a fibrous structure which has fibrillin-
1 as a major component. NEI-supported investigators are studying the 
protein interactions of fibrillin-1 in health and disease in the zonule 
of Zinn to understand the disease mechanisms that cause ectopia lentis. 
It is hoped that this research will provide therapeutic insights to 
better treat this complication of Marfan syndrome.
National Institute of Arthritis and Musculoskeletal and Skin Diseases 
        (NIAMS)
    The Marfan Foundation is proud of its longstanding partnership with 
NIAMS. Dr. Steven Katz has been a strong proponent of basic research on 
Marfan syndrome during his tenure as NIAMS director. The Foundation 
would like to thank the Institute for its 10 years of invaluable 
support for the program project entitled ``Consortium for Translational 
Research in Marfan Syndrome'' which has enhanced our understanding of 
the disorder and increased the ability to stop the disease progression 
using a drug-based therapy. The discoveries of fibrillin-1, TGF-beta, 
and their role in muscle regeneration and connective tissue function 
were made possible in part through collaboration with NIAMS. NIAMS 
continues to support critically important research in connective 
tissues disorders. Unpublished results show dramatic breakthroughs in 
the underlying mechanisms brought about by a mutation in the fibrillin-
1 gene putting Marfan women at extremely high risk during pregnancy. 
These studies have enabled scientists to identify four medications that 
can protect against pregnancy-associated aortic tear or rupture in 
mouse models and these therapies are now being studied for their use in 
all people with Marfan syndrome. Similarly, scientists have uncovered 
the potential importance of the interaction between the TGF? binding 
complexes and fibrillin-1 microfibrils in the control of detrimental 
TGF? signaling involved in aneurysm pathogenesis. Blocking activation 
of these complexes might represent a potentially novel and specific 
therapeutic approach to preventing aortic disease. These types of 
studies indicate the high potential for research to derive novel 
treatment strategies for Marfan syndrome, and that these insights will 
prove relevant to other presentations of aortic aneurysm.
    In addition to research in Marfan syndrome, we look to NIAMS to 
help support research in other related connective tissue disorders such 
as Loeys-Dietz Syndrome, Ehlers Danlos, Shprintzen Goldberg, and Beals 
syndrome. A mouse model for Loeys-Dietz Syndrome has been established 
using a mutation in the TGF-? type 2 receptor associated with severe 
Loeys-Dietz syndrome in humans. The skeletal phenotype observed in the 
Loeys-Dietz mouse closely resembles the principal structural features 
of bone in humans with Loeys-Dietz syndrome and establishes this mouse 
as a valid in vivo model for further investigation of TGF-? receptor 
signaling in bone. We look to NIAMS to specifically support further 
bone and skeletal research for this group of related disorders. As 
always, we hope that NIAMS continues to support as basic, translational 
and clinical research in the pathogenesis of Marfan and related 
phenotypes which can lead to novel therapies for these disorders.

    [This statement was submitted by Michael Weamer, President and CEO, 
The Marfan Foundation.]
                                 ______
                                 
                Prepared Statement of the MEadvocacy.org
    Dear Ladies and Gentlemen of the Committee: MEadvocacy.org (1) is a 
project of the non-profit organization May12.org and is asking Health 
and Human Services to fund $250 million for research into the disease 
myalgic encephalomyelitis (ME).
    There is an urgent need for a systemic overhaul at the Department 
of Health and Human Services (HHS), including the National Institutes 
of Health (NIH) and the Centers for Disease Control (CDC), in regard to 
its funding and handling of this disease.
    ME is a chronic, disabling, neuroimmune disease that affects an 
estimated one million American men, women and children in the U.S. Yet, 
the past three decades, since the Lake Tahoe outbreak where the disease 
was redefined, there have been few biomedical scientific advances and 
no FDA approved treatments for this heavily burdened disease. This is 
due to the fact HHS, NIH and CDC have had an institutional bias leading 
to marginalization, neglect, underfunding and mistreatment of this 
patient community.
    Advances in the science of the disease have been repeatedly 
squashed by the gross lack of funding by NIH for the disease. In 
addition, misinformation and badly outdated information published by 
the CDC, along with the lack of education about the disease in medical 
schools, has caused a dearth of palliative care for patients 
nationwide. Most importantly, after 30 years, we still are not any 
closer to finding an FDA approved treatment or cure to help the 
estimated 17 million ME patients worldwide.
    MEadvocacy.org is a non-profit grassroots movement of advocates and 
patients who are rising up and saying it is time for a change. We are 
lawyers, laborers, teachers, students, fathers, mothers, and children. 
Our productive lives have been cut short by this disease and we 
currently have no hope of treatment or cure. We have had enough and are 
saying, ``No More!''
ME Incidence and Prevalence
    ME, also known in the U.S. as chronic fatigue syndrome (CFS) and 
myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), sickens an 
estimated 1 million people in the U.S. and 17 million worldwide. A 
majority of patients are disabled, unable to work, attend school or 
participate in activities of daily life. A quarter, an estimated 
250,000 people, are so severely affected as to render them bedbound, 
unable to care for themselves.
ME History, Criteria and Name
    ME has a long history, appearing worldwide in epidemic and endemic 
forms. A 1955 outbreak in London resulted in what Dr. A. Melvin Ramsay 
(2) described it as an infectious neuromuscular illness and formally 
used the term ``myalgic encephalomyelitis.'' Disregarding this, the CDC 
broadly redefined the disease and renamed it the marginalizing name 
chronic fatigue syndrome (CFS) in response to 1985 cluster outbreaks of 
the disease in Incline Village, Nevada and Lyndonville, New York. This 
redefinition resulted in three decades of confused research findings 
rather than answers to the cause and treatment of this disease. In 
addition, the undignified name and poor criteria causes stigmatization 
and marginalization of patients.
Disease Burden and Funding
    Some ME patients have died prematurely from complications of ME. 
Others have died at their own hands due to the severity and length of 
their suffering without proper palliative care, as well as dismissal 
and stigmatization by the medical community. If we do not act on behalf 
of these severely affected patients, we are complicit in their 
suffering and untimely deaths. The patients will no longer carry this 
burden quietly and we are looking at Congress to require HHS to 
properly fulfill their duty to ME sufferers.
    In 2009, Dr. Nancy Klimas, the director of AIDS research at the 
Miami Veterans Affairs Medical Center stated: ``My H.I.V patients for 
the most part are hale and hearty thanks to three decades of intense 
and excellent research and billions of dollars invested. Many of my CFS 
patients, on the other hand, are terribly ill and unable to work or 
participate in the care of their families. I split my clinical time 
between the two illnesses, and I can tell you if I had to choose 
between the two illnesses, (in 2009) I would rather have HIV. '' (3)
    In the intervening 7 years, nothing has changed. It is very clear 
that real change at HHS regarding this disease will not come about 
naturally. We have come to you, the subcommittee for Labor, Health and 
Human Services, Education, and Related Agencies, for help in addressing 
this dire need for oversight and investigation.
    It is estimated that the burden to the economy for ME is between 
$17 to $24 billion, yet NIH funding for research has stagnated at a 
mere $5 to $6 million a year, less than funding for hay fever. HHS has 
placed funding for ME at the rock bottom of their funding budget list 
(4). The yearly allocation for ME/CFS is a fraction of what other 
similarly burdened diseases receive. Dr. Francis Collins, the director 
of NIH, has promised increased help, but the proposed funding for ME/
CFS is only $7 million.
    HHS/NIH funding data for 2015 for several diseases: HIV/AIDS $3 
billion; M.S. $94 million; Parkinson's $146 million; Alzheimer's $589 
million; ME/CFS $6 million.
    The great divide between NIH funding for ME and other diseases 
cannot be explained away. Simply advising and recommending that NIH 
increase funding for ME, has not worked. The Secretaries of Health and 
Human Services have not responded to most of the nearly 100 
recommendations made by the Chronic Fatigue Syndrome Advisory Committee 
(CFSAC) (5) during the past 10 years. It ignored specific requests by 
CFSAC, medical experts, patient advocates, patients and their families 
to adopt ME expert authored, well defined criteria for the disease and 
calls for RFAs and increases in NIH funding.
    HHS did not heed the call by President Obama as a result of a call 
out at a townhall meeting by the wife of a patient. It has not listened 
to the many recommendations by this Appropriations Committee over the 
past 20 years. In order to fund ME on par with MS, a similarly serious 
disease, ME would need $250 million a year to bring them on par with 
other similarly burdened diseases yet, gets a mere $6 million. This is 
just on a premise of equality, not equity. If evaluated based on 
equity, a disease with no FDA approved treatment and an abysmal quality 
of life (lower than AIDS and MS), it should be getting much more 
funding to bring it up to par. To be equitable ME should be funded at 
greater than $3 billion.
    We need a different approach and a complete overhaul at all agency 
levels. We need an investigation by Congress into the mishandling and 
neglect of ME by HHS, NIH and CDC and active, ongoing Congressional 
oversight until HHS' negative institutional bias is rectified. We are 
therefore coming to you for help in this matter.
    The following are the recommendations and goals that we at 
MEadvocacy.org feel the Appropriations Committee needs to require that 
HHS meet, in order to bring myalgic encephalomyelitis back on par with 
other similarly burdened diseases:
  --Fund biomedical research for ME commensurate with its severity and 
        burden to patients and the economy. We are asking for specific 
        funding in the amount of $250 million, the amount we believe is 
        needed to bring ME on par with other similarly burdened 
        diseases. HHS should clearly allocate funds to study patients 
        from past ME cluster outbreaks as well as the study of the 
        epidemiology of patients with severe ME. The additional funding 
        needed for ME might be accomplished by means of a sliding scale 
        of allocation from other diseases related to immune, cognitive 
        and nervous system dysfunctions.
  --Heed the ME stakeholders' request to adopt the diagnostic and 
        research criteria authored by those experienced in the disease, 
        namely the 2003 Canadian Consensus Criteria (CCC) (6), which 
        has been adopted by the International Association of Chronic 
        Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME) (7). In a 
        letter to the Secretary of HHS, 50 experts (8) in the disease 
        declared their consensus agreement to adopt the CCC. This was 
        endorsed by a letter signed by 171 advocates (9) as well as a 
        petition (10) signed by over 6,000 patients. The 2011 revision 
        known as the International Consensus Criteria (ICC) (11) would 
        be an alternatively acceptable criteria for adoption.
  --Retain the historical name for this disease, myalgic 
        encephalomyelitis, which has been coded since 1969 by the World 
        Health Organization under neurological disease with the code 
        G93.3 and is similarly coded in the 2015 U.S. ICD Codes as U.S. 
        ICD-10-CM.
    Additionally, we request that the Appropriation Committee 
recommends HHS:
  --Ensure that NIH completes their 2015 promise of placing ME into the 
        National Institute of Neurological Disorders and Stroke 
        (NINDS), which also manages similar neuroimmune diseases such 
        as MS, fibromyalgia, and Lyme Disease. The Office of Research 
        on Women's Health, where ME is currently housed, is entirely 
        inappropriate for a disease which also strikes men and 
        children.
  --Provide opportunities for dissemination of information through the 
        development of a curriculum for all U.S. based medical schools, 
        as well as physician continuing education, about ME as defined 
        solely by disease experts, in order to provide the tools needed 
        for physicians and other medical professionals to appropriately 
        recognize and treat this disease. Currently, this would mean 
        using either the 2003 Canadian Consensus Criteria or the 2011 
        International Consensus Criteria, not the overly broad criteria 
        developed by the non-expert IOM panel which the CDC is 
        defiantly implementing in their educational materials. In 
        addition, the CCC (6) or ICC Primer (11) should be widely 
        distributed and made available to clinicians, particularly 
        primary care physicians, nationwide in order to facilitate the 
        best care for their ME patients.
  --Partner openly and transparently with stakeholders within 1 year to 
        establish a comprehensive, aggressive and fully funded cross 
        agency strategy and implementation plan, with well defined 
        objectives and milestones, and to develop a plan to monitor 
        progress and provide for Congressional oversight.
    ``We've documented, as have others, that the level of functional 
impairment in people who suffer from CFS is comparable to multiple 
sclerosis, AIDS, end stage renal failure, chronic obstructive pulmonary 
disease. The disability is equivalent to that of some well known, very 
severe medical conditions.''
--Dr. William Reeves, former CDC Chief of Viral Diseases Branch (2006 
CDC Press Conference)
Links:
    (1)--Http://www.meadvocacy.org.
    (2)--Http://www.name-us.org/DefintionsPages/DefRamsay.htm.
    (3)--Http://consults.blogs.nytimes.com/2009/10/15.
    (4)--Https://report.nih.gov/categorical_spending.aspx.
    (5)--Http://www.hhs.gov/advcomcfs/recommendations/index.html#.
    (6)--Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
ConsensusDocument%20Overview.pdf.
    (7)--Http://www.iacfsme.org.
    (8)--Https://dl.dropboxusercontent.com/u/89158245/
Case%20Definition%20Letter%20Sept%2023%202013.pdf.
    (9)--Https://thoughtsaboutme.files.wordpress.com/2013/10/
sebelius_letter_advocates2.pdf.
    (10)--Https://secure.avaaz.org/en/petition/
Stop_the_HHSIOM_contract_and_accept_the_CCC_definition_of_ME/?pv=4.
    (11)--Http://www.name-us.org/DefintionsPages/DefinitionsArticles/
2012_ICC%20primer.pdf.
                                 ______
                                 
             Prepared Statement of Meals on Wheels America
    Chairman Blunt and Ranking Member Murray: Thank you for the 
opportunity to present testimony to your Subcommittee concerning fiscal 
year 2017 appropriations for Older Americans Act (OAA) Nutrition 
Programs administered by the Administration for Community Living (ACL)/
Administration on Aging (AoA) within the U.S. Department of Health and 
Human Services. We are sincerely grateful for your ongoing support for 
these proven and effective programs, including the more than $20 
million increase provided in H.R. 2029, the Consolidated Appropriations 
Act of 2015. We urge you to continue to build on the bipartisan, 
bicameral support that exists for these vital programs and adopt the 
funding levels included in the President's fiscal year 2017 Budget 
Request to Congress. For the three OAA Nutrition Programs authorized 
under Title III of the Act, that request is as follows:
  --Congregate Nutrition Services (Title III, C-1)--$454 million
  --Home-Delivered Nutrition Services (Title III, C-2)--$234 million
  --Nutrition Services Incentive Program (Title III, NSIP)--$160 
        million
    At this critical juncture in our Nation's history, when both the 
need and demand are already substantial and will continue to climb 
exponentially, we ask that you to give this request your utmost 
consideration due to the significant social and economic benefits that 
OAA Nutrition Programs offer. These programs represent one of the best 
examples of a successful public-private partnership, leveraging about 
$3 for every $1 appropriated though the OAA, as well as an army of two 
million volunteers to support their operations and reach more seniors 
in need. The nutritious meals, friendly visits, and safety and wellness 
checks these programs deliver each day are providing an efficient and 
vital support service for our most vulnerable seniors, our families, 
our communities and taxpayers as a whole. OAA Nutrition Programs (both 
congregate and home-delivered) enable seniors to live more nourished 
and independent lives longer in their own homes--where they want to 
be--reducing unnecessary visits to the emergency room, admissions and 
readmissions to hospitals and premature institutionalization. Not only 
are they providing more than just a meal to those who are fortunate 
enough to receive their services, but these programs are also an 
essential part of the solution to our Nation's fiscal and demographic 
challenges.
                      serving the most vulnerable
    For more than 50 years in communities large and small, urban and 
rural, OAA Nutrition Programs have been effectively serving seniors in 
the greatest economic and social need. What started as a demonstration 
project has grown into a highly effective community-based, nationwide 
network of more than 5,000 local programs. The Federal dollars 
authorized under Title III of the Act provide a pivotal foundation on 
which to leverage additional State, local and private resources to 
serve more seniors in need--those who are frail, isolated, and at 
significant risk of hunger and losing their ability to live in their 
home.
    Data from ACL's State Program Reports and National Survey of OAA 
Participants demonstrates that the seniors receiving meals at home and 
in congregate settings, such as senior centers, need these services to 
remain healthier and independent. They are primarily women, age 75 or 
older, who live alone. Additionally, they have multiple chronic 
conditions, take six or more medications daily, are functionally 
impaired, and the single meal provided through the OAA Nutrition 
Program represents half or more of their total daily food intake. 
Significant numbers of seniors are impoverished, live in rural areas, 
and belong to a minority group. In short, the individuals served 
through the OAA nutrition network are high risk and potentially high 
cost to Medicare and Medicaid.
    Furthermore, findings from a ground-breaking 2015 study entitled 
More Than a Meal, conducted by Meals on Wheels America in conjunction 
with Brown University and AARP Foundation, found that those receiving 
and/or requesting Meals on Wheels services are significantly more 
vulnerable compared to a nationally representative sample of comparably 
aged Americans. Specifically, seniors on Meals on Wheels waiting lists 
were significantly more likely to:
  --Report poorer self-rated health (71 percent vs. 26 percent)
  --Screen positive for depression (28 percent vs. 14 percent) and 
        anxiety (31 percent vs. 16 percent)
  --Report recent falls (27 percent vs. 10 percent) and fear of falling 
        that limited their ability to stay active (79 percent vs 42 
        percent)
                 defining the magnitude of the problem
    Regardless of what statistic you see, it is undeniable that the 
problem of senior hunger is grave, growing and expensive. Today, 9.6 
million seniors--or one in six--may not know from where their next meal 
will come. Since the start of the recession in 2007 to 2013, the number 
of seniors age 60 or older experiencing ``very low food security''--or 
``hunger'' as expressed by the National Commission on Hunger--has 
increased by 63 percent. In 2013, the last year for which we have data 
from ACL, funding provided through the OAA supported the provision of 
meals to fewer than 2.5 million seniors nationwide. Tragically, the 
gaps continue to widen between the number of seniors struggling with 
hunger and those receiving nutritious meals through the OAA. Funding 
for the OAA has simply not kept pace with inflation or need.
    In fact, a Government Accountability Office report released last 
summer found that about 83 percent of food insecure seniors and 83 
percent of physically impaired seniors did not receive meals [through 
the OAA], but likely needed them. Currently, the OAA network overall is 
serving 21 million fewer meals annually to seniors in need than we were 
in 2005 due to declining Federal and State grants, stagnant private 
funding, and rising food and, transportation and other operational 
costs. At a minimum, we must stave off this continuous decline not only 
for the health of our seniors, but for the health of our Nation at 
large. The graphs on the following page illustrate this troubling 
trend.
    [The graphics follows:]

    
    
                      presenting the economic case
    We all know that without proper nutrition, one's health 
deteriorates and inevitably fails. It is extremely costly not only in 
personal terms for the individuals who struggle, but also for taxpayers 
in terms of increased healthcare costs. For seniors, even a slight 
reduction in nutritional intake can exacerbate existing health 
conditions, accelerate physical impairment, impede recovery from 
illness, injury or surgery, and increase the risk of chronic 
disease(s). The good news is that the infrastructure already exists to 
meet the escalating nutritional needs of seniors, if adequately funded. 
Evidence continues to build that proves that bolstering funding for OAA 
Nutrition Programs will substantially reduce healthcare costs--both in 
the short- and long-term. On average, a program can deliver Meals on 
Wheels to a senior for an entire year for about the same cost as just 
one day in the hospital or ten days in a nursing home--costs that are 
often incurred by Medicare and Medicaid and for which taxpayers foot 
the bill.
    The aforementioned More Than a Meal study found that those who 
received daily home-delivered meals (the traditional Meals on Wheels 
model of a daily, in-home-delivered meal, friendly visit and safety 
check), experienced the greatest improvements in health and quality of 
life. Specifically, between baseline and follow-up, seniors receiving 
daily home-delivered meals were more likely to exhibit:
  --Improvement in mental health (i.e., levels of anxiety)
  --Improvement in self-rated health
  --Reductions in the rate of falls and the fear of falling
  --Improvement in feelings of isolation and loneliness
  --Decreases in worry about being able to remain in home
    Further, in addition to being a preventative measure for ER visits 
and hospital admissions, investing in home-delivered meals is also a 
proven way to reduce hospital readmissions and post-discharge costs. 
For example, Meals on Wheels America worked with a national insurer 
over a 5 year span, covering more than 135,000 Medicare Advantage 
seniors post-discharge across 36 States. While this intervention 
involved just a one-time delivery of ten frozen meals and follow-up 
phone calls, it produced significant results including average overall 
healthcare savings of 31 percent per member per month (PMPM) for the 
first month following discharge and referral opportunities for about 30 
percent of recipients for ongoing meal and other needed community 
services. Subsequent engagements have shown that daily meal delivery 
over a longer period of time (30 days--6 months or more) produced even 
more favorable health outcomes and longer term cost savings when 
compared to national readmission rates. In addition, across six pilots 
funded by Meals on Wheels America in CA, KS, NC, OH, ME and TX, the 
average reduction in 30 day readmission rates ranged from 6-7 percent 
as compared to national readmission rates of 15-33 percent over the 
same period.
                          scaling the solution
    It is clear that those who are in need of home-delivered meal 
services represent our Nation's most frail and vulnerable senior 
population. This is a group with significant health and social support 
needs. The More Than a Meal study reinforces the wealth of past 
research, indicating that home-delivered meals improve the health and 
well-being of older adults, particularly for those who receive daily 
home-delivered meals and live alone. By decreasing feelings of 
isolation and loneliness and reducing the rate of falls, the research 
suggests that the traditional Meals on Wheels service delivery model 
has the greatest potential to decrease healthcare costs. When reviewing 
the reduction in falls alone, which adjusted for inflation equaled $34 
billion in direct medical costs in 2013, further investments in OAA 
Nutrition Programs are an untapped solution and have the potential to 
produce billions of dollars in savings to the Mandatory side of the 
budget.
    We certainly understand the difficult decisions you and your 
colleagues are tasked with in Fiscal year 2017 and beyond. However, the 
evidence proves that these programs are not only saving lives and 
taxpayer dollars every day, but they are effectively reaching our 
Nation's most at-risk seniors and have the capacity to serve 
significantly more, if properly resourced. As such, we hope that you 
recognize the need to invest further in Discretionary programs, like 
OAA Nutrition Programs, as they help prevent and mitigate the effects 
of chronic diseases, improve quality of life, expedite recovery after 
an illness, injury, surgery or treatment, and reduce unnecessary 
Medicare and Medicaid expenses both today and in the future.
    As your Subcommittee crafts and considers the fiscal year 2017 
Labor-HHS-Education Appropriations Bill, we ask that you provide the 
funding levels included in the President's fiscal year 2017 Budget 
Request to Congress for all three nutrition programs authorized under 
the OAA: Congregate Nutrition Program, Home-Delivered Nutrition Program 
and the Nutrition Services Incentive Program. You have the ability to 
eliminate waiting lists altogether and to increase the number of 
nutritious meals we can serve to seniors today. By doing so, you will 
be investing in a stronger fiscal path for our country by reducing 
future healthcare costs. Given the magnitude of the senior hunger 
problem, the time to act is now.
    Thank you for your leadership and continued support through the 
appropriations process, as well as your efforts to ensure passage of S. 
192, the Older Americans Act Reauthorization Act of 2016. We hope our 
testimony has been instructive and are pleased to offer our assistance 
and expertise at any time throughout this process.
                                 ______
                                 
 Prepared Statement of the Medical Library Association and Association 
                 of Academic Health Sciences Libraries
              summary of fiscal year 2017 recommendations
_______________________________________________________________________

  --Continue the commitment to the National Library of Medicine (NLM) 
        by supporting the President's budget proposal which requests 
        $395,110,000.
  --Continue to support the medical library community's role in NLM's 
        outreach, telemedicine, disaster preparedness, health 
        information technology initiatives, and healthcare reform 
        implementation.
_______________________________________________________________________
                              introduction
    The Medical Library Association (MLA) and Association of Academic 
Health Sciences Libraries (AAHSL) thank the Subcommittee for the 
opportunity to submit testimony supporting fiscal year 2017 
appropriations for the National Library of Medicine (NLM), an agency of 
the National Institutes of Health (NIH). Working in partnership with 
the NIH and other Federal agencies, NLM is the key link in the chain 
that translates biomedical research into practice, making the results 
of research readily available to all who need it. As health sciences 
librarians who use NLM's programs and services every day, we can attest 
that these resources literally save lives making NLM an investment in 
good health.
NLM Leverages NIH Investments in Biomedical Research
    In today's challenging budget environment, we recognize the 
difficult decisions Congress faces as it works to improve our Nation's 
fiscal stability. We thank the Subcommittee for its long-standing 
commitment to strengthening NLM's budget. NLM's budget supports 
intramural services and programs that sustain the Nation's biomedical 
research enterprise and more--it builds, sustains, and augments NLM's 
suite of more than 200 databases which provide information access to 
health professionals, researchers, educators, and the public. NLM's 
budget also supports all aspects of library operations and programs, 
including the acquisition, organization, preservation, and 
dissemination of the world's biomedical literature, no matter the 
medium.
    In fiscal year 2017 and beyond, it is critical to continue 
augmenting NLM's baseline budget to support expansion of its 
information resources, services, and programs which collect, organize, 
and make readily accessible rapidly expanding biomedical knowledge 
resources and data. NLM maximizes the return on the investment in 
research conducted by the NIH and other organizations. The Library 
makes the results of biomedical information more accessible to 
researchers, clinicians, business innovators, and the public, enabling 
such data and information to be used more efficiently and effectively 
to drive innovation and improve health. NLM is a leader in Big Data and 
plays a critical role in accelerating nationwide deployment of health 
information technology, including electronic health records (EHRs), by 
leading the development, maintenance and dissemination of key standards 
for health data interchange that are now required of certified EHRs. 
NLM also contributes to Congressional priorities related to drug safety 
through expansion of its clinical trial registry and results database 
(ClinicalTrials.gov) in response to legislative requirements, and to 
the Nation's ability to prepare for and respond to disasters.
Growing Demand for NLM's Basic Services
    NLM delivers more than 50 trillion bytes of data to millions of 
users daily that helps researchers advance scientific discovery and 
accelerate its translation into new therapies; provides health 
practitioners with information that improves medical care and lowers 
its costs; and gives the public access to resources and tools that 
promote wellness and disease prevention. Every day, medical librarians 
across the Nation use NLM services to assist clinicians, students, 
researchers, and the public in accessing information they need to save 
lives and improve health. Without NLM, our Nation's medical libraries 
would be unable to provide the quality information services that our 
Nation's health professionals, educators, researchers and patients 
increasingly need.
    NLM's data repositories and online integrated services such as 
GenBank, Genetics Home Reference (GHR), PubMed, and PubMed Central are 
revolutionizing medicine and ushering in an era of personalized 
medicine in which care is based on an individual's unique genetic 
profile. GenBank is the definitive source of gene sequence information. 
More than 2.2 million users accessed consumer-level information about 
genetics from GHR which contains 2,649 summaries of genetic conditions, 
genes, gene families, and chromosomes. PubMed, with more than 25 
million references to the biomedical literature, is the world's most 
heavily used source of bibliographic information. Approximately 806,000 
new citations were added in fiscal year 2016, and the database provided 
high quality medical information to more than 2 million users each day. 
PubMed Central is NLM's digital archive which provides public access to 
the full-text versions of more than 3.6 million biomedical journal 
articles, including those produced by NIH-funded researchers. On a 
typical weekday more than one million users download more than 2 
million full-text articles, including those submitted in compliance 
with the NIH Public Access Policy.
    As the world's largest and most comprehensive medical library, 
NLM's traditional print and electronic collections continue to steadily 
increase each year, standing at more than 21 million items--books, 
journals, technical reports, manuscripts, microfilms, photographs and 
images. By selecting, organizing and ensuring permanent access to 
health sciences information in all formats, NLM ensures the 
availability of this information for future generations, making it 
accessible to all Americans, irrespective of geography or ability to 
pay, and guaranteeing that citizens can make the best, most informed 
decisions about their healthcare.
Encourage NLM Partnerships
    NLM's outreach programs are essential to MLA and AAHSL membership 
and to the profession. Through the National Network of Libraries of 
Medicine (NN/LM), with over 6,400 members in communities nationwide, 
the NN/LM educates medical librarians, health professionals and the 
general public about NLM's services and trains them in the most 
effective use of these services. Beginning with the 2016-2021 funding 
cycle, the NN/LM includes Coordinating Offices that will independently 
support Network activities by providing technical expertise, planning, 
and coordination, and serve as the Network's central point of contact 
to reduce redundancy of effort throughout the Network.
    The NN/LM serves the public by promoting educational outreach for 
public libraries, secondary schools, senior centers and other consumer-
based settings, and its emphasis on outreach to underserved populations 
helps reduce health disparities among large sections of the American 
public. NLM's ``Partners in Information Access'' program improves 
access by local public health officials to information which prevents, 
identifies and responds to public health threats and ensures every 
public worker has electronic health information services that protect 
the public's health.
    NLM's MedlinePlus provides consumers with trusted, reliable health 
information on more than 900 topics in English and Spanish. It has 
become a top destination for those seeking information on the Internet, 
attracting more than 3 million visitors daily. NLM has continued to 
make enhancements to MedlinePlus, with selected materials now available 
in forty other languages. New versions of MedlinePlus and MedlinePlus 
en espanol have been released and have been optimized for easier use on 
mobile phones and tablets. Other products and services that benefit 
public health and wellness include the NIH MedlinePlus Magazine and NIH 
MedlinePlus Salud, available in doctors' offices nationwide, and NLM's 
MedlinePlus Connect--a utility which enables clinical care 
organizations to implement links from their electronic health records 
systems to relevant patient education materials in MedlinePlus. MLA and 
AAHSL applaud the success of NLM's outreach initiatives, and we look 
forward to continuing to work with NLM on these programs.
Emergency Preparedness and Response
    Through its Disaster Information Management Research Center, NLM 
collects and organizes disaster-related health information, ensures 
effective use of libraries and librarians in disaster planning and 
response, and develops information services to assist responders. NLM 
responds to specific disasters worldwide with specialized information 
resources appropriate to the need, including information on 
bioterrorism, chemical emergencies, fires and wildfires, earthquakes, 
tornadoes, and pandemic disease outbreaks. MLA and NLM continue to 
develop the Disaster Information Specialization (DIS) program to build 
the capacity of librarians and other interested professionals to 
provide disaster-related health information outreach. Working with 
libraries and publishers, NLM's Emergency Access Initiative makes 
available free full-text articles from hundreds of biomedical journals 
and reference books for use by medical teams responding to disasters. 
MLA and AAHSL ask the Subcommittee to support NLM's role in this 
crucial area which ensures continuous access to health information and 
use of libraries and librarians when disasters occur. NLM has created a 
comprehensive Web page to gather resources on emerging health issues 
arising from the Zika Virus. Many medical libraries include links to it 
on their Web sites. This is another example of the fine work that NLM 
does on behalf of the public.
    In 2015, NLM and the Health and Human Services Office of the 
Assistant Secretary for Preparedness and Response released a new 
version of the Radiation Emergency Medical Management (REMM) website 
which gives healthcare personnel key information about the diagnosis 
and treatment of radiation injuries and access to interactive clinical 
tools and data. The site provides just-in-time, evidence-based, usable 
information with sufficient background and context to make complex 
issues understandable to health providers without formal training or 
expertise in radiation medicine.
Health Information Technology and Bioinformatics
    For more than 40 years, NLM has supported informatics research, 
training and the application of advanced computing and informatics to 
biomedical research and healthcare delivery including telemedicine 
projects. Many of today's biomedical informatics leaders are graduates 
of NLM-funded informatics research programs at universities nationwide. 
A number of the country's exemplary electronic and personal health 
record systems benefit from findings developed with NLM grant support.
    The importance of NLM's work in health information technology 
continues to grow as the Nation moves toward more interoperable health 
information technology systems. A leader in supporting the development, 
maintenance, and dissemination of standard clinical terminologies for 
free nationwide use (e.g., SNOMED), NLM works closely with the Office 
of the National Coordinator for Health Information Technology to 
promote the adoption of interoperable electronic records, and has 
developed tools to make it easier for EHR developers and users to 
implement accepted health data standards in their systems and link to 
relevant patient education materials.
Dissemination of Clinical Trial Information
    ClinicalTrials.gov, the world's largest clinical trials registry, 
was expanded in fiscal year 2016, and now includes more than 212,000 
registered studies and summary results for more than 21,000 trials, 
including many not available elsewhere. As health sciences librarians 
who fulfill requests for information from clinicians, scientists, and 
patients, we applaud the NIH and NLM for their efforts to expand and 
clarify the regulations for clinical trials registration and results 
submission, and for work to apply the ClinicalTrials.gov requirements 
to all NIH clinical trials. These efforts will enhance the transparency 
of clinical trial results, and provide patients with more information 
to make necessary healthcare decisions, including critical information 
about the safety of products and treatment options. Clinicians will 
have access to results information about efficacy, adverse effects, and 
safety; and biomedical researchers will have information on research 
design, safety, and scientific results that can inform future protocols 
and discoveries. We also support timely, easily understood, and 
accurate reporting of all clinical trials, especially those supported 
by Federal funding, regardless of agency and phase of the clinical 
trial, and information about studies that have been terminated due to 
adverse events, difficulties in research design making accrual 
difficult, or simply feasibility problems. Ultimately, expanding the 
requirements will create an incredible and vastly important database of 
clinical data and knowledge for clinicians, scientists, and patients 
who need access to cutting-edge information.
    In addition to these efforts, NLM recently launched MedPix, a free 
online medical image database of 53,000 indexed and curated images, 
from over 13,000 patients. As a public education service, NLM and 
MedPix provide the storage space, indexing, and Web server hosting. 
Individuals as well as institutions may participate with no additional 
software required other than an Internet browser. The primary target 
audience includes physicians and nurses, allied health professionals, 
medical students, nursing students and others, and will include a 
continuing medical education module in the near future.
Improving Public Access to Funded Research Results
    Last year, the Department of Health and Human Services (DHHS) 
announced it plans and common policy approach to expanding public 
access to the results of scientific research funded by HHS agencies. 
Its operating divisions (Agency for Healthcare Research and Quality, 
Centers for Disease Control, Food and Drug Administration, and NIH) as 
well as the Assistant Secretary for Preparedness and Response will 
utilize NLM's PubMed Central as the common repository for its peer-
reviewed publications and PubMed, a repository of citations, for the 
sharing of metadata. NLM's experience in developing these systems and 
related tools and engaging the health sciences library community in 
outreach will be essential to effective implementation of HSS-wide 
policies and improving compliance.
    Thank you again for the opportunity to present our views. As health 
sciences librarians who use NLM's products and services, and as 
intermediaries who serve the information needs of researchers, 
clinicians, and the public, we value and rely upon the high quality 
resources, services, and leadership that NLM provides in support of our 
Nation's health professionals, educators, researchers, and the public. 
As the needs of these audiences continue to evolve, we are confident 
that NLM's vision and understanding of the role of information, data, 
and technology will continue to fuel the development of just-in-time 
resources and tools that will keep our Nation's health, biomedical, and 
scientific professionals at the forefront of healthcare, discovery, and 
innovation.
    We look forward to continuing this dialogue and supporting the 
Subcommittee's efforts to secure the highest possible funding level for 
NLM in fiscal year 2017 and the years beyond to support the Library's 
mission and growing responsibilities.
Organizational Bios
    The Medical Library Association (MLA) is a nonprofit, educational 
organization with 3,500 health sciences information professional 
members worldwide. Founded in 1898, MLA provides lifelong educational 
opportunities, supports a knowledgebase of health information research, 
and works with a global network of partners to promote the importance 
of quality information for improved health to the healthcare community 
and the public.
    The Association of Academic Health Sciences Libraries (AAHSL) 
supports academic health sciences libraries and directors in advancing 
the patient care, research, education and community service missions of 
academic health centers through visionary executive leadership and 
expertise in health information, scholarly communication, and knowledge 
management.
                                 ______
                                 
    Prepared Statement of Mid-Ohio Board for an Independent Living 
                              Environment
    I am writing to support the National Council on Independent 
Living's request for Congress to reaffirm your commitment to the more 
than 57 million Americans disabilities by increasing funding in the HHS 
appropriations for Centers for Independent Living (CILs). I am asking 
that you increase funding by $200 million, for a total of $301 million 
for the Independent Living line item in fiscal year 2017.
    The Mid-Ohio Board for an Independent Living Environment (MOBILE) 
is cross-disability, non-residential, community-based, nonprofit 
organizations that are designed and operated by individuals with 
disabilities. MOBILE like other CILs across America are unique in that 
they are directly governed and staffed by people with all types of 
disabilities, including people with mental, physical, sensory, 
cognitive, and developmental disabilities. As a CIL, MOBILE is a 
federally funded center providing five core services: information and 
referral, individual and systems advocacy, peer support, independent 
living skills training, and transition services, which were added with 
the passage of the Workforce Innovation and Opportunity Act (WIOA). 
From 2012-2014, CILs provided the core services to nearly 5 million 
people with disabilities, and provided additional services such as 
housing assistance, transportation, personal care attendants, and 
employment services to hundreds of thousands of individuals. During 
this same period, prior to transition being added as a core service, 
CILs transitioned 13,030 people with disabilities from nursing homes 
and other institutions into the community.
    Transition services were added as a fifth core service with the 
2014 reauthorization of the Rehabilitation Act within the Workforce 
Innovation and Opportunity Act. Transition services include the 
transition of individuals with significant disabilities from nursing 
homes and other institutions to home and community-based residences 
with appropriate supports and services, assistance to individuals with 
significant disabilities at risk of entering institutions to remain in 
the community, and the transition of youth with significant 
disabilities to postsecondary life. This core service is vital to 
achieving full participation for people with disabilities.
    Every day, MOBILE and the national network of CILs fight to ensure 
that people with disabilities gain and maintain control over our own 
lives. We know that this cannot occur when people reside in 
institutional settings. Opponents of deinstitutionalization say that 
allowing people with disabilities to live in the community will result 
in harm. We know that the 13,030 people with disabilities who CILs 
successfully transitioned out of nursing homes and institutions from 
2012-2014 prove otherwise. Additionally, when services are delivered in 
an individual's home, the result is a tremendous cost savings to 
Medicaid, Medicare, and States. Community-based services enable people 
with disabilities to become less reliant on long-term government 
supports, and they are significantly less expensive than nursing home 
placements. We are grateful that Congress demonstrated their 
understanding and support for community-based services when WIOA was 
passed and transition was added as a fifth core service.
    Since transition services were added as a core service, the need 
for funding is critical. Moreover, CILs need additional funding to 
restore the devastating cuts to the Independent Living program, make up 
for inflation costs, and address the increased demand for independent 
living services. In 2016, the Independent Living Program is receiving 
$2.5 million less in funding than it was in 2010. It is simply not 
possible to meet the increasing demand for services and effectively 
provide transition services without additional funding. Increased 
funding should be reinvested from the billions currently spent to keep 
people with disabilities in costly Medicaid nursing homes and 
institutions and out of mainstream society.
    Centers for Independent Living play a crucial role in the lives of 
people with disabilities, and work tirelessly to ensure that people 
with disabilities have a real choice in where and how they live, work, 
and participate in the community. Additionally, CILs are an excellent 
service and a bargain for America, keeping people engaged with their 
communities and saving taxpayer money. NCIL is dedicated to increasing 
the availability of the invaluable and extremely cost-effective 
services CILs provide, and they have submitted written testimony with a 
similar request. I strongly support NCIL's testimony.

    [This statement was submitted by John T. Coats, II, Executive 
Director, Mid-Ohio Board for an Independent Living Environment.]
                                 ______
                                 
Prepared Statement of the National Alliance for Eye and Vision Research
                           executive summary
    NAEVR thanks Congress for its bipartisan action in fiscal year 2016 
to increase NIH funding by $2 billion over fiscal year 2015, which is 
the largest actual dollar and percent increase since fiscal year 2003. 
To continue to rebuild NIH's discretionary funding base--especially as 
it has lost 22 percent of purchasing power since fiscal year 2003, in 
terms of constant dollars--and to ensure predictable and sustained 
funding, NAEVR requests fiscal year 2017 appropriated NIH funding of at 
least $34.5 billion, a 7.5 percent increase reflecting 5 percent real 
growth above projected 2.5 percent biomedical inflation.
    NAEVR also thanks Congress for the $31 million National Eye 
Institute (NEI) increase over fiscal year 2015, especially since it 
reflects the first time in 4 years that NEI's operating budget exceeds 
that of the pre-sequester fiscal year 2012 level, albeit by a modest 
0.8 percent. To continue to rebuild NEI's discretionary funding base--
especially as it has lost 25 percent of purchasing power since fiscal 
year 2003, in terms of constant dollars--and to ensure predictable and 
sustained funding, NAEVR requests fiscal year 2017 appropriated NEI 
funding of $770 million, also a 7.5 percent increase.
    NAEVR shares the concerns expressed by bipartisan Leaders and 
Members of the Appropriations Committee and the LHHS Appropriations 
Subcommittee regarding the President's proposal to replace $1 billion 
of the NIH discretionary base funding with mandatory funding. NAEVR is 
especially concerned that the President proposes to not only flat-fund 
most of the Institutes and Centers (I/Cs), but achieve this through the 
use of mandatory funding. In the case of the NEI, its discretionary 
base would be reduced to $687 million, with the difference reflecting 
mandatory funding that would raise it to the flat-funded level of $708 
million.
    NAEVR looks forward to working with the appropriators to secure an 
increase of 5 percent real growth above inflation in fiscal year 2017 
NIH and NEI funding as the next step in ensuring the security and 
momentum of the Nation's biomedical research enterprise. We also stand 
ready to work with the authorizers on potential mechanisms to provide 
short-term ``surge'' funding to take advantage of the exceptional 
scientific opportunities now available to address current and emerging 
health challenges.
   nei's budget is not keeping pace as the burden of eye disease and 
                        vision impairment grows
    NEI's fiscal year 2016 enacted funding of $715.9 million--reduced 
to a $708 million operating budget due to pass-throughs--reflects the 
first time in four fiscal years that NEI's operating budget exceeds 
that of the pre-sequester fiscal year 2012 funding level of $702 
million. In the 4 years it has taken the NEI budget to grow a modest 
0.8 percent, it has experienced the compounded loss of purchasing power 
due to biomedical inflation rates ranging from 2 to 2.5 percent. During 
that timeframe, NEI's operating budget was also reduced as a result of 
a transfer back to the NIH Office of AIDS Research (OAR) for funding of 
the successfully completed NEI-sponsored Studies of the Ocular 
Complications of AIDS (SOCA). Although OAR's funding to NEI was not 
committed indefinitely, its return to NIH Central in the amounts of 
$5.6 million (fiscal year 2013), $6.9 million (fiscal year 2014), and 
$7.4 million (fiscal year 2015) had essentially cut NEI's budget 
further, resulting in a new baseline upon which future funding 
increases were calculated.
    In June 2014, Prevent Blindness (PB) released a report entitled The 
Future of Vision: Forecasting the Prevalence and Costs of Vision 
Problems, which it commissioned from the University of Chicago's 
National Opinion Research Center (NORC). This report estimates the 
current annual cost (inclusive of direct and indirect costs) of vision 
disorders at $145 billion, an increase of $6 billion from the $139 
billion estimate in PB's 2013 study entitled Cost of Vision Problems: 
The Economic Burden of Vision Loss and Eye Disorders in the United 
States, which also concluded that direct medical costs associated with 
vision disorders are the fifth highest--only less than heart disease, 
cancers, emotional disorders, and pulmonary conditions. PB's 2014 study 
projects that the total annual cost of vision disorders, which includes 
government, insurance, and patient costs, will grow to $373.2 billion 
in 2050 when expressed in 2014 dollars--which is $717 billion when 
adjusted for inflation. Of the $373.2 billion estimated 2050 costs, 
$154 billion or 41 percent will be borne by the Federal Government as 
the Baby-Boom generation ages into the Medicare program.
    Current NEI funding of $708 million is still less than 0.5 percent 
of the $145 billion annual cost of vision disorders. The U.S. is 
spending only $2.20 per-person, per-year for vision research at the 
NEI, while the 2013 PB report estimates that the cost of treating low 
vision and blindness is at least $6,690 per-person, per-year.
    The very health of the vision research community is also at stake. 
The convergence of past factors which have reduced NEI funding has 
affected both young and seasoned investigators and threatened the 
continuity of research and the retention of trained staff, while making 
institutions more reliant on private bridge and philanthropic funding.
    In 2009, Congress spoke volumes in passing S. Res 209 and H. Res. 
366, which designated 2010-2020 as The Decade of Vision and recognized 
NEI's 40th anniversary as the lead institute in funding research to 
save sight and restore vision. With the fiscal year 2017 LHHS spending 
bill, Congress can act upon its past resolutions regarding vision and 
ensure that NEI is funded at $770 million to meet these challenges.
    $770 million fiscal year 2017 funding enables nei to pursue its 
                   audacious goal of restoring vision
    Despite past funding challenges, NEI has demonstrated leadership in 
identifying more than 500 genes associated with common and rare eye 
diseases. Its International Age-related Macular Degeneration (AMD) 
Genomics Consortium and its Glaucoma Human Genetics Collaboration 
Heritable Overall Operational Database (NEIGHBORHOOD) Consortium have 
each announced identification of additional gene variants associated 
with these leading causes of vision loss. Understanding the genetic 
bases of these eye diseases enables researchers and clinicians to 
identify those at risk and to potentially develop personalized 
treatment approaches, which is an NIH-wide initiative.
    Among NEI's most exciting pursuits is the Audacious Goals 
Initiative (AGI), which aims to restore vision within the next decade 
through regeneration of the retina by replacing cells that have been 
damaged by disease and injury and restoring their visual connections to 
the brain. The AGI builds upon discoveries from past investment in 
biomedical research, such as gene sequencing, gene therapy, and stem 
cell therapies, and combines these with new discoveries--such as 
imaging technologies that enable researchers to non-invasively view in 
real-time biological processes occurring in the retina at a cellular 
level--to develop new therapies for degenerative retinal disorders.
    NEI has awarded the first set of grants associated with novel 
imaging technologies to help clinicians observe the function of 
individual neurons in human patients and follow them over time as they 
test new therapies. It is proceeding with a second round of awards 
associated with identifying new factors that control regeneration and 
comparing the regenerative process among model organisms, rodents, and 
non-human primates.
    As NEI Director Paul Sieving, M.D., Ph.D. noted in his February 
2013 comments at the first AGI meeting:
    ``Success would transform life for millions of people with eye and 
        vision diseases. It would have major implications for medicine 
        of the future, for vision diseases, and even beyond this, for 
        neurological diseases.''
    These are ambitious goals that require sustained and predictable 
funding increases. Our Nation's investment in vision health is an 
investment in its overall health. NEI's breakthrough research is a 
cost-effective investment, since it is leading to treatments and 
therapies that can ultimately delay, save, and prevent health 
expenditures, especially those associated with the Medicare and 
Medicaid programs. It can also increase productivity, help individuals 
to maintain their independence, and generally improve the quality of 
life--especially since vision loss is associated with increased 
depression and accelerated mortality.
  americans fear vision loss, which is a growing public health problem
    The 2012 study entitled Vision Problems in the United States, 
released by Prevent Blindness and funded in part by the NEI reported 
that, of the nearly 143 million Americans age 40-plus (per the 2010 
U.S. Census), 4 million were blind or had significant vision impairment 
and 37 million had an age-related eye disease, such as AMD, glaucoma, 
diabetic retinopathy, or cataracts. An additional 48 million Americans 
have a refractive error. This prevalence of vision impairment and eye 
disease will only grow, driven by:
  --The aging of the population--the ``Silver Tsunami'' of the 78 
        million baby boomers who will turn age 65 this decade and 
        experience increased risk for eye disease.
  --The disproportionate risk/incidence of eye disease in Hispanic and 
        African American communities, which increasingly account for a 
        larger share of the U.S. population.
  --Vision loss as a co-morbid condition of chronic disease, such as 
        diabetes, which is at epidemic levels due to the increased 
        incidence of obesity.
    In September 2014, the Alliance for Eye and Vision Research (AEVR) 
released results of a new poll entitled The Public's Attitudes about 
the Health and Economic Impact of Vision Loss and Eye Disease. It was 
commissioned by Research!America and conducted by Zogby Analytics with 
a grant from Research to Prevent Blindness (RPB), a private vision 
funding foundation which conducted the first-ever poll of the public's 
attitudes about vision loss in 1965. The 2014 poll--the most rigorous 
conducted to-date of attitudes about vision and vision loss among 
ethnic and racial groups including non-Hispanic Whites, African 
Americans, Hispanics, and Asian Americans--found that:
  --a significant number of Americans across all racial lines rate 
        losing their eyesight as having the greatest impact on their 
        daily life, affecting independence, productivity, and quality 
        of life.
  --African Americans, when asked what disease or ailment is the worst 
        that could happen, ranked blindness first, followed by HIV/
        AIDS. Hispanics and Asians ranked cancer first and blindness 
        second, while non-Hispanic Whites ranked Alzheimer's disease 
        first, followed by blindness.
  --America's minority populations are united in the view that not only 
        is eye and vision research very important and needs to be a 
        national priority, but many feel that the current annual 
        Federal funding is not enough and should be increased.
    In summary, NAEVR requests fiscal year 2017 NIH funding of at least 
$34.5 billion and NEI funding of $770 million--the latter to better 
understand the scientific bases upon which to save sight and restore 
vision.
                              about naevr
    NAEVR, which serves as the ``Friends of the NEI,'' is a 501(c)4 
non-profit advocacy coalition comprised of 55 professional 
(ophthalmology and optometry), patient and consumer, and industry 
organizations involved in eye and vision research. Visit NAEVR's Web 
site at www.eyeresearch.org.

    [This statement was submitted by James Jorkasky, Executive 
Director, National Alliance for Eye and Vision Research.]
                                 ______
                                 
 Prepared Statement of the National Alliance of State and Territorial 
                             AIDS Directors
    The National Alliance of State & Territorial AIDS Directors 
(NASTAD) represents the Nation's chief State health agency staff who 
have programmatic responsibility for administering HIV and hepatitis 
healthcare, prevention, education, and supportive service programs 
funded by State and Federal Governments. On behalf of NASTAD, we urge 
your support for increased funding for Federal HIV and hepatitis 
programs in the fiscal year 2017 Labor-Health-Education Appropriations 
bill, and thank you for your consideration of the following critical 
funding needs for HIV and hepatitis programs in fiscal year 2017:

------------------------------------------------------------------------
                                                          NASTAD Funding
              Agency                       Program          Request  ($
                                                             millions)
------------------------------------------------------------------------
Health Resources and Services       Ryan White Part B                437
 Administration.                     Base.
Health Resources and Services       Ryan White Part B              943.3
 Administration.                     ADAP.
Centers for Disease Control and     Division of HIV                822.6
 Prevention.                         Prevention.
Centers for Disease Control and     Division of Viral               62.8
 Prevention.                         Hepatitis.
------------------------------------------------------------------------

    For the first time, we can visualize the end of the HIV and 
hepatitis epidemics. In order to achieve the goals of the National HIV/
AIDS Strategy: Updated to 2020 and the Viral Hepatitis Action Plan, 
funding must be robust for prevention and care programs. Domestic 
prevention efforts must match the commitment to the care and treatment 
of people living with HIV (PLWH). To be successful, we must expand 
traditional efforts and scale-up proven new biomedical prevention 
modalities such as treatment as prevention, while reimaging how the 
compendium of effective prevention tools can work in tandem to curb 
incidence in the U.S. We must also prioritize funding and efforts to 
the populations disproportionately impacted by HIV in the U.S.--
especially men who have sex with men (MSM) of color. Among the services 
necessary to improve health outcomes are the needs for linkage to and 
retention in care, and access to medications that suppress viral load, 
which make HIV more difficult to transmit--ultimately leading to fewer 
new infections. The Centers for Disease Control and Prevention's (CDC) 
prevention programs and the Ryan White Program are crucial to 
preventing new infections and improving health outcomes.
    Even with the continued implementation of the Affordable Care Act 
(ACA), public health remains a critical in meeting the needs of the 
hardest to reach, most vulnerable populations (e.g., MSM, youth, 
persons who inject drugs) from actively identifying and locating 
persons at risk, to ensuring linkage to and retention in medical care 
in a manner that is responsive to the needs of PLWH and/or hepatitis. 
While the ACA provides opportunities to increase access for many PLWH 
and/or hepatitis to the care and prevention services needed to help end 
these twin epidemics, access to insurance alone does not replace the 
key role of State public health programs to monitor diseases within 
their borders.
                  hiv/aids care and treatment programs
    The Health Resources and Services Administration (HRSA) administers 
the $2.3 billion Ryan White Program that provides health and support 
services to more than 500,000 PLWH. NASTAD requests a minimum increase 
of $65.3 million in fiscal year 2017 for State Ryan White Part B 
grants, including an increase of $22.3 million for Part B and $43 
million for AIDS Drug Assistance Programs (ADAPs). The Ryan White Part 
B Program funds State health departments to provide care, treatment, 
and support services for low-income uninsured and underinsured 
individuals living with HIV. With these funds States and territories 
provide access to HIV clinicians, life-saving and life-extending 
therapies, and a full range of vital coverage completion services to 
ensure adherence to complex treatment regimens. The State ADAPs provide 
medications to low-income PLWH who have limited or no coverage from 
private insurance, Medicare, and/or Medicaid. Health departments are 
creating new infrastructure and leveraging existing systems to ensure 
continuous, high quality care for PLWH. The Ryan White Program 
continues to serve PLWH in order to ensure that clients do not 
experience gaps in coverage or access to treatment.
             hiv/aids prevention and surveillance programs
    NASTAD requests an increase of $67 million in fiscal year 2017 for 
CDC's Division of HIV Prevention (DHAP). The flagship HIV prevention 
program, HIV Prevention by Health Departments, funds State and local 
health departments to provide the foundation for HIV prevention and 
control nationwide. Health departments are the cornerstone implementers 
of Federal public health policy and are essential to lowering HIV 
infections. HIV prevention activities and services are targeted to 
communities where HIV is most heavily concentrated, particularly among 
racial and ethnic minorities and gay men/MSM of all races and 
ethnicities.
    The number of new HIV infections must decrease in order to see 
meaningful improvements in individual and community level health 
outcomes, particularly among disproportionately impacted populations. 
Of the 1.2 million PLWH, currently, 14 percent are unaware of their 
infection therefore unable to access adequate care. Furthermore, it is 
increasingly clear that early detection, linkage to and retention in 
care, and adherence to treatment will suppress individual and community 
viral loads and reduce the incidence of HIV. Addressing interventions 
along the HIV care continuum is our newest and most effective tool to 
reduce HIV infections; however, health departments need additional 
support to successfully implement these strategies.
    Pre-exposure prophylaxis (PrEP) is a prevention method where a HIV-
negative individual takes a daily pill to prevent the acquisition of 
HIV. Currently, there is limited categorical funding within public 
health programs to pay for the medication and costs associated with 
assessment and care engagement of PrEP clients. Often, these patients 
are among populations being disproportionately impacted by HIV. For 
these reasons, there needs to be appropriate funding streams for 
expanding PrEP implementation in public health settings and to provide 
technical assistance to health departments. NASTAD supports the 
demonstration project proposed in the President's Budget that would 
allow health departments to purchase PrEP and provide other supportive 
services.
    Robust surveillance systems are essential for high-impact 
prevention, including using surveillance data for program planning and 
response, strategically directing resources to populations and 
geographic areas, and linking and retaining individuals in care. 
Additional resources will allow improvements in core surveillance and 
expand surveillance for HIV incidence, behavioral risk, and receipt of 
point of care information. This will, in turn, contribute to improved 
testing and linkage to care, retention and re-engagement in care, and 
reducing risk behaviors.
    NASTAD requests that the Committee continue to allow States and 
localities the discretion to use Federal funds to support cost-
effective and scientifically proven, syringe services programs (SSPs). 
Overwhelming scientific evidence has shown SSPs and access to sterile 
syringes are an evidenced-based and cost-effective means of lowering 
HIV and hepatitis infection rates, reducing use of illegal drugs, and 
helping connect people to HIV and hepatitis medical treatment, 
including substance abuse treatment.
                  viral hepatitis prevention programs
    NASTAD requests an increase of $23.8 million in fiscal year 2017 
for the CDC's Division of Viral Hepatitis (DVH). This increase will 
better enable State and local health departments to provide the basic, 
core public health services to combat hepatitis, increase surveillance, 
testing and education efforts nationwide and effectively implement the 
recommendations set by the IOM's Hepatitis and Liver Cancer: A National 
Strategy for Prevention and Control of Hepatitis B and C, the Action 
Plan for Viral Hepatitis, and the CDC and United States Preventive 
Services Task Force viral hepatitis testing recommendations for 
populations with risk factors, including baby boomers. NASTAD requests 
that CDC dedicate at least $14.5 million for the viral hepatitis 
prevention coordinators (VHPC) program to support and expand programs 
in all existing jurisdictions. The IOM report and the Viral Hepatitis 
Action Plan, set prevention goals, established program priorities and 
assigned responsibilities for actions to HHS operating divisions, 
including CDC. In turn, CDC has provided funds to State and local 
health departments to coordinate prevention and surveillance efforts 
via the VHPC.
    For over a decade, the VHPC program has been and remains the only 
national program dedicated to the prevention and control of the 
hepatitis epidemics. The CDC has estimated that up to 5.3 million 
people are living with hepatitis B (HBV) and/or hepatitis C (HCV) in 
the U.S. and as much as 75 percent are not aware of their infection. 
Additionally, recent alarming epidemiologic reports indicate a rise in 
HCV infection among young people throughout the country. Some 
jurisdictions have noted that the number of people ages 15 to 29 being 
diagnosed with HCV infection now exceeds the number of people diagnosed 
in all other age groups combined--a trend that is following the 
prescription drug overdose epidemic and increasing use of heroin in 
rural and suburban areas. NASTAD encourages the committee to prioritize 
disproportionately impacted populations and increase funding for 
primary prevention efforts.
    As you contemplate the fiscal year 2017 Labor-Health-Education 
Appropriations bill, we ask that you consider all of these critical 
funding needs. We thank the Chairman, Ranking Member, and members of 
the Subcommittee, for their thoughtful consideration of our 
recommendations. Our response to the HIV and hepatitis epidemics in the 
U.S. defines us as a society, as public health agencies, and as 
individuals living in this country. There is no time to waste in our 
Nation's continued fight against these epidemics.

    [This statement was submitted by Murray Penner, Executive Director, 
National Alliance of State and Territorial AIDS Directors.]
                                 ______
                                 
     Prepared Statement of the National Alliance on Mental Illness
    Chairman Blunt and members of the Subcommittee, I am Mary 
Giliberti, Chief Executive Officer of NAMI (the National Alliance on 
Mental Illness). I am pleased, today, to offer NAMI's views on the 
Subcommittee's upcoming fiscal year 2017 bill. NAMI is the Nation's 
largest grassroots advocacy organization dedicated to building better 
lives for the millions of Americans affected by mental illness.
    Through NAMI State Organizations and over 900 NAMI Affiliates 
across the country, we raise awareness and provide support, education 
and advocacy on behalf of people living with mental health conditions 
and their families.
    An estimated 1 in 5 people live with a mental health condition in 
the United States which means more than 43 million Americans are 
affected. Almost 10 million of those live with a serious mental 
illness, such as schizophrenia, bipolar disorder, and major depression. 
People with mental health conditions are our neighbors, our families 
and ourselves. They work in all sectors of the U.S. economy, from the 
boardroom to the factory floor, from academia to art.
    But, without investment in research and appropriate services and 
supports, the social and economic costs associated with mental health 
conditions are tremendous.
    Over 42,000 American lives are lost each year to suicide, more than 
21/2 times the number of lives lost to homicide. Suicide is the 2nd 
leading cause of death for Americans age 15-24 and the 10th leading 
cause of death for adults.
    Mental illness is the 3rd most costly medical condition in terms of 
overall healthcare expenditures, behind only heart conditions and 
traumatic injury. The direct and indirect financial costs associated 
with mental illness in the U.S. has been estimated to be well over $300 
billion annually.
    Investing in mental health research and services and supports can 
make these startling statistics a thing of the past and improve the 
lives of millions of Americans who live with mental health conditions 
and their families. NAMI views these investments as the highest 
priority for our Nation and this Subcommittee.
National Institute of Mental Health (NIMH) Research Funding
    As a member of the Ad Hoc Group for Medical Research Funding, NAMI 
supports an overall allocation of no less than $34.5 billion for the 
National Institutes of Health (NIH). This $2.4 billion increase 
represents 5 percent real growth above the projected rate of biomedical 
inflation and will help ensure that NIH-funded research can continue to 
improve our Nation's health and enhance our competitiveness in today's 
global information and innovation-based economy. As you know, the 
President is requesting flat funding for the National Institute for 
Mental Health (NIMH) for fiscal year 2017 at $1.519 billion. This is 
extremely disappointing, although the President is requesting an 
additional $45 million for the BRAIN Initiative. NAMI is extremely 
grateful for the strong bipartisan support for NIMH that resulted in 
the $85 million increase for fiscal year 2016. It is critical that this 
momentum continues in fiscal year 2017.
Supporting the NIMH Strategic Plan
    NAMI supports the current 5-year NIMH Strategic Plan and its four 
overarching goals:
  --Leveraging progress in genomics, imaging, and cognitive science to 
        define the biology of complex behaviors,
  --Building on the concept of mental disorders as neurodevelopmental 
        disorders to chart trajectories and determine optimal times for 
        interventions,
  --Using discoveries to focus on new treatments (and eventually cures) 
        based on precision medicine and moving trials into community 
        settings, and
  --Increasing the public health impact of NIMH research through 
        improved services that improve access and quality of care.
Accelerating the Pace of Psychiatric Drug Discovery
    In NAMI's view, there is an urgent need for new medications to 
treat serious mental illness. Existing medications can be helpful, but 
they often have significant limitations; in some cases requiring weeks 
to take effect, failing to relieve symptoms in a significant proportion 
of patients, or resulting in debilitating side effects. However, 
developing new medications is a lengthy and expensive process. Many 
promising compounds fail to prove effective in clinical testing after 
years of preliminary research. To address this urgent issue, NAMI is 
encouraging NIMH to accelerate the pace of drug discovery through an 
`experimental medicine' approach to evaluate novel interventions for 
mental illnesses. This ``fast-fail'' strategy is designed not only to 
identify quickly candidates that merit more extensive testing, but also 
to identify targets in the brain for the development of additional 
candidate compounds. Through small trials focused on proof-of-concept 
experimental medicine paradigms, we can make progress to demonstrate 
target engagement, safety, and early signs of efficacy.
Advancing Services and Intervention Research
    NAMI enthusiastically supports the NIMH Recovery After an Initial 
Schizophrenia Episode (RAISE) Project, aimed at preventing the long-
term disability associated with schizophrenia by intervening at the 
earliest stages of illness. The RAISE Early Treatment Program (RAISE 
ETP) will conclude this year. The RAISE Connection Program has 
successfully integrated a comprehensive early intervention program for 
schizophrenia and related disorders into an existing medical care 
system. This implementation study is now evaluating strategies for 
reducing duration of untreated psychosis among persons with early-stage 
psychotic illness. When individuals with schizophrenia and bipolar 
disorder progress to later stages of their illness, they become more 
likely to develop--and die prematurely--from medical problems such as 
heart disease, diabetes, cancer, stroke, and pulmonary disease than 
members of the general population. NIMH-funded research is 
demonstrating progress advancing the health of people with serious 
mental illness. NIMH needs to advance this research to large-scale 
clinical trials aimed at reducing premature mortality with people 
living with serious mental illness.
Investing in Early Psychosis Prediction and Prevention (EP3)
    As many as 100,000 young Americans experience a first episode of 
psychosis (FEP) each year. The early phase of psychotic illness is a 
critical opportunity to alter the downward trajectory and social, 
academic, and vocational challenges associated with serious mental 
illnesses such as schizophrenia. The timing of treatment is critical; 
short- and long-term outcomes are better when individuals begin 
treatment close to the onset of psychosis. Unfortunately, the majority 
of people with mental illness experience significant delays in seeking 
care--up to 2 years in some cases. Such delays result in periods of 
increased risk for adverse outcomes, including suicides, incarceration, 
homelessness and in a small number of cases, violence.
    NIMH-funded research has focused on the prodrome, the high-risk 
period preceding the onset of the first psychotic episode of 
schizophrenia. Through the North American Prodrome Longitudinal Study 
(NAPLS) and other studies focused on early prediction and prevention of 
psychosis, NIMH has launched the Early Psychosis Prediction and 
Prevention (EP3) initiative. EP3 is showing promise in detecting risk 
States for psychotic disorders and reducing the duration of untreated 
psychosis in adolescents that have experienced FEP.
Advancing Precision Medicine
    NAMI supports efforts at NIMH to translate basic research findings 
on brain function into more person-centered and multifaceted diagnoses 
and treatments for mental disorders. The Research Domain Criteria 
(RDoC) is showing promise toward efforts to build a classification 
system based more on underlying biological and basic behavioral 
mechanisms than on symptoms. Through continued development, RDoC should 
begin to give us the precision currently lacking with traditional 
diagnostic approaches to mental disorders.
Funding for Programs at SAMHSA's Center for Mental Health Services 
        (CMHS)
    As noted above, the costs of untreated mental illness to our Nation 
are enormous--as high as $300 billion when taking into account lost 
wages and productivity and other indirect costs. These costs are 
compounded by the fact that across the Nation States and localities 
devote enormous resources addressing the human and financial costs of 
untreated mental illness through law enforcement, corrections, homeless 
shelters and emergency medical services. This phenomenon of ``spending 
money in all the wrong places'' is tragic given that we have a vast 
array of proven evidence-based interventions that we know work such as 
assertive community treatment (ACT), supported employment, family 
psycho-education and supportive housing.
    NAMI supports programs at the Center for Mental Health Services 
(CMHS) at SAMHSA that are focused on replication and expansion of these 
evidence-based practices that serve children and adults living with 
serious mental illness. The most important of these programs is the 
Mental Health Block Grant (MHBG). NAMI is extremely grateful for the 
$50 million increase for the MHBG that this Subcommittee enacted for 
fiscal year 2016, boosting funding to $532.57 million.
    NAMI strongly supports the doubling of the 5 percent set aside in 
the in the MHBG to 10 percent for early intervention in psychosis. As 
noted above, the NIMH RAISE study validated the most effective 
approaches for providing coordinated care for adolescents experiencing 
FEP. Among these is Coordinated Specialty Care (CSC), a collaborative, 
recovery-oriented approach that emulates the assertive community 
treatment approach, combining evidence-based services into an 
effective, coordinated package. CSC emphasizes shared decision-making--
which NAMI strongly supports--with the recipient of services taking an 
active role in determining treatment preferences and recovery goals.
    In 2014, CMHS issued guidance to the States specifying that funding 
as part of this set aside must be used for those who have developed the 
symptoms of early serious mental illness, not for ``preventive 
intervention for those at high risk of serious mental illness.'' NAMI 
supports this guidance and we recommend that the Subcommittee continue 
this 10 percent set aside for FEP in fiscal year 2017 and beyond. It is 
critically important for Congress to continue supporting the 
replication of evidence-based FEP programs in all 50 States. In 
addition to the MHBG set-aside, NAMI also supports the President's 
request for a new $115 million State formula grant program for 
evidence-based early intervention in serious mental illness.
    NAMI also recommends the following priorities for CMHS for fiscal 
year 2017:
  --Continuation of the Children's Mental Health program at $117 
        million,
  --Suicide prevention programs under the Garrett Lee Smith Memorial 
        Act at $41.6 million,
  --$15 million in funding for States and localities as part of the 
        Assisted Outpatient Treatment (AOT) pilot program as authorized 
        by Congress in Section 224 of Public Law 113-93). NAMI is 
        grateful for the initial allocation of funding made available 
        by the Subcommittee for the AOT pilot for fiscal year 2016. 
        NAMI supports efforts develop a variety of approaches to 
        engaging people with serious mental illness in treatment, 
        including voluntary approaches for engaging people before they 
        reach the point of requiring court-based interventions.
Early Mortality and Serious Mental Illness, Integrating Primary and 
        Behavioral Health Care
    The CMHS Primary Behavioral Health Care Integration (PBHCI) program 
supports community behavioral health and primary care organizations 
that partner to provide essential primary care services to adults with 
serious mental illnesses. Because of this program, more than 33,000 
people with serious mental illnesses and substance use disorders are 
screened and treated at 126 grantee sites for diabetes, heart disease, 
and other common and deadly illnesses in an effort to stem the alarming 
early mortality rate from these health conditions in this population. 
NAMI urges the Subcommittee to reject the President's proposal to cut 
this program by $23.8 million in fiscal year 2017 and fund the PBHCI at 
$50 million.
Addressing the Needs of Homeless Individuals Living with Serious Mental 
        Illness
    NAMI recommends allocating $100 million for services in permanent 
supportive housing at CMHS. Years of reliable data and research 
demonstrate that the most successful intervention to solve chronic 
homelessness is linking housing to appropriate support services. 
Current SAMHSA investments in homeless programs are highly effective 
and cost-efficient. However, funding for SAMHSA homeless programs has 
remained flat for the past 4 years, often making it difficult for 
communities to increase the number of homeless households they are 
serving with the service dollars. As communities are investing 
additional housing resources into serving high-need homeless 
populations, Congress should increase investments in services to help 
those populations address their long-term health related issues.
    For the Projects for Assistance in Transition from Homelessness 
(PATH) program, NAMI recommends $75 million for fiscal year 2017. PATH 
provides funding for essential outreach to homeless people with serious 
mental illness and helps them navigate both the homeless and mainstream 
services systems to get the services they need. PATH-supported programs 
served over 185,000 people through outreach in fiscal year 2014. Of 
these, 28 percent were unsheltered at the time they started receiving 
PATH services. 64 percent needed mental health services and 52 percent 
had co-occurring substance use disorders. NAMI also recommends an 
allocation of $10 million from PATH to a demonstration program to 
create permanent statewide coordination capacity for the SSI/SSDI 
Outreach, Access and Recovery (SOAR) program. Finally, NAMI urges an 
allocation of $100 million, the fully authorized level, for services 
for people experiencing homelessness within the Programs of Regional 
and National Significance (PRNS) accounts of both SAMHSA's Center for 
Mental Health Services and Center for Substance Abuse Treatment.
                               conclusion
    Chairman Blunt, thank you for the opportunity to share NAMI's views 
on the Labor-HHS-Education Subcommittee's fiscal year 2017 bill. NAMI's 
members across the country thank you for your leadership on these 
important national priorities.

    [This statement was submitted by Mary Giliberti, Chief Executive 
Officer, National Alliance on Mental Illness.]
                                 ______
                                 
   Prepared Statement of the National Alliance to End Sexual Violence
    Thank you for the opportunity to present outside written testimony 
to the U.S. House of Representatives, Committee on Appropriations' 
Labor, Health and Human Services, Education, and Related Agencies 
Subcommittee. I am Monika Johnson Hostler, President of the Board of 
Directors of the National Alliance to End Sexual Violence (NAESV), 
representing 56 State and territorial sexual assault coalitions and 
more than 1300 local rape crisis centers. I am respectfully requesting 
fiscal year 2017 Department of Health and Human Services Federal 
funding to support comprehensive rape prevention and education and 
direct services for victims of sexual violence. Specifically, NAESV is 
urging Congress to provide $50 million, including at least $5.6 million 
in additional program dollars to meet the local demand for prevention 
and education and the implementation of evidence-based strategies 
through the Rape Prevention & Education program (RPE) in the Centers 
for Disease Control and Prevention's (CDC) National Center for Injury 
Prevention and Control, Intentional Injury Prevention budget. In 
addition, NAESV is requesting level funding of $160 million for the 
Preventive Health and Health Services Block Grant, which includes a $7 
million set-aside for rape victim services and prevention, in CDC's 
State, Tribal, Local and Territorial Support program budget. Together, 
we must make our communities safer.
    One in five women has been the victim of rape or attempted rape. 
Nearly one in two women has experienced some form of sexual violence, 
and one in five men has experienced a form of sexual violence other 
than rape in their lifetime. The CDC National Intimate Partner and 
Sexual Violence Survey study confirmed that the impacts of sexual 
violence on society are enormous. Over 80 percent of women who were 
victimized experienced significant short and long-term impacts related 
to the violence such as Post-Traumatic Stress Disorder (PTSD), injury 
(42 percent) and missed time at work or school (28 percent). The CDC 
report also shows that most rape and partner violence is experienced 
before the age of 24, highlighting the importance of preventing this 
violence before it occurs.
    The 2015 Rape Crisis Center Survey, distributed by NAESV, 
demonstrated that almost half of rape crisis centers had to decrease 
the number of public awareness or prevention services due to 
insufficient funding while over 1/3 of rape crisis centers could not 
provide counseling services within 1 month of a request. High profile 
cases of sexual assault on campuses, our military bases, military 
academies, and by celebrities and professional athletes have resulted 
in unprecedented media attention. This has also resulted in a 
tremendous increase in sexual assault survivors seeking assistance from 
local rape crisis centers, as well as an increase in educators and 
community organizations requesting prevention and training services. 
The media attention certainly points to the need for comprehensive 
community responses to sexual violence like those funded through the 
CDC Rape Prevention and Education program and the Preventive Health and 
Health Services Block Grant. As you begin the fiscal year 2017 
appropriations process, please fund these programs so critically 
important to the prevention and response to sexual assault.
Rape Prevention and Education (RPE)
    The National Alliance to End Sexual Violence urges Congress to 
appropriate $50 million, including at least $5.6 million in additional 
program dollars to meet the demand for prevention and education and the 
implementation of evidence-based strategies. Funding for RPE through 
the CDC Injury Center's budget for Intentional Injury Prevention 
strengthens sexual violence prevention efforts at the State and local 
levels. The RPE program provides formula funding to every State and 
territory to raise awareness of the problem of sexual assault, support 
efforts to prevent first-time perpetration and victimization, and 
brings together diverse partners to develop, implement and evaluate 
statewide sexual assault prevention plans. The RPE program engages boys 
and men as partners, supports interdisciplinary research 
collaborations, fosters cross-cultural approaches to prevention, 
promotes healthy relationships, and funds the critically important 
National Sexual Violence Resource Center. High profile cases and the 
focus on campuses have increased the demand for prevention and 
education in middle and high schools, as well as the community, beyond 
the current capacity of State sexual assault coalitions and local rape 
crisis centers. Program funding must be increased in this unprecedented 
time of opportunity. With fiscal year 2013 funding, the program reached 
over 2 million students, answered 340,000 hotline calls, and trained 
nearly 160,000 professionals about sexual abuse.
    Program Evaluation.--There is a need to increase the evidence base 
for sexual violence prevention. However, those efforts should be funded 
by additional funding--not from program funds to States and local rape 
crisis centers. We support the CDC's proposed budget request for 
evaluation funds, but not at the expense of program funding. We do not 
want program funds diverted from the communities at a time when demand 
and opportunity for prevention and education, as well as services, is 
increasing at such a rapid rate. Increased program funding is required 
to avoid critical shortfalls at a time of increased awareness and 
opportunity for prevention and education.
    In fiscal year 2016, CDC plans to fund a maximum of five academic 
or research institutions to evaluate prevention strategies that are 
being used in communities to address immediate and divergent needs in 
the field, but have limited research evidence to show effectiveness in 
reducing rates of sexual violence. In order to build RPE program 
evaluation capacity at the State health department level, CDC will fund 
state-wide evaluations to better assess how RPE prevention efforts are 
impacting health outcomes, sexual violence risk and protective factors, 
and rates of sexual violence. Efforts will be made to improve data 
collection and performance measures. Additional research will be done 
to build evaluation capacity of RPE grantees and identify community 
developed prevention strategies ready for rigorous evaluation. Within 
the past year, CDC decided to make ``state level evaluation'' mandatory 
despite many States starting local, regional or targeted evaluation 
efforts. It was the CDC's stated perspective that this would be ``less 
labor intensive.'' However, this strategy forced everyone down one 
path, without a recognition of the work and progress that was currently 
underway in many States, nor of each State's individual goals, projects 
or bandwidth to accomplish the work. Strong partnerships between 
evaluators and community-based sexual assault programs and State sexual 
assault coalitions engaged in prevention are essential for success.
    In fiscal year 2015, CDC funded two awards to evaluate strategies 
that engage boys/men for their impact on rates of sexual violence 
perpetration. An additional two research grants were awarded to focus 
on rigorously evaluating primary prevention strategies for dating and 
sexual violence among youth. One grant focuses on bystander prevention 
while the second grant examines a program which trains athletic coaches 
to modify gender norms that contribute to dating and sexual violence 
and to promote bystander intervention skills. Research results and 
recommendations are pending.
Preventive Health & Health Services Block Grant (PHHSBG)
    We are very grateful for the fiscal year 2015 and fiscal year 2016 
funding of $160 million enacted by Congress and disappointed with the 
Administration's efforts to eliminate the program which provides much 
needed resources to communities. The Public Health Service Act of 2010 
authorizes the block grant and CDC moved its administration from 
Chronic Disease to State, Tribal, Local and Territorial Support. 
Congress provided a rape set-aside provision which guarantees at least 
$7 million for rape services and prevention. Please retain the block 
grant funding that supports local rape crisis centers providing 
services, statewide training and technical assistance to increase 
capacity to assist rape victims and prevent future victimization. 
Maximum funding is requested.
    We must have the resources to meet the education and prevention 
needs in the community. Victims deserve support, our young people 
deserve to grow up safely, and research tells us that appropriate and 
early intervention and prevention can mitigate the costs and 
consequences of sexual violence and prevent that violence from 
occurring in the first place. The best way to prevent victimization is 
to prevent first time perpetration. The best way to convict a rapist is 
to support and advocate for the victim, obtain evidence and provide 
assistance and training to law enforcement. At this time of increased 
media attention, increased demand for services, increased demand for 
education in the schools and among community organizations, now is the 
best time for the implementation of community based prevention 
strategies.
    Thank you for the opportunity for the National Alliance to End 
Sexual Violence to present testimony for the record as the Senate 
Committee on Appropriations Subcommittee on Labor, Health and Human 
Services, Education, and Related Agencies begins the process to prepare 
the fiscal year 2017 Appropriations bill. If we can provide further 
information, please contact me at monika@nccasa.org and 
www.endsexualviolence.org, or Terri Poore, NAESV Public Policy 
Director, at terri@endsexualviolence.org. National Alliance to End 
Sexual Violence, 1129 20th Street, NW, Suite 801, Washington, DC 20036.

    [This statement was submitted by Monika Johnson Hostler, President, 
Board of Directors, National Alliance to End Sexual Violence.]
                                 ______
                                 
     Prepared Statement of the National Alopecia Areata Foundation
       the associations's fiscal year 2017 l-hhs appropriations 
                            recommendations
_______________________________________________________________________

  --$7.8 billion in program level funding for the Centers for Disease 
        Control and Prevention (CDC), which includes budget authority, 
        the Prevention and Public Health Fund, Public Health and Social 
        Services Emergency Fund, and PHS Evaluation transfers.
    --A proportional fiscal year 2017 funding increase for CDC's 
            National Center for Chronic Disease Prevention and Health 
            Promotion (NCCDPHP).
  --At least $34.5 billion in program level funding for the National 
        Institutes of Health (NIH).
    --Proportional funding increases for National Institute of 
            Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and 
            the National Center for Advancing Translational Science 
            (NCATS).
_______________________________________________________________________

    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the priorities of the 
community of individuals affected by alopecia areata as you work to 
craft the fiscal year 2017 L-HHS Appropriations Bill.
                         about alopecia areata
    Alopecia areata is a prevalent autoimmune skin disease resulting in 
the loss of hair on the scalp and elsewhere on the body. It usually 
starts with one or more small, round, smooth patches on the scalp and 
can progress to total scalp hair loss (alopecia totalis) or complete 
body hair loss (alopecia universalis).
    Alopecia areata affects approximately 2.1 percent of the 
population, including more than 6.5 million people in the United States 
alone. The disease disproportionately strikes children and onset often 
occurs at an early age. This common skin disease is highly 
unpredictable and cyclical. Hair can grow back in or fall out again at 
any time, and the disease course is different for each person. In 
recent years, scientific advancements have been made, but there remains 
no cure or indicated treatment options.
    The true impact of alopecia areata is more easily understood 
anecdotally than empirically. Affected individuals often experience 
significant psychological and social challenges in addition to the 
biological impact of the disease. Depression, anxiety, and suicidal 
ideation are health issues that can accompany alopecia areata. The 
knowledge that medical interventions are extremely limited and of minor 
effectiveness in this area further exacerbates the emotional stresses 
patients typically experience.
                          about the foundation
    NAAF, headquartered in San Rafael, California, supports research to 
find a cure or acceptable treatment for alopecia areata, supports those 
with the disease, and educates the public about alopecia areata. NAAF 
is governed by a volunteer Board of Directors and a prestigious 
Scientific Advisory Council. Founded in 1981, NAAF is widely regarded 
as the largest, most influential, and most representative foundation 
associated with alopecia areata. NAAF is connected to patients through 
local support groups and also holds an important, well-attended annual 
conference that reaches many children and families.
    Recently, NAAF initiated the Alopecia Areata Treatment Development 
Program (TDP) dedicated to advancing research and identifying 
innovative treatment options. TDP builds on advances in immunological 
and genetic research and is making use of the Alopecia Areata Clinical 
Trials Registry which was established in 2000 with funding support from 
the National Institute of Arthritis and Musculoskeletal and Skin 
Diseases; NAAF took over responsibility financial and administrative 
responsibility for the Registry in 2012 and continues to add patients 
to it. NAAF is engaging scientists in active review of both basic and 
applied science in a variety of ways, including the November 2012 
Alopecia Areata Research Summit featuring presentations from the Food 
and Drug Administration (FDA) and NIAMS.
                        the patient perspective
    Vashti Wood--Reston, VA.--Alopecia areata is an autoimmune skin 
disease that impacts millions of Americans, including children. There 
are currently no FDA-approved therapies indicated to treat alopecia 
areata and options for affected individuals are extremely limited.
    My daughter Sophia, now 9 has, alopecia universalis. She was 1st 
diagnosed at 5. The 1st time only 40-50 percent fell out and then grew 
back and for almost 3 years she had a full head that she combed 
admiringly many times a day and was a bit obsessed with it for her age 
but I could understand since she had experienced the loss. About a year 
ago, I noticed a bald spot the size of a pencil eraser and within days 
it was the size of a softball, and within weeks every piece of her 
beautiful hair was gone. One of the hardest things in my life was 
trying to stay strong for her and not burst into tears every time I 
looked at her beautiful face and bald head, but I had to be because she 
was not. It was devastating to her and she cried and cried. A few 
months ago her eyebrows disappeared and then her eyelashes. She is a 
vibrant girl and one who had much confidence but this condition has 
taken that away. I fear for the challenges she has ahead of her, going 
into puberty and middle school is so stressful and hard even for those 
that appearance is perfect, that I will do anything and everything in 
my power to try to find a way to get her hair back. We have put 
$1,000's of dollars on credit cards this past year for hair 
accessories, a wig, finding herbs from Australia and having them 
shipped here to the U.S., holistic doctor (that insurance doesn't cover 
at all), and of course dermatologist to no avail unless I would like to 
put or inject steroids into my 9 year old. No thanks! My husband and I 
fight over what I am spending and doing and that breaks our daughter's 
heart even more, but I refuse to not keep trying. I have asked her, do 
you want me to keep searching, trying things or do you want me to stop? 
She wants me to keep on finding a way to get her hair back.
    I thank you on behalf of myself and of the entire alopecia areata 
community for consideration of NAAF's requests.
                     national institutes of health
    NIH hosts a modest alopecia areata research portfolio, and the 
Foundation works closely with NIH to advance critical activities. NIH 
projects, in coordination with the Foundation's TDP, have the potential 
to identify biomarkers and develop therapeutic targets. In fact, 
researchers at Columbia University Medical Center (CUMC) have 
identified the immune cells responsible for destroying hair follicles 
in people with alopecia areata and have tested an FDA-approved drug 
that eliminated these immune cells and restored hair growth in a small 
number of patients. This huge breakthrough lead to NIAMS providing a 
research grant to the researchers at Columbia to continue this work. In 
this regard, please provide NIH with meaningful funding increases to 
facilitate growth in the alopecia areata research portfolio.
                         additional activities
    FDA nominated alopecia areata as a potential condition for specific 
review through the Patient-Focused Drug Development Initiative (PFDDI). 
This is because many of the impacts of alopecia areata have to be 
reported by patients and cannot be measured biologically. While we 
appreciate that FDA falls under the jurisdiction of the Agriculture 
Appropriations Subcommittee, we ask that you work with your colleagues 
on the Appropriations Committee to support this important program. 
Further, FDA should be encouraged to review all originally-nominated 
conditions in a timely manner so the PFDDI can continue to move 
forward.
    Additionally, Congresswoman Ileana Ros-Lehtiten is working with the 
community on introducing a bill that will allow for Medicaid to cover a 
significant portion of the cost of a cranial prostheses when a doctor 
deems it medically necessary. The disease can be incredibly 
debilitating not only physically and psychologically but financially as 
well. This bill is designed to help lessen the burden placed upon those 
effected by the disease. Please consider cosponsoring the bill when it 
is introduced.
    Thank you for your time and your consideration of the community's 
requests.

    [This statement was submitted by Dory Kranz, Chief Executive 
Officer, National Alopecia Areata Foundation.]
                                 ______
                                 
 Prepared Statement of the National Association for Geriatric Education
    As members of and president of the National Association for 
Geriatric Education (NAGE), we are pleased to submit this statement for 
the record recommending at least $44.7 million in fiscal year 2017 to 
support geriatrics programs under the Geriatrics Workforce Enhancement 
Program (GWEP) administered by the Health Resources and Services 
Administration (HRSA). We thank you for your past support.
    Last year, the Health Resources and Services Administration (HRSA) 
combined the geriatric education programs in Titles VII and VIII along 
with portions of the Alzheimer's Disease Prevention, Education, and 
Outreach Program to establish the Geriatrics Workforce Enhancement 
Program (GWEP). The GWEP is now the only Federal program designed to 
improve healthcare quality and safety for older adults, plus reduce 
associated costs of care through appropriate training of healthcare 
professionals, caregivers, and direct service workers. Proven results 
from activities under the predecessor programs include an important 
increase in the number of teaching faculty with geriatrics expertise in 
a variety of disciplines, plus thousands of healthcare providers and 
family caregivers better prepared to support older Americans. 
Therefore, NAGE requests a total of at least $44.7 million for these 
programs which are critical to caring for the elderly population. They 
were funded at $38.7 million in fiscal year 2016.
    We recognize that the Subcommittee faces difficult decisions in a 
constrained budget environment, but we believe that a continued 
commitment to geriatric education programs that help the Nation's 
health professions better serve the older and disabled population 
should remain a top priority. The Nation faces a shortage of geriatric 
health professionals. Every day in America 10,000 more persons reach 65 
years of age. There simply are not enough geriatricians, geriatric 
nurse practitioners and other health professionals trained in 
geriatrics needed to care for this rapidly increasing older population. 
Too often, the result is expensive walk-in care. We believe that 
funding for GWEP-based geriatric education supports your important work 
to establish a sustainable future for the Nation's healthcare and 
Social Security systems by ensuring that (a) healthcare specialists 
trained in geriatric care do not become a rare and expensive resource 
and (b) direct service workers and family caregivers are prepared to 
support a lower cost, independent lifestyle for community residing 
elders.
    Under the new structure of GWEP, forty newly funded education 
centers continue much of the work conducted by Geriatric Education 
Centers (GEC), Comprehensive Geriatric Education Programs (CGEP), 
Geriatric Academic Career Awards (GACA), and Geriatric Training for 
Physicians, Dentists and Behavioral and Mental Health Providers (GTPD) 
awards. A primary purpose of these GWEP centers is to continue training 
healthcare professions faculty, students, and field practitioners in 
interprofessional diagnosis, management and prevention of disease, 
disability, and other chronic health problems of older adults.
    Although baseline data for the new program will be set to fiscal 
year 2015, it will not be reported until the fiscal year 2018 budget. 
However, HRSA's fiscal year 2016 Justification of Estimates for 
Appropriations Committees notes that for the 2014-2015 reporting year, 
these programs accomplished an extraordinary amount of work:
  --GEC programs provided over 2,800 unique continuing education 
        courses to over 150,900 faculty members and practicing 
        providers, exceeding the program's performance goals again. GEC 
        grantees offered training at primary care settings and/or in 
        medically underserved communities, and many of the courses 
        focused on Alzheimer's disease treatment and education.
  --Grantees also provided more than 39,100 clinical training 
        experiences for healthcare professions students at more than 
        1,770 healthcare delivery sites, with 32 percent located in 
        medically-underserved communities.
  --GEC grantees supported the training of faculty in geriatrics with 
        more than 2,900 structured faculty development programs with 
        more than 13,200 faculty members receiving training in 
        geriatric-related topics.
    New GWEP awardees received expanded authorization to provide to 
family caregivers and direct service workers instruction on prominent 
issues in the care of older adults, such as Alzheimer's disease and 
other dementias, palliative care, self-care, chronic disease self-
management, falls, and maintaining independence, among others.
    Geriatric education programs have improved the supply, 
distribution, diversity, capabilities, and quality of healthcare 
professionals who care for our Nation's growing older adult population, 
including the underserved and minorities. We need your continued 
support for geriatric programs to adequately prepare the next 
generation of health professionals for the rapidly changing and 
emerging needs of the growing and aging population.
    On behalf of NAGE and those who have benefitted in Missouri and 
North Carolina and from our colleagues around the country, thank you 
for this opportunity to share our request for support for these 
important programs. We ask that you thoughtfully consider our request 
for funding in fiscal year 2017.
    NAGE is a non-profit membership organization representing 
Geriatrics Workforce Enhancement Programs, Geriatric Education Centers, 
and other programs that provide education and training to health 
professionals in the areas of geriatrics and gerontology.

    [This statement was submitted by John E. Morley, MB, BCh, Saint 
Louis, University School of Medicine, Dammert Professor of Gerontology, 
Chair, Division of Geriatric Medicine & Department of Endocrinology; 
Marla Berg-Weger, Ph.D., LCSW, Executive Director, Saint Louis 
University Gateway Geriatric Education Center, Professor, Saint Louis 
University School of Social Work; Jan Busby-Whitehead, MD, Mary and 
Thomas Hudson Distinguished Professor of Medicine, Chief, Division of 
Geriatric Medicine, Department of Medicine, Director, Center for Aging 
and Health, University of North Carolina School of Medicine.]
                                 ______
                                 
   Prepared Statement of the National Association of Clinical Nurse 
                              Specialists
    The National Association of Clinical Nurse Specialists (NACNS) is 
the voice of more than 72,000 clinical nurse specialists (CNSs). CNSs 
are licensed advanced practice registered nurses (APRN) who have 
graduate preparation (master's or doctorate) in nursing as a clinical 
nurse specialist. They have unique and advanced level competencies that 
meet the increased needs of improving quality and reducing costs in 
today's healthcare system. CNSs provide direct patient care, including 
assessment, diagnosis, and management of patient healthcare issues. 
They are leaders of change in health organizations, developers of 
scientific evidence-based programs to prevent avoidable complications, 
and coaches of those with chronic diseases to prevent hospital 
readmissions. CNSs are facilitators of multidisciplinary teams in acute 
and chronic care facilities to improve the quality and safety of care, 
including preventing hospital acquired infections, reducing length of 
stays, and preventing hospital readmissions.
    The NACNS urges the subcommittee to fund the Title VIII Nursing 
Workforce Development Programs at $244 million in fiscal year 2017.
    According to the Bureau of Labor Statistics (BLS), the registered 
nurse (RN) workforce will grow 16 percent from 2014 to 2024, outpacing 
the 7 percent average for most other occupations. BLS also projects 
that this growth will result in 439,300 job openings, representing one 
of the largest numeric increases for all occupations.
    In addition, employment of APRNs is projected to grow 31 percent 
from 2014 to 2024, much faster than the average for all occupations. 
Growth will occur because of an increase in the demand for healthcare 
services. Several factors will contribute to this demand, including a 
large number of newly insured patients resulting from healthcare 
legislation, an increased emphasis on preventive care, and the large, 
aging baby-boom population.
    BLS notes that the healthcare sector is a critically important 
industrial complex for the Nation. It is key to economic recovery with 
the number of jobs climbing steadily. Healthcare jobs are up 
nationwide, and BLS projects health-care occupations and industries to 
have the fastest employment growth and which will add the most jobs 
between 2014 and 2024. Over three million workers are in hospital 
settings, which often are the largest employer in a State. Healthcare 
has been a stimulus program generating employment and income, and 
nursing is the predominant occupation in the healthcare industry with 
more than 4.331 million active, licensed RNs in the United States in 
January 2016.
    The Nursing Workforce Development Programs provide training for 
entry-level and advanced degree nurses to improve the access to, and 
quality of, healthcare in underserved areas. The Title VIII nursing 
education programs are fundamental to the infrastructure delivering 
quality, cost-effective healthcare. NACNS applauds the subcommittee's 
bipartisan efforts to recognize that a strong nursing workforce is 
essential to a health policy that provides high-value care for every 
dollar invested in capacity building for a 21st century nurse 
workforce.
    The current Federal funding falls short of the healthcare 
inequities facing our Nation today. Absent consistent support, slight 
boosts to Title VIII will not fulfill the expectation of generating 
quality health outcomes, nor will episodic increases in funding fill 
the gap generated by a more than 15-year nurse and nurse faculty 
shortage felt throughout the U.S. health system.
    NACNS believes that the deepening health inequities, inflated 
costs, and poor quality of healthcare outcomes in this country will not 
be reversed until the concurrent shortages of nurses, advanced practice 
registered nurses, and qualified nurse educators are addressed. Your 
support will help ensure that future nurses exist who are prepared and 
qualified to take care of you, your family, and all those who will need 
our care. Without national efforts of some magnitude to match the 
healthcare reality facing the Nation today, it will be difficult to 
avoid the adverse effects on the health of our Nation from the 
inability of our under resourced nursing education programs to produce 
sufficient numbers of high quality RNs and APRNs.
    In closing, NACNS urges the subcommittee to maintain the Title VIII 
Nursing Workforce Development Programs by funding them at a level of 
$244 million in fiscal year 2017.
                                 ______
                                 
  Prepared Statement of the National Association of Community Health 
                                Centers
                              introduction
    Chairman Cochran, Ranking Member Murray, and Members of the 
Subcommittee: on behalf of our Nation's community health centers, we 
wish to thank you for the opportunity to submit testimony for the 
record as you consider the fiscal year 2017 Labor-Health and Human 
Services-Education and Related Agencies Appropriations bill.
                   health centers-general background
    For over 50 years, health centers have been operating as community-
owned, non-profit entities providing primary medical, dental, and 
behavioral healthcare as well as pharmacy and a variety of enabling and 
support services to patients and communities in need. In 2014, over 
1,300 health center organizations served more than 9,000 urban and 
rural communities nationwide, serving as the ``healthcare home'' for 
more than 24 million patients, including nearly 7 million children and 
nearly 300,000 veterans. Health centers operate in all 50 States, the 
District of Columbia, all U.S. Territories, and nearly every 
Congressional district.
    By statute and mission, health centers are located in medically 
underserved areas (or serve medically underserved populations) and are 
governed by patient-majority boards to ensure they are responsive to 
the needs of each individual community they serve. Health centers offer 
comprehensive care to all residents of the community, regardless of 
ability to pay or insurance status, and offer services on a sliding fee 
scale. Health centers' unique model of care has resulted in savings to 
the entire health system of approximately $24 billion annually. Health 
center care reduces preventable hospitalizations and emergency 
department (ED) use, as well as the need for more expensive specialty 
care. The services provided at health centers save $1,263 per patient 
per year when compared to expenditures for non-health center patients.
    In addition to reducing costs, health centers also serve as small 
businesses and economic drivers in their communities. Health centers 
employ over 175,000 individuals and generate an estimated $26.5 billion 
in needed economic activity for communities that need it the most.
                  fiscal year 2016 funding background
    We want to thank the members of this Subcommittee for their strong 
support of health centers within the Consolidated and Further 
Continuing Appropriations Act of 2016 to ensure health center funding 
continues to reach communities in need. In fiscal year 2016, the Health 
Centers program received a total of $5.1 billion in total Federal 
funding. This includes $1.49 billion in discretionary funding provided 
by the Subcommittee and $3.6 billion in mandatory funding for health 
centers through the continuation of Community Health Center Fund in 
H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 
(MACRA).
                    fiscal year 2017 funding request
    Thanks to investments by Congress and with support from this 
Subcommittee, health centers have doubled the number of patients served 
since 2000 and expanded to new communities. Since 2005, health centers 
have gone from serving one in five Americans living in poverty to one 
in four, and today serve a higher proportion of the uninsured than at 
any time in the last 10 years. In addition to serving more people and 
communities, health centers are offering an increasingly comprehensive 
range of services on-site--81 percent now offer mental health and/or 
substance abuse treatment, 77 percent offer oral health, and 40 percent 
offer pharmacy. However, continued investment is needed to make each 
health center a truly integrated ``one-stop shop'' for patient care.
    Therefore, health centers are respectfully requesting Congress and 
this Subcommittee ensure funding for the Health Centers Program remains 
whole and does not suffer any funding reductions in fiscal year 2017, 
within either the discretionary or mandatory funding streams. This 
includes rejecting proposals to shift funds to mandatory spending with 
a corresponding reduction in discretionary funding below fiscal year 
2016 levels. Continued funding for the Health Centers Program at the 
fiscal year 2016 program level of $5.1 billion is consistent with the 
levels outlined on an overwhelmingly bipartisan basis in MACRA and will 
preserve the high quality cost-effective primary care offered today at 
health centers across the country.
    We also have support from a record number of Members of Congress 
for continued health center funding. In March, 62 Senators signed a 
letter led by Sens. Roger Wicker (R-MS) and Debbie Stabenow (D-MI) to 
this Subcommittee as part of the annual appropriations process. The 
letter highlighted the important role of health centers in providing 
primary care and their proven track record of success in fostering 
innovation and cost savings within the healthcare system. A copy of the 
letter can be viewed here: http://www.nachc.com/client//
FY17%20Final%20SIGNED%20CHC%
20letter.pdf.
   leveraging investments in access with a robust clinical workforce
    As the health center model has grown and evolved to meet the 
increasingly complex needs for care in underserved communities, 
combating workforce shortages has been a constant battle for health 
centers. Though the ranks of health center clinical care staff have 
nearly doubled since 2000, workforce shortages are limiting the ability 
of individual health centers to serve as many patients as they could if 
fully staffed. A recent report issued by NACHC focusing on clinical 
workforce needs, entitled Staffing the Safety Net: Building the Primary 
Care Workforce at America's Health Centers, found that virtually all 
health centers are experiencing at least one clinical vacancy and that 
70 percent of health centers say they currently have at least one 
vacancy for a family physician. The crucial finding related to how much 
further health centers collectively could leverage Federal investments: 
according to their own projections, if fully staffed, health centers 
could serve an additional two million patients.
    Addressing the workforce needs of health centers is a major factor 
in providing high quality care to all patients. Health centers work 
synergistically with the National Health Service Corps (NHSC) to 
address staffing needs, but are also working to ``grow our own'' 
workforce though residency training programs at health centers 
including through Teaching Health Centers and Nurse Practitioner 
Residency Training Programs. However, while roughly half of all 
National Health Service Corps clinicians serve in health centers, many 
health centers still cannot gain access to NHSC providers due to 
insufficient funding for the program. We feel now, more than ever, is 
the time for sustainable investments by Congress in order for health 
centers to meet existing and future demands for care. We urge the 
Subcommittee to fund the National Health Service Corps at the 
President's Budget request of $380 million, to provide scholarships and 
loan repayment to thousands more clinicians.
    Of course, we are also looking towards the end of fiscal year 2017 
when funding provided under MACRA for the Health Center Fund is set to 
expire again. Without Congressional action, health centers will once 
again face a 70 percent reduction of funding. A reduction in funding of 
that magnitude will directly impact every health center in nearly every 
Congressional district. When facing this potential reduction in 2015, 
we estimated 7.4 million patients would have lost access to care at 
their local health center and nearly 57,000 clinicians and other staff 
would have lost their jobs--given recent investments called for by 
Congress, these numbers would almost surely be higher if this funding 
were to expire next year. We strongly believe the Federal investments 
that support the health center system of care must be sustained and 
stabilized to ensure access to care is not disrupted. To that end, we 
look forward to working with the members of the Subcommittee to ensure 
the ``Health Center Funding Cliff' will not occur. We urge Congress to 
take action well before the September 2017 expiration of the Health 
Center Fund to make the Health Centers Fund permanent and reduce the 
uncertainty caused by year-by-year renewals of this critical investment 
in access to care.
                               conclusion
    As the fiscal year 2017 appropriations process moves forward, we 
urge you to maintain current funding levels for our Nation's health 
centers. Despite the progress made in expanding the program in recent 
years, health centers continue to see unmet need in our communities and 
are experiencing increased demand. Though some health center patients 
have gained insurance, this doesn't automatically translate into 
meaningful access to care. Health centers are still serving a large 
number of under-insured patients, as well as those who remain 
uninsured. We are extremely grateful for your past support and ask for 
the Subcommittee's continued support for the Health Centers Program. We 
look forward to working with you and thank you for your consideration.

    [This statement was submitted by Daniel R. Hawkins, Jr., Senior 
Vice President, Public Policy and Research, National Association of 
Community Health Centers.]
                                 ______
                                 
   Prepared Statement of the National Association of County and City 
                            Health Officials
    The National Association of County and City Health Officials 
(NACCHO) is the voice of the 2,800 local health departments across the 
country. City, county, metropolitan, district, and tribal health 
departments work to ensure the public's health and safety. On behalf of 
local health departments, NACCHO submits the following requests:
Emergency Funding for Zika Virus
    NACCHO urges Congress to provide emergency supplemental funding 
without delay to respond to the Zika virus. Recently the Centers for 
Disease Control and Prevention (CDC) announced that evidence links the 
virus to serious health impacts, miscarriages and birth defects. With 
this funding, State and local health departments would be supported by 
CDC with increased virus readiness and response capacity; enhanced 
laboratory, epidemiology and surveillance capacity in at-risk areas to 
reduce the opportunities for Zika transmission and surge capacity 
through rapid response teams to limit potential clusters of Zika virus 
in the United States.
Public Health Emergency Preparedness--CDC
    NACCHO urges the Subcommittee to provide $675 million for the 
Public Health Emergency Preparedness (PHEP) cooperative agreements in 
fiscal year 2017. Sustained funding to support local preparedness and 
response capacity is needed to make sure that every community is 
prepared for emergencies including infectious diseases like Zika and 
mumps, as well as severe and frequent weather events causing natural 
disasters. CDC cut $44 million from PHEP grants in fiscal year 2016 to 
transfer to the agency's response to the Zika virus. More than 55 
percent of local health departments rely solely on Federal funding for 
emergency preparedness.
Hospital Preparedness Program--Assistant Secretary for Preparedness and 
        Response (ASPR)
    The Hospital Preparedness Program (HPP) provides grant funding to 
States and four directly funded cities to enhance regional and local 
hospital preparedness through regional healthcare coalitions (HCCs). 
NACCHO urges Congress to begin restoring HPP funding that was cut by a 
third ($104 million) in fiscal year 2014 by increasing it to $300 
million in fiscal year 2017.
Medical Reserve Corps--ASPR
    In 2002, the Medical Reserve Corps (MRC) was created after the 
terrorist attacks of 9/11 to establish a way for medical, public 
health, and other volunteers to address local health and preparedness 
needs. These highly skilled volunteers include doctors, dentists, 
nurses, pharmacists, and other community members. The program is 
comprised of 200,000 volunteers enrolled in 1,000 units in all 50 
States and territories. Two-thirds of MRC units are coordinated by 
local health departments. NACCHO opposed the President's proposed cut 
to MRC in fiscal year 2016 and requests $11 million in funding in 
fiscal year 2017 to restore funding to the fiscal year 2014 level.
Section 317 Immunization Program--CDC
    In an effort to prevent and control the spread of infectious 
diseases, the promotion of vaccinations to reduce the spread of disease 
is needed more now than ever. In 2014, the United States experienced 
the greatest number of cases since measles elimination was documented 
in the U.S. in 2000. The 317 Immunization Program funds vaccine 
purchase for at-need populations and immunization program operations, 
including support for implementing billing systems. NACCHO opposes the 
President's $50 million cut in fiscal year 2017 and supports the $8 
million included in the President's budget to build health department 
capacity for billing to provide reimbursement for services.
Core Infectious Diseases, Including Antibiotic Resistance and Vector-
        Borne Diseases--CDC
    The Core Infectious Disease Program identifies and monitors the 
occurrence of known infectious diseases and new emerging diseases and 
respond to outbreaks. Funding for this program also addresses 
antibiotic resistance, emerging infections, healthcare-associated 
infections, infectious disease laboratories, high-consequence 
pathogens, and vector-borne diseases. NACCHO supports the President's 
$40 million increase ($428 million total) for fiscal year 2017.
Prescription Drug (Opioid) Overdose Prevention--CDC
    The Prescription Drug (Opioid) Overdose Prevention Program provides 
States with the funding for prescription drug abuse and overdose 
prevention programs in the hardest hit communities, enhances 
prescription drug monitoring programs (PDMPs), implements insurer and 
health system interventions to improve prescribing practices, and 
collaborates with a variety of State entities such as law enforcement. 
The number of deaths due to opioid overdose has increased to 78 people 
per day. Thus, NACCHO supports the President's $10 million increase 
($80 million total) for fiscal year 2017 and urges CDC to ensure that 
these funds reach local communities in order to respond effectively to 
this epidemic.
Childhood Lead Poisoning Prevention--CDC
    NACCHO supports the restoration of childhood lead prevention 
funding to the fiscal year 2010 level of $35 million in fiscal year 
2017. The recent tragedy of lead poisoning in Flint, MI emphasizes the 
need to tackle this continuing public health threat. This program 
provides funding for 29 State and 6 city health departments to identify 
families with harmful exposure to lead, track incidence and causes, 
inspect homes and remove environmental threats, connect children with 
appropriate services, and provide education to healthcare providers as 
well as the public.
Preventive Health and Health Services Block Grant--CDC
    NACCHO urges the rejection of the President's proposed elimination 
(a cut of $160 million) of the Preventive Health and Health Services 
(PHHS) Block Grant. The PHHS Block Grant gives States the autonomy and 
flexibility to solve State problems and support similar issues in local 
communities, with accountability for demonstrating the impact of their 
investments. NACCHO also asks for report language asking CDC to report 
the amount of money going to the local level.
Prevention and Public Health Fund--HHS
    In fiscal year 2017, NACCHO requests $1 billion for the Prevention 
and Public Health Fund (PPHF), a dedicated Federal investment in 
programs that prevent disease at the community level and continued 
allocation of the PPHF through the annual appropriations process.
                                 ______
                                 
 Prepared Statement of the National Association of Nutrition and Aging 
                           Services Programs
    Chairman Blunt, Ranking Member Murray: On behalf of the National 
Association of Nutrition and Aging Services Programs (NANASP), an 
1,100-member nonpartisan, nonprofit, membership organization for 
national advocates for senior health and well-being, we thank you for 
the opportunity to offer testimony in support of the Department of 
Health and Human Services' proposed increase of $13.8 million for Older 
Americans Act Title III(C) senior nutrition programs within the 
Administration for Community Living, and in support of, at a minimum, 
the President's request for level funding for the Senior Community 
Service Employment Program within the Department of Labor.
       older americans act title iii(c) senior nutrition programs
    Older Americans Act congregate and home-delivered meals programs 
are provided in every State and congressional district in this Nation. 
Approximately 2.4 million seniors in 2014 received these services. 
Studies have found that 50 percent of all persons age 85 and over need 
help with instrumental activities of daily living, including obtaining 
and preparing food. Older Americans Act nutrition programs address 
these concerns. Thus, these meal recipients are able to remain 
independent in their homes and communities and are not forced into 
hospitals or nursing homes due to an inability to maintain a proper 
diet.
    In addition, for participants in the congregate program, the 
nutrition programs provide a daily opportunity for socialization, 
preventing isolation and promoting health and wellness. For home-
delivered meals recipients, their delivery driver may be the only 
person they see all day--therefore, this wellness check is also key to 
their health.
    In fiscal year 2016, Older Americans Act Title III(C) programs 
received appropriations in the amount of $835 million. Though we are 
thankful that this represents an increase from fiscal year 2015, 
unfortunately, this does not keep pace with the rising cost of food, 
inflation, and the growing numbers of older adults. In fact, year over 
year, the number of older adults receiving meals is shrinking even as 
the need is growing.
    The additional $13.8 million in funding for congregate and home-
delivered meals will help to counteract inflation and provide more than 
1.3 million additional meals. This does not keep up with the growing 
demand for services, but it would at least prevent further reductions 
in services. As we saw in fiscal year 2013 when sequestration was in 
effect, our programs had lengthy wait lists and some sites even closed 
for lack of funding. One NANASP program created its first wait list in 
over 90 years of operation.
    Investing in these programs is cost-effective because many common 
chronic conditions such as hypertension, heart disease, diabetes, and 
osteoporosis can be effectively prevented and treated with proper 
nutrition. The Academy of Nutrition and Dietetics estimates that 87 
percent of older adults have or are at risk of hypertension, high 
cholesterol, diabetes, or some combination of all of these. These 
seniors need healthy meals, access to lifestyle programs, and nutrition 
education and counseling to avoid serious medical care.
    Older adults who are not receiving proper meals can also become 
malnourished and undernourished. This makes it harder for them to 
recover from surgery and disease, makes it more difficult for their 
wounds to heal, increases their risk for infections and falls, and 
decreases their strength that they need to take care of themselves. 
Malnourished older adults are more likely to have poor health outcomes 
and to be readmitted to the hospital--their health costs can be 300 
percent greater than those who are not malnourished on entry to the 
healthcare system.
    Access to Older Americans Act meals is essential to keeping these 
older adults out of costly nursing facilities and hospitals. On 
average, a senior can be fed for a year for about $1,300. The cost of 
feeding a senior for a year is approximately the same as the cost of 
one day's stay in a hospital or less than the cost of 10 days in a 
nursing home. The cost savings to Medicare and Medicaid that this 
creates cannot be over-emphasized. One study estimates that for every 
dollar invested in the Older Americans Act nutrition programs, Medicaid 
saves $50.
    Further, these services are designed to target those in the 
``greatest social and economic need,'' according to the Older Americans 
Act and to actual practice in the field. According to ACL's studies, 
approximately two-thirds of home-delivered meal recipients have annual 
incomes of $20,000 or less. Sixty-two percent of these recipients 
report that these meals represent at least half their food intake each 
day. And yet, the Government Accountability Office found that only 
about 9 percent of low-income older adults are even receiving meals 
services. For a small investment, more at-risk older adults could 
receive nutritious meals.
              senior community service employment program
    The Senior Community Service Employment Program (SCSEP), also known 
as Community Service Employment for Older Americans, is authorized by 
the Older Americans Act but administered and funded by the Department 
of Labor. SCSEP is the only Federal program targeted to serve 
specifically older adults seeking employment and training assistance; 
moreover, the Government Accountability Office has previously 
identified SCSEP as one of only three Federal workforce programs with 
no overlap or duplication.
    SCSEP currently provides jobs for about 67,000 older adults in 
every State and territory, and in nearly every county in every State. 
Many of these jobs are in the service of other older adults--SCSEP 
participants may work as senior center staff members, transportation 
providers, or home-delivered meals cooks and drivers. The average age 
of a program participant is 62; according to the Department of Labor, 
65 percent of all SCSEP participants in Program Year 2012 were women, 
46 percent were minorities, and 88 percent were at or below the Federal 
poverty level.
    NANASP has one SCSEP national grantee and approximately 80 SCSEP 
State and local sub-grantees who are NANASP members, as well as many 
nutrition providers among our membership who have SCSEP employees on 
staff.
    SCSEP, as authorized by Title V of the Older Americans Act (OAA), 
has a dual purpose: ``to foster individual economic self-sufficiency 
and to increase the number of participants placed in unsubsidized 
employment in the public and private sectors, while maintaining the 
community service focus of the program.''
    By providing subsidized employment opportunities for this highly 
vulnerable and underemployed/unemployed segment of the population, 
SCSEP helps participants build their resumes and receive the training 
they need to transition into unsubsidized employment. These subsidized 
employment opportunities also provide staff members for other community 
programs that may lack funding for regular hires--not only senior 
centers, but also public libraries, schools, hospitals, and other 
community agencies.
    Considering that other programs that received cuts during the 
fiscal year 2013 sequestration have not had their funding even 
partially restored, we are pleased that in fiscal year 2016, funding 
for SCSEP held level at $434.4 million where it has remained since its 
partial restoration in fiscal year 2014. However, this is not enough to 
meet the growing need for SCSEP--both in participants and in wages.
    Many States and localities are raising the minimum wage, and this 
dilutes SCSEP funding, which has to increase to match increasing wages. 
This decreases the number of participants SCSEP can handle, yet the 
older population is growing. The last time there was an increase in 
funding for SCSEP, other than under the fiscal years 2009-2010 stimulus 
package, was when the Federal minimum wage was increased. Though wages 
have not increased at the Federal level, they have increased in enough 
States and localities to the point that SCSEP is becoming strained.
    With more than 10,000 seniors turning 65 every day, now is the time 
to provide an even greater investment in these proven and cost-
effective programs for older adults.
    Thank you for your past and future support.

    [This statement was submitted by Ann Cooper, Chair, and Robert 
Blancato, Executive Director, National Association of Nutrition and 
Aging Services Programs.]
                                 ______
                                 
  Prepared Statement of the National Association of State Head Injury 
                             Administrators
    Dear Chairman Roy Blunt and Ranking Member Patty Murray: On behalf 
of the National Association of State Head Injury Administrators 
(NASHIA), thank you for the opportunity to submit testimony regarding 
the fiscal year 2017 appropriations for programs authorized by the 
Traumatic Brain Injury (TBI) Act within the U.S. Department of Health 
and Human Services (HHS). NASHIA, a non-profit organization, is 
comprised of State governmental officials who administer an array of 
short-term and long-term rehabilitation and community services and 
supports for individuals with TBI and their families necessary to live 
and work in the community as independently as possible. My name is 
Susan L. Vaughn and I am the Director of Public Policy for NASHIA, 
having previously worked for almost 30 years for State agencies 
administering an array of disability and brain injury services, 
including serving as the co-project director for Federal grants awarded 
to our State through the Federal TBI State Grant Program authorized by 
the TBI Act.
    The HHS Federal TBI State Grant Program is the only program that 
assists States in addressing the complex needs of individuals with TBI 
and their families. Currently, only 20 States receive grants to expand 
and improve service delivery, yet TBI is a leading cause of death and 
disability in the United States. To that end NASHIA supports increasing 
the State Grant Program by $1.5 million to fund an additional four 
States. It is imperative that all States have access to resources to 
address this robust population.
    Federal funding is necessary to offer incentives for States to 
direct attention to the needs of individuals with TBI. States which 
have not received funding for a number of years are finding it 
difficult to continue their previous work, even though the numbers of 
individuals with TBI are increasing, especially with regard to older 
adults; sports-related concussions and returning servicemembers with 
TBI.
    In a 2015 survey completed by State governmental programs and State 
brain injury associations, survey respondents listed the following as 
the top three most pressing needs in their States:
  --services/alternatives for individuals with behavioral issues;
  --long-term services and supports; and
  --post-acute rehabilitation services.
    With limited State resources to address these needs, States often 
place people out of State or in State institutional settings. 
Unfortunately, many individuals, particularly those with behavioral 
issues, including addiction, and poor judgment will find themselves 
homeless or in correctional facilities. In fact, several States are now 
working with their juvenile justice and correctional systems to screen 
incidence of TBI within the incarcerated population and are finding 
alarming results. These States are now conducting training with 
corrections staff and law enforcement in order for them to understand 
how to address their behaviors and assist with identifying community 
resources upon release hoping for successful community re-entry. The 
Federal program has played a critical role in helping States to address 
these issues.
    We are pleased that the HHS Secretary has transferred the Federal 
TBI Program from the Health Resources and Services Administration to 
the Administration for Community Living (ACL) following the passage of 
the reauthorization of the TBI Act in 2014. NASHIA believes that the 
program transfer will align the program better with other disability 
programs offering services across the lifespan and to maximize 
resources accordingly, as well as benefit from research conducted by 
the TBI Model Systems funded by the National Institute on Disability, 
Independent Living and Rehabilitation Research also housed in the ACL. 
While our members are especially interested in Federal funding that 
assists States in providing services, members also support funding for 
injury prevention to reduce the incidence of TBI and research to 
further the field in providing appropriate and effective treatment and 
service delivery.
    For fiscal year 2017, NASHIA supports an additional $5,000,000 for 
the Centers for Disease Control and Prevention's (CDC) National Center 
for Injury Prevention and Control to establish and oversee a national 
concussion surveillance system to accurately determine the incidence of 
concussions, particularly among the children and youth. With the 
requested increase of $5,000,000, CDC will launch a national 
surveillance system on concussions, making the agency fully responsive 
to the recommendations issued in a 2013 report by the National 
Academies of Sciences, Engineering, and Medicine (formerly known as the 
Institute of Medicine, or the IOM). The report specifically called on 
CDC to establish a surveillance system that would capture a rich set of 
data on sports- and recreation-related concussions among 5-21 year olds 
that otherwise would not be available.
    As you are probably aware, all 50 States and the District of 
Columbia, have enacted return to play laws to address concussion 
management in youth athletics. The data gathered from the national 
surveillance system will help States and local educational systems by 
having data regarding the incidence, prevalence, and outcomes of 
sports-related concussions in order to carry out their policies 
according to their State law. Currently, data is only collected when 
injury occurs in a school athletic setting and through emergency room 
visits.
    In closing, over the past 30 years, States have initiated efforts 
to develop capacity for offering information and referral services, 
service coordination, rehabilitation, in-home support, personal care, 
counseling, transportation, housing, vocational and other support 
services for persons with TBI and their families. These services, 
however, vary in size and scope across the country and even within a 
State, creating a patchwork of services.
    Twenty-four States have enacted legislation to assess fines or 
surcharges to traffic related offenses or other criminal offenses and/
or assessed additional fees to motor vehicle registration or drivers 
license to generate funding for TBI programs and services, generally 
referred to as trust fund programs. These laws vary significantly with 
regard to the amount of revenue generated, how the funds are used, and 
what the funds are used for. Twenty-three States have also implemented 
27 brain injury Home and Community-Based Services (HCBS) Medicaid 
Waiver Programs to divert individuals from nursing and institutional 
care. At least twelve of these States have the advantage of 
administering both a trust fund for non-Medicaid eligible individuals 
or non-Medicaid services and Medicaid waiver programs for those 
individuals who are eligible and are in need of nursing level of care. 
Across the country, these programs are administered by State public 
health, Vocational Rehabilitation, mental health, Medicaid, 
intellectual disabilities, education or social services agencies within 
the States. As no two brain injuries are alike, no two States are alike 
with regard to how services are provided and funded.
    Yet, through the TBI Act Programs, Federal funding has provided an 
avenue for States to assess needs, develop State plans; and to 
implement strategies for coordinating and maximizing resources across 
State and local agencies and to build partners to sustain these 
efforts. We ask that you continue to fund and increase this important 
program, as well as to establish the CDC national concussion 
surveillance system to address this critical issue.
    Should you wish additional information, please do not hesitate to 
contact Rebeccah Wolfkiel, Governmental Consultant, at 
rwolfkiel@ridgepolicygroup.com. You may also contact Susan L. Vaughn, 
Director of Public Policy, at publicpolicy@nashia.org or William A.B. 
Ditto, Chair of the Public Policy Committee, at williamabditto@aol.com. 
Thank you.

    [This statement was submitted by Susan L. Vaughn, Director of 
Public Policy, National Association of State Head Injury 
Administrators.]
                                 ______
                                 
     Prepared Statement of the National Coalition of STD Directors

            CDC's DIVISION OF STD PREVENTION FUNDING HISTORY
------------------------------------------------------------------------
                       Fiscal Year                         ($ millions)
------------------------------------------------------------------------
2017 Funding Request....................................         * 165.4
2017 President's Budget Request.........................           157.3
Funding Level:
    2016................................................           157.3
    2015................................................           157.3
    2014................................................           157.7
    2013................................................           154.9
    2012................................................             163
------------------------------------------------------------------------
* A requested increase of $8.1 million.

    On behalf of the members of the National Coalition of STD Directors 
(NCSD), I am writing to request an additional $8.1 million for the 
Division of STD Prevention in fiscal year 2017 funding. The Division of 
STD Prevention is part of the National Center for HIV/AIDS, Viral 
Hepatitis, STD and TB Prevention at the Centers for Disease Control and 
Prevention (CDC). NCSD members represent sexually transmitted disease 
(STD) programs in all fifty Nations, seven cities counties and eight 
U.S. territories.
    STDs remain major epidemics in the United States. Each year, there 
are nearly 20 million new cases of STDs, approximately half of which go 
undiagnosed and untreated. These new STDs cost the U.S. healthcare 
system $16 billion every year--and cost individuals even more in 
immediate and life-long health consequences, including infertility and 
a higher risk of certain cancers. In addition, having other STDs 
increases the likelihood of contracting HIV, and in turn, having HIV 
also increases the likelihood of contracting and spreading STDs. 
Investments in STD prevention and treatment further the National HIV/
AIDS Strategy's goal of reducing new HIV infections.
    CDC's Division of STD Prevention (DSTDP) guides national efforts to 
prevent and control STDs. DSTDP invests most of its Federal funding in 
Nation, territorial, and large city or county health departments who 
carry out on-the-ground efforts to control STDs. State, territorial, 
and local public health STD programs are the backbone of our national 
STD infrastructure, not only monitoring and controlling STD epidemics, 
but responding to emergency outbreaks of all kinds, from Ebola to food-
borne illnesses to flu. However, the current public health 
infrastructure has been continually strained by budget reductions at 
the Federal, Nation, and local levels and is currently not sufficiently 
prepared for the reality of rising rates of STDs, particularly 
syphilis, and other outbreaks.
    Today, STD programs in these departments across the country are 
facing skyrocketing syphilis rates, including increases in congenital 
syphilis. In fact, last year, for the first time since 2006, rates for 
chlamydia, gonorrhea, and syphilis all increased concurrently. DSTDP 
and these health departments across the country need additional Federal 
resources to reverse the alarming and costly trends of STDs. Flat 
funding will not address these growing needs for outreach, treatment 
assurance and surveillance. In fiscal year 2017 funding, please support 
an urgent funding increase of $8.1 million to the CDC's Division of STD 
Prevention to ensure those on the front lines of STD prevention have 
funding to respond to the rising STD rates, particularly syphilis, and 
prepare for other unforeseen outbreaks.
Increasing Syphilis Rates, Including Congenital Syphilis
    Additional funding is needed to address our syphilis epidemic and 
to ensure the needs of hard to reach populations are addressed. In 
2014, for the third year in a row, reported cases of primary and 
secondary syphilis--the stages where the infection is most likely to 
spread--have increased by double digits. In 2012, primary and secondary 
syphilis increased by 11 percent, in 2013, by 10 percent, and in 2014, 
by a shocking 15 percent. There was not a single demographic that 
escaped these increases. Males and females, LGBT persons and 
heterosexuals, and even newborns experienced increases in syphilis.
    In fact, between 2012 and 2014, congenital syphilis, which can be a 
disabling, and often life-threatening infection for infants, increased 
by 38 percent, to the highest rate in almost 15 years. While syphilis 
is primarily a sexually transmitted disease, it may be passed on by an 
infected woman during pregnancy. Passing on the infection during 
gestation or at birth may lead to serious health problems including 
premature birth, stillbirth, and in some cases, death shortly after 
birth. Sadly, untreated syphilis in pregnant women results in infant 
death in up to 40 percent of cases. Untreated infants who survive will 
often develop problems in multiple organs, including the brain, eyes, 
ears, heart, skin, teeth, and bones.
    Increases have also occurred in cases of ocular syphilis that are 
resulting in significant eyesight and vision problems, including 
instances of complete and irreversible blindness. Between December 2014 
and March 2015, 12 cases of ocular syphilis were reported from two 
major cities, San Francisco and Seattle. Subsequent case finding 
indicated more than 200 cases over the past 2 years from 20 Nations.
Strained Public Health Infrastructure
    Responding to these ever-increasing STDs is a strained public 
health infrastructure. Since 2003, Federal investments in STD 
prevention have been stagnant when adjusted for inflation. In fact, due 
to mostly flat funding, the real buying power of Federal funding has 
plummeted 38 percent. State, territorial and local health departments 
across the country that spearhead STD prevention and control have 
charged forward with STD prevention and control, but the weight of the 
work is being overburdened by a lack of national investment in these 
efforts and in public health.
    According to Trust for America's Health, combined Federal, Nation 
and local public health spending is currently below pre-recession 
levels. Adjusting for inflation, public health spending is currently 10 
percent lower in 2013 than in 2009. At the same time, Nation and local 
investments, largely as a result of the recession budget crunch, have 
equally collapsed. At the height of the recession, the National 
Association of County and City Health Officials reports that up to 45 
percent of local health departments reported budget cuts; one in four 
is still affected by budget cuts today. Since 2008, 51,700 jobs have 
been lost at local health departments. As a result, when it comes to 
STDs, we are in the midst of true genuine crisis.
A New Response is Needed
    Due to these infrastructure losses, our STD public health 
infrastructure is in a state of crisis and additional resources are 
needed to combat our growing STD epidemics. If fully funded, this 
request would go to two distinct but complimentary needs, which are 
outlined below.
Additional Workforce Needs: $5.1 million
  --Funding would be disseminated to public health departments for more 
        boots on the ground.
  --This could include trained epidemiology staff, more staff to ensure 
        positive cases are tracked down and treated, or medically 
        trained staff to best respond to each health department's needs 
        for dealing with their epidemics.
Program Science Activities: $3 million
  --Our current system of prevention and control careens from one 
        emergency outbreak to another, and this cannot continue.
  --Improved data is needed to show, empirically, what is causing this 
        surge in STDs and which evidenced-based interventions work to 
        best to reduce STDs in the U.S.
  --Additional program science evidence is also needed to better 
        understand how to reach communities hardest hit by STD 
        increases.
  --This would result in evidence-based interventions that can be 
        scaled up across the country to respond to these ever-rising 
        rates.
    In fiscal year 2017 funding, please support an urgent funding 
increase of $8.1 million to the Division of STD Prevention to ensure 
those on the front lines of STD prevention have funding to respond to 
the rising rates of all STDs, particularly syphilis, and prepare for 
other foreseen outbreaks. For more information, please contact the 
National Coalition of STD Director's Director of Policy and 
Communications, Stephanie Arnold Pang at sarnold@ncsddc.org.

    [This statement was submitted by William Smith, Executive Director, 
National Coalition of STD Directors.]
                                 ______
                                 
    Prepared Statement of the National Congress of American Indians
    The National Congress of American Indians (NCAI) is the 
intergovernmental body for American Indian and Alaska Native tribal 
governments. NCAI is the oldest and largest national tribal 
organization in the United States that is dedicated to protecting the 
rights of tribal governments to achieve self-determination and self-
sufficiency. For over 60 years tribal governments have come together as 
a representative Congress through NCAI to consider issues of critical 
importance to tribal governments and endorse consensus policy 
positions. NCAI appreciates the opportunity to offer the following 
testimony on tribal programs in the Departments of Labor, Education, 
and Health and Human Services.
              u.s. department of health and human services
    NCAI supports investments in tribal health and well-being across 
the Department of Health and Human Services (HHS) agencies.
Substance Abuse Mental Health Services Administration
    NCAI appreciates the funding increases made to Tribal Behavioral 
Health Grants in the fiscal year 2016 appropriations bill. NCAI 
requests continued funding of at least $30 million, which includes $15 
million in the Mental Health appropriation and $15 million in the 
Substance Abuse Prevention appropriation. These funds are essential in 
the promotion of mental health and prevent substance activities for 
high-risk American Indian/Alaska Native (AI/AN) youth and their 
families.
Administration for Community Living (ACL)
    Native American Nutrition and Supportive Services: NCAI recommends 
$31 million for this program. This program provides nutrition and other 
direct supportive services to American Indian, Alaska Native, and 
Native Hawaiian elders. These programs help to reduce the need for 
costly nursing home care by supporting adult day care, meal delivery 
and transportation.
Head Start
    Head Start funds provide early education to over 24,000 Native 
children. This vital program combines education, health, and family 
services to model traditional Native education, which accounts for its 
success rate. NCAI recommends the Subcommittee to provide $9.6 billion 
total funding for Head Start, which includes Indian Head Start. Head 
Start has been and continues to play an instrumental role in Native 
education.
Administration for Children and Families
    NCAI supports start-up funding for tribal IV-E programs and 
improving of tribal access to Promoting Safe and Stable Families.
    Start-up Funding and Increase Match for Tribal IV-E Programs.--NCAI 
urges Congress to improve tribes' capacity to operate title IV-E 
programs by providing start-up funding and an increased match for 
tribal IV-E. The President's budget includes a proposal that allows 
Indian tribes, tribal organizations, or consortia that are approved to 
operate a title IV-E program to apply for start-up funding to assist 
with the implementation of the program requirements in title IV-E of 
the Social Security Act. A second proposal would amend title IV-E to 
develop the tribal child welfare workforce by increasing the match rate 
for tribal case work activities and increasing the Federal financial 
participation to 90 percent for training tribal caseworkers.
    Increasing Tribal Access to Promoting Safe and Stable Families 
(PSSF).--NCAI supports an increase of $20 million in the discretionary 
PSSF appropriation from the fiscal year 2016 enacted level to improve 
tribal capacity to administer child welfare services. American Indian 
and Alaska Native children are disproportionately represented at two 
times their population in State child welfare systems nationally. Among 
individual State foster care systems they are overrepresented at as 
much as 10 times their population rate. NCAI urges Congress to help 
address the disproportionality affecting Native children by investing 
in tribal child welfare systems.
    Many tribes lack infrastructure and stable funding. While tribes 
may directly administer title IV-E programs, many tribes still need to 
build their child welfare programs. With this increase, total funding 
reserved for formula grants for tribes will be $31 million, including 
$22 million discretionary and $9 million mandatory.
    Tribal Court Improvement.--A $2.75 million increase is proposed for 
this program to allow ACF to fund a total of 25 tribal court 
improvement grants. The expansion of the Tribal Court Improvement 
Program would continue to strengthen the tribal court's capacity to 
exercise jurisdiction in Indian Child Welfare Act cases and to 
adjudicate child welfare cases in tribal court.
    Low-Income Home Energy Assistance Program (LIHEAP).--Provide $4.7 
billion for LIHEAP, with $51 million allocated to tribes and tribal 
organizations. The LIHEAP is intended to assure that low-income 
families will not be forced to choose between food and heat. With high 
unemployment and long-standing barriers to economic development, much 
of Indian Country cannot afford the rising costs of heat and power. 
Alaska Native villages are experiencing some of the highest costs for 
energy with fuel prices recently reaching $7 per gallon. In fiscal year 
2011, LIHEAP was appropriated $4.7 billion total, with $51 million 
allocated to tribes and tribal organizations. Full funding is crucial 
to address the extreme need for heating assistance in Indian Country. 
Accordingly, funding for fiscal year 2017 should be $51 million for 
tribes.
                      u.s. department of education
    Title I Part A Local Education Agency Grants.--Title I of the Every 
Student Succeeds Act (ESSA) provides critical financial assistance to 
local educational agencies (LEAs) and schools with high percentages of 
children from low-income families that ensure all children meet 
challenging State academic standards. Currently, there are over 600,000 
Native students across the country with nearly 93 percent of those 
students attending public schools in rural and urban locations. A 
drastic increase in funding to counter annual inflation and 
sequestration, as well as to match the amount appropriated under the 
American Reinvestment and Recovery Act (ARRA), is necessary to meet the 
needs of Native students and students from low-income families. NCAI 
recommends funding of $25 billion for Title I, Part A.
    Impact Aid.--Impact Aid provides direct payments to public school 
districts as reimbursement for the loss of traditional property taxes 
due to a Federal presence or activity, including the existence of an 
Indian reservation. With nearly 93 percent of Native students enrolled 
in public schools, Impact Aid provides essential funding for schools 
serving Native students. Funding for Impact Aid must not be less than 
this requested amount. Furthermore, Impact Aid should be converted to a 
forward-funded program to eliminate the need for cost transfers and 
other funding issues at a later date. NCAI requests the Subcommittee to 
provide $2 billion in funding for Impact Aid, Title VII funding under 
the Every Student Succeeds Act.
                       title vi-indian education
    Grants to Local Education Agencies (Title VI, Part A).--Increases 
are needed as this critical grant funding is designed to supplement the 
regular school program and assist Native students so they have the 
opportunity to achieve the same educational standards and attain parity 
with their non-Native peers. Title VI funds support early-childhood and 
family programs, academic enrichment programs, curriculum development, 
professional development, and culturally-related activities. These 
grants provide much needed resources to Native communities to invest in 
the success of their students. NCAI recommends funding of $198 million 
for LEA grants.
    Native American and Alaska Native Language Immersion Schools and 
Programs (Title VI, Part A, Subpart 3).--Native American and Alaska 
Native Language Immersion Schools and Programs would strengthen tribal 
sovereignty, while protecting the cultural and linguistic heritage of 
Native students in education systems. In years past, funding for Title 
VI only reached 500,000 Native students leaving over 100,000 without 
supplementary academic and cultural programs in their schools. As 
Native students lag behind their non-Native peers in educational 
achievement, increased funding is necessary to address this substantial 
gap. NCAI urges the Subcommittee to fund immersion programs at $6.6 
million for fiscal year 2017.
    Alaska Native Education Program (Title VI, Part C).--This essential 
program funds the development of curricula and education programs that 
address the unique educational needs of Alaska Native students, as well 
as the development and operation of student enrichment programs in 
science and mathematics. Other eligible activities include professional 
development for educators, activities carried out through Even Start 
programs and Head Start programs, family literacy services, and dropout 
prevention programs. NCAI recommends the Alaska Native Education Equity 
Assistance Program be funded at $35 million for fiscal year 2017.
    Native Hawaiian Education Program (Title VI, Part B).--Increases 
are needed as this critical grant program funds the development of 
curricula and education programs that address the unique needs of 
Native Hawaiian students to help bring equity to this Native 
population. The Native Hawaiian Education Program empowers innovative 
culturally appropriate programs to enhance the quality of education for 
Native Hawaiians. These programs strengthen the Native Hawaiian culture 
and improve educational attainment, both of which are correlated with 
positive economic outcomes. NCAI recommends funding of $35 million for 
Native Hawaiian Education Program for fiscal year 2017.
Tribal Colleges and Universities: Supporting Financially Disadvantaged 
        Students
    Titles III and V of the Higher Education Act, known as Aid for 
Institutional Development programs, support institutions with a large 
proportion of financially disadvantaged students and low cost-per-
student expenditures. Tribal Colleges and Universities (TCUs) clearly 
fit this definition. The Nation's 37 TCUs serve Native and non-Native 
students in some of the most impoverished areas in the Nation. Congress 
recognized the TCUs as emergent institutions, and, as such, authorized 
a separate section of Title III (Part A, Sec. 316) specifically to 
address their needs. Additionally, a separate section (Sec. 317) was 
created to address similar needs of Alaska Native and Native Hawaiian 
institutions. NCAI urges this Subcommittee to appropriate $60 million 
($30 million in discretionary funding and $30 million in mandatory 
funding) for Title III-A grants under the Higher Education Act for 
Tribal Colleges and Universities.'
Tribally Controlled Post-Secondary Career and Technical Institutions
    Section 117 of the Carl Perkins Career and Technical Education 
Improvement Act authorizes funding for operations at tribally 
controlled postsecondary career and technical institutions. Vocational 
education/training programs are very expensive to conduct, but are 
vital to preparing a future workforce that will operate safely and 
efficiently contributing greatly to the global economy. Currently, two 
TCUs participate in this funding program: United Tribes Technical 
College in Bismarck, North Dakota, and Navajo Technical College in 
Crownpoint, New Mexico. NCAI recommends $10 million for tribally 
controlled postsecondary career and technical institutions program 
funds under the Carl Perkins Career and Technical Education Improvement 
Act.
Native American-Serving, Non-Tribal Institutions (Higher Education Act 
        Title III-F)
    As the primary Federal funding for non-tribal, Native-serving 
institutions of higher education, the current funding levels are 
insufficient. With nearly 100 institutions potentially qualifying as 
Native-serving, non-tribal institutions, this strains the small amount 
of available funding. Increasing the funding will provide the 
opportunity for more Native-serving institutions to better serve their 
students and increase graduation rates among Native students. NCAI 
urges the Subcommittee to fund $10 million for non-tribal, Native-
serving institutions of higher education.
    In conclusion, NCAI appreciates the opportunity to share these 
recommendations with the Subcommittee. The needs in Indian Country are 
great and we thank this Subcommittee for working to honor the Federal 
Indian trust responsibility.
                                 ______
                                 
     Prepared Statement of the National Council of Social Security 
                        Management Associations
    On behalf of the National Council of Social Security Management 
Associations (NCSSMA), thank you for the opportunity to submit this 
testimony regarding the Social Security Administration's (SSA's) fiscal 
year 2017 Appropriation. NCSSMA respectfully requests that Congress 
consider full funding of the President's fiscal year 2017 budget 
request for SSA, which includes $13.067 billion for SSA's Limitation on 
Administrative Expenses (LAE) account.
    NCSSMA is a membership organization of approximately 3,200 SSA 
managers and supervisors who provide leadership in nearly 1,250 
community-based field offices and teleservice centers throughout the 
country. We are the front-line service providers for SSA in communities 
all over the Nation. Since the founding of our organization over 46 
years ago, NCSSMA has considered a stable SSA, which delivers quality 
and timely community-based service to the American public, our top 
priority. We also consider it paramount to be good stewards of the 
taxpayers' monies and the Social Security programs we administer.
    NCSSMA respectfully requests that Congress consider full funding of 
the President's fiscal year 2017 budget request, which includes $13.067 
billion for SSA's Limitation on Administrative Expenses (LAE) account. 
This level of funding will allow SSA to improve and modernize customer 
service, enhance program integrity efforts, deter and detect fraud and 
errors, and continue to address high volumes of work.
    SSA's fiscal year 2016 LAE account funding is $12.162 billion. 
Although greatly appreciated, this level of funding did not fully cover 
the agency's inflationary costs. At the same time, SSA is experiencing 
an increase in visitors to field offices as members of the baby boom 
generation retire or file for disability benefits. Nearly 3 million 
cases are currently pending in the agency's Program Service Centers 
(PSCs), of which the average case is nearly 4 months old. Many cases 
involve a dire need for funds, resulting in hardship for the people 
involved, often including the inability to get Medicare coverage. Over 
1.114 million people are waiting for a hearing decision. The number of 
pending hearings has reached an all-time high. Of serious concern is 
that this wait is now a record setting 535 days. The processing time 
for hearings has now increased for 36 consecutive months.
LAE Funding History

                                      FISCAL YEAR 2017--SSA BUDGET FORECAST
                                              (Dollars in millions)
----------------------------------------------------------------------------------------------------------------
                                                                           Fiscal Year
                                                ----------------------------------------------------------------
                                                                                                         2017
                                                     2013         2014         2015         2016     President's
                                                   Enacted      Enacted      Enacted      Enacted       Budget
----------------------------------------------------------------------------------------------------------------
SSA's LAE Funding..............................      $11,046      $11,697      $11,806      $12,162      $13,067
----------------------------------------------------------------------------------------------------------------

    Adequate resources for SSA have a positive impact on delivering 
vital services to the American public and in fulfilling the agency's 
stewardship responsibilities. Full funding is critical to maintain 
staffing in SSA's front-line components, cover inflationary costs, 
increase deficit-reducing program integrity work, and to address the 
significantly increased hearings backlog. It is important to note that 
the fiscal year 2017 budget request includes inflationary increases of 
over $319 million in fixed costs, including rent, guards, postage, and 
employee salaries and benefits.
Program Integrity Initiatives
    Program integrity initiatives save taxpayer dollars and contribute 
to reducing the Federal budget and deficit. To address program 
integrity, the President's fiscal year 2017 SSA budget request includes 
$1.819 billion for the two most cost-effective tools to reduce improper 
payments--Medical Continuing Disability Reviews (CDRs) and SSI 
Redeterminations. It is important to note that in fiscal year 2015, the 
same SSA field office employees who answered telephone calls, took 
initial claim applications, and developed and adjudicated benefit 
claims, also processed the following program integrity workloads:
  --799,000 Medical CDRs; and
  --2.267 million SSI Redeterminations.
    In fiscal year 2016, SSA projections indicate the agency will 
complete 850,000 Medical CDRs and 2.522 million SSI Redeterminations. 
The fiscal year 2017 budget request calls for SSA to process 1,100,000 
Medical CDRs, which is an increase of 38 percent over fiscal year 2015 
and 2.822 million SSI Redeterminations, which is an increase of 25 
percent over fiscal year 2015. In order to process this large increase 
in volume of Medical CDRs and SSI Redeterminations, the field offices 
and Disability Determination Services (DDSs) will need to have adequate 
staffing levels in fiscal year 2017, or there could be delays in 
processing initial disability claims and reconsiderations, and 
degradation of other services field offices provide.
    CDRs conducted in fiscal year 2017 will yield net Federal program 
savings, on average over the next 10 years, of $8 for every $1 budgeted 
from dedicated program integrity funding including OADSI, SSI, Medicare 
and Medicaid program effects. SSI Redeterminations conducted in fiscal 
year 2017 will yield a return on investment (ROI) averaging about $3 of 
net Federal program savings over 10 years per $1 budgeted for dedicated 
program integrity funding, including SSI and Medicaid program effects.
Funding for Fiscal Year 2017
    SSA's fiscal year 2017 budget request includes $301.4 million for 
over 2,800 work years to handle the additional program integrity 
workloads, address the massive hearings backlog, increases in other 
workloads, visitors, and telephone calls in field offices, teleservice 
centers and Program Service Centers.
    The budget request also includes funding of $352.2 million for 
Information Technology (IT) Modernization. SSA's database systems are 
over 40 years old and include more than 60 million lines of COBOL 
coding. Additional IT funding will allow SSA to modernize its computer 
language, database and infrastructure, including moving its data to the 
cloud. The budget request also contains a proposal for additional 
mandatory IT funding through fiscal year 2020. SSA also plans to spend 
$87 million on cybersecurity.
    Again, SSA is challenged by ever-increasing workloads, very complex 
programs to administer, and increased program integrity work with 
diminished staffing and resources. With the current fiscal challenges 
confronting SSA, we encourage Congress to consider changes to the 
Social Security and SSI programs that have the potential to increase 
administrative efficiency and lower operational costs.
    It is critical SSA receives adequate, yet flexible funding for the 
LAE account to respond to requests for assistance from the American 
public, and to fulfill our stewardship responsibilities. SSA's TSCs, 
hearing offices, PSCs, DDSs, and the nearly 1,250 field offices are in 
grave need of adequate resources to address their growing workloads. 
Without adequate funding, SSA will not be able to provide the high-
quality customer service Americans deserve, and have paid for. Examples 
of decreased levels of customer service include inordinately long wait 
times when visiting SSA field offices or difficulty reaching those same 
offices by telephone. These very same field offices will also be unable 
to process program integrity workloads, which save taxpayers billions 
of dollars and reduce the Federal budget and deficit.
    We realize the fiscal year 2017 funding level of $13.067 billion 
for SSA's LAE account requested above is not insignificant, 
particularly in this difficult Federal budget environment; however, 
Social Security serves as the largest and most vital component of the 
social safety net of America and is facing unprecedented challenges. 
The American public expects and deserves SSA's assistance and support.
    In fiscal year 2017, SSA's programs are projected to pay a combined 
total of $1.0 trillion in Federal benefits to 68.4 million recipients. 
Spending on administrative costs for these programs is projected to be 
only about 1.3 percent of benefit outlays.
    On behalf of NCSSMA members nationwide, thank you for the 
opportunity to submit this written testimony. We respectfully ask that 
you consider our comments, and would appreciate any assistance you can 
provide in ensuring the American public receives the critical and 
necessary service they deserve from the Social Security Administration.

    [This statement was submitted by Richard E. Warsinskey, President, 
National Council of Social Security Management Associations.]
                                 ______
                                 
    Prepared Statement of the National Council on Independent Living
    Dear Chairman Blunt, Ranking Member Murray, and Members of the 
Subcommittee, my name is Kelly Buckland, and I am the Executive 
Director of the National Council on Independent Living (NCIL). I am 
writing to you on behalf of the Nation's Centers for Independent Living 
(CILs). I would like to start by thanking you for your commitment to 
enabling people with disabilities to participate fully in their 
communities by investing in the Independent Living Program. I write 
today to ask that you reaffirm your commitment to the over 57 million 
Americans with disabilities by increasing funding for CILs by $200 
million, for a total of $301 million for the Independent Living line 
item in fiscal year 2017.
    NCIL is dedicated to increasing the availability of the invaluable 
and extremely cost-effective services CILs provide. NCIL is the oldest 
cross-disability, national grassroots organization run by and for 
people with disabilities. NCIL's membership includes people with 
disabilities, Centers for Independent Living, Statewide Independent 
living Councils, and other disability rights organizations. NCIL 
advances independent living and the rights of people with disabilities, 
and we envision a world in which people with disabilities are valued 
equally and participate fully.
    Centers for Independent Living are non-residential, community-
based, non-profit organizations that are designed and operated by 
individuals with disabilities and provide five core services: advocacy, 
information and referral, peer support, independent living skills 
training and transition services that facilitate the transition of 
individuals with significant disabilities from nursing homes and other 
institutions to home and community-based residences with appropriate 
supports and services. Also included are assistance to individuals with 
significant disabilities who are at risk of entering institutions so 
that the individuals may remain in the community, and the transition of 
youth with significant disabilities to postsecondary life.
    CILs are unique in that they operate according to a strict 
philosophy of consumer control, in which people with any type of 
disability, including people with mental, physical, sensory, cognitive, 
and developmental disabilities, of any age, directly govern and staff 
the Center. Each of the 365 federally funded Centers are unique because 
they are run by people with disabilities and reflect the best interest 
of each community individually.
    Centers for Independent Living address discrimination and barriers 
that exist in society through direct advocacy. These barriers are 
sometimes architectural, but more often reflect attitudes and 
prejudices that have been reinforced for generations. They have 
deterred people with disabilities from working, leaving many in poverty 
and unjustly detained in institutions. As my own life experience has 
proven, with increased opportunities, individuals with disabilities can 
claim their civil rights and participate in their communities in ways 
their non-disabled counterparts often take for granted.
    NCIL estimates that to meet the current demand- including the 
addition of a fifth core service as authorized by WIOA-and overcome 
years of devastating funding cuts, appropriations for the IL Program 
will need to increase by $200 million. In fiscal year 2010 funding for 
the IL Program was $103,716,000, and in fiscal year 2016 funding for 
the IL Program is $101,183,000. That equals a loss of $2.5 million, not 
including adjusting for inflation. Increased funding should be 
reinvested from the billions currently spent to keep people with 
disabilities in costly Medicaid nursing homes and institutions and out 
of mainstream of society.
    According to data collected by the Rehabilitation Services 
Administration, during fiscal years 2012-2014, Centers for Independent 
Living:
  --Attracted over $2.26 Billion through private, State, local, and 
        other sources;
  --Moved 13,030 people out of nursing homes and institutions, saving 
        States and the Federal Government over $500 million, not to 
        mention improving people's quality of life, and;
  --Provided the four core services, including: advocacy to 233,230 
        consumers, information and referral to 4,189,922 consumers, 
        peer support to 172,287 consumers, and independent living 
        skills training to 274,991 consumers.
    In that same period, CILs provided other services to hundreds of 
thousands of individuals with disabilities in their respective 
communities that included:
  --Services to 35,137 youth with disabilities;
  --Assistance to 145,937 people in securing accessible, affordable, 
        and integrated housing;
  --Transportation services to 103,175 people with disabilities;
  --Personal assistance services to 184,240 people with disabilities;
  --Vocational and employment services to 96,492 people with 
        disabilities; and
  --Assistance with Assistive Technology for 171,441 people with 
        disabilities.
    Beyond the direct services they provide, CILs seek ways to broadly 
change traditional service delivery in their communities and throughout 
the Nation, including reform of the long term care system. For over 40 
years, CILs have sought community based programs to assist people with 
all types of disabilities, across the lifespan, to remain in or return 
to their family and friends, in their homes and communities. When such 
services are delivered in an individual's home, rather than a costly 
nursing facility or other institution, the result is tremendous cost 
savings to Medicaid, Medicare and States, while enabling people with 
disabilities to become more independent, financially self-sufficient, 
and less reliant on long term government supports. And research has 
found that community-based services are significantly less expensive 
than nursing home placements.
    In 2015 alone, CILs have had major successes in increasing access 
and equality for people with disabilities. The DIAL Center for 
Independent Living in Clifton, New Jersey joined a local wheelchair 
user in efforts to work with the city of Montclair, and those efforts 
will result in accessible parking spaces outside schools, parks, and 
other public parking areas, as well as the hiring of an ADA Coordinator 
for the city. The Montana Independent living Project collaborated on a 
snow ordinance policy for the city of Helena that requires sidewalks, 
ADA ramps, corners, bulb-outs, and driveway and alley aprons used for 
pedestrian travel to be cleared within 24 hours, with enforcement and 
penalties for non-compliance. Access Living in Chicago, Illinois 
conducted phone-based fair housing tests and used the results to draw 
attention to the issue of discrimination against home seekers who are 
Deaf or hard of hearing. And the Disabled Resource Services CIL (DRS) 
in Fort Collins and Loveland, Colorado conducted its first Women's 
Empowerment Group, which has led to ongoing efforts by DRS staff to 
create an empirical research design model that can be used in future 
groups to quantitively measure the concept of ``empowerment,'' an area 
of study in which little research exists.
    Additionally, CILs have been extremely effective in helping people 
remain in or transition back into the community. The Whole Person's 
Money Follows the Person program completed 32 consumer transitions from 
institutions to apartments/homes in the Kansas City, Missouri metro 
area. Tri?County Patriots for Independent Living in Washington, 
Pennsylvania transitioned 54 people from nursing homes and other 
institutions into their own homes, saving the State and Federal 
Government $2,268,000. The Houston Center for Independent Living in 
Texas transitioned 186 nursing home residents into community-based 
living, saving the State of Texas and the Federal Government 
approximately $8,779,200. And the Center for Disability Rights in 
Rochester, New York was instrumental in achieving introduction of the 
Disability Integration Act by Senator Schumer, which has the potential 
to provide access to community services and supports to people with 
disabilities all across the country.
    As previously mentioned, the Workforce Innovation and Opportunity 
Act created a fifth core service for Centers: transition. NCIL strongly 
supported the addition of this fifth core service, but additional 
funding is sorely needed to effectively carry it out. Funding these 
transition services will be critical to promoting effective employment 
outcomes, successful nursing home transition, and increased community 
participation for transitioning students. Current funding levels barely 
sustain day-to-day operations. CILs struggle to meet the demands of the 
community and provide leadership and common sense solutions. Without 
increased funds our vision to achieve full integration of people with 
disabilities in society will be undercut and taxpayers will continue to 
pay for costly Medicaid nursing homes and bear the economic impact of 
negative employment outcomes and continued dependence on programs that 
disincentive work and community involvement. CILs are an excellent 
service and a bargain for America. They keep people active and engaged 
in their communities, and they save taxpayer money.
    Thank you for the opportunity to provide testimony. We welcome any 
questions you may have. We also welcome each of you to visit your local 
Center for Independent Living so you can see first-hand their 
contributions to your Congressional Districts. We look forward to 
working with you to ensure that Americans with disabilities have the 
opportunity become active members of society.

    [This statement was submitted by Kelly Buckland, Executive 
Director, National Council on Independent Living.]
                                 ______
                                 
             Prepared Statement of the National Energy and 
                    Utility Affordability Coalition
    The Low Income Home Energy Assistance Program (LIHEAP) is America's 
cornerstone energy safety net program. Since its inception nearly 35 
years ago, LIHEAP has assisted low-income families, those on a fixed 
income and seniors, to ease energy burdens, especially in the cold 
winter and hot summer months. LIHEAP is federally administered by the 
U.S. Department of Health and Human Services, Administration of 
Children and Families, Office of Community Services. It is presently 
funded at $3.39 billion. The President's fiscal year 2017 budget 
proposes a cut of $390 million to LIHEAP's discretionary appropriation. 
The National Energy and Utility Affordability Coalition (NEUAC) urges 
you to reject that proposed cut and instead restore LIHEAP funding to 
earlier levels of at least $4.7 billion for fiscal year 2017.
    Why the need for more funding? In fiscal year 2015 LIHEAP served 
about 18 percent of qualifying U.S. households. In other words, 82 
percent of LIHEAP-eligible households received no assistance. (National 
and State by State fact sheets about LIHEAP can be found at http://
neuac.org/wp-content/uploads/2015/10/2016LAD
StateSheetsFINAL.pdf).
    Federal eligibility rules governing LIHEAP require that household 
income may not exceed 150 percent of the Federal poverty level or 60 
percent of the State's median income. Simply stated, a family of three 
would only qualify if they made less than $30,000 annually. However, 
most LIHEAP recipients fall well under that requirement; according to 
HHS the typical family receiving assistance in fiscal year 2014 had a 
median income of 83.5 percent of the Federal poverty guidelines--about 
$16,000.\1\
---------------------------------------------------------------------------
    \1\ HHS FY 2017 Budget Justification; https://www.acf.hhs.gov/
sites/default/files/olab/final_cj_2017_print.pdf.
---------------------------------------------------------------------------
    Families who rely on LIHEAP are truly the most vulnerable among us. 
State LIHEAP administrators report that nearly 73 percent of LIHEAP 
recipient households had at least one vulnerable person, that is a 
senior age 60 or older, a child age 5 and under, or an individual with 
a disability.\2\
---------------------------------------------------------------------------
    \2\ NEADA 2014 LIHEAP Household Report http://neada.org/wp-content/
uploads/2015/06/State-Table-FY14-Households-Served.pdf.
---------------------------------------------------------------------------
    LIHEAP is not an entitlement, it must come before Congress every 
year and no one is assured of assistance, not even households in 
crisis. Since 2009, LIHEAP funding has been reduced by one third, but 
the need has not fallen by a similar measure.
    NEUAC notes that while the Administration seeks a cut in the 
discretionary LIHEAP funding in fiscal year 2017, it did include a ``a 
contingency fund providing additional mandatory funds to respond to 
increases in the number of low-income households, spikes in the price 
of natural gas, electricity, or oil, and extreme cold at the beginning 
of winter.''
    Additionally, the Administration proposes allowing States to ``use 
up to 40 percent'' of its LIHEAP appropriation for weatherization 
``without regard to the waiver process.'' Currently, a State is not 
required to spend any LIHEAP money on weatherization. Further, States 
are limited to not more than 15 percent to be used for weatherization 
without a waiver, and with a waiver, States may spend a maximum of 25 
percent on weatherization. There is already a Federal block grant for 
low-income weatherization, funded in the Energy and Water Development 
Appropriations bill.
    NEUAC's position is that while both proposals are well-intentioned; 
they have the practical effect of reducing the commitment of core 
LIHEAP resources to States and Tribes. Thus, NEUAC opposes both 
proposals, and urges the Subcommittee to maximize its commitment to 
LIHEAP, to concentrate all resources into the program's base block 
grants, and to enable the program to focus upon the core mission 
Congress established it to accomplish.
    Thank you for the opportunity to express the views of the National 
Energy and Utility Affordability Coalition on this important matter. We 
thank you for consideration of our request to fund LIHEAP at an amount 
no lower than $4.7 billion in fiscal year 2017.
    NEUAC is national, broad-based and diverse. Its mission is to 
heighten awareness of the energy needs of low- and moderate-income 
Americans. NEUAC members--including non-profits, fuel funds, energy 
providers, charitable organizations, Tribes, and many others--are 
working to reduce the energy burden of vulnerable households through 
advocacy, policy improvements and partnerships.

    [This statement was submitted by Mary Thompson Grassi, Interim 
Executive Director, the National Energy and Utility Affordability 
Coalition.]
                                 ______
                                 
    Prepared Statement of the National Energy Assistance Directors' 
                              Association
    The members of National Energy Assistance Directors' Association 
(NEADA), representing the State directors of the Low Income Home Energy 
Assistance Program (LIHEAP) would like to first take this opportunity 
to thank the members of the Subcommittee for considering our funding 
request for fiscal year 2017. For fiscal year 2017 we are requesting 
the Committee restore program funding to the fiscal year 2011 level of 
$4.7 billion.
    The funding request would allow States to increase program services 
to the level provided in fiscal year 2011 and allow us to increase the 
number of households served from 6.7 million to 8 million and the 
percentage of households served from about 19 percent in fiscal year 
2016 to about 22 percent and fund about 50 percent of the cost of home 
heating for eligible households.
    In addition, the lack of a final program appropriation prior to the 
beginning of the fiscal year creates significant administrative 
problems for States in setting their program eligibility guidelines. We 
are concerned that States will be hampered in their ability to 
administer their programs efficiently due to the lack of advanced 
funding. In order to address this concern, we are requesting advance 
appropriations of $4.7 billion for fiscal year 2018.
    LIHEAP is the primary source of heating and cooling assistance for 
some of the poorest families in the United States. In fiscal year 2016, 
the number of households receiving heating assistance is expected to 
remain at about 6.7 million or about 19 percent of eligible households, 
with an average grant size of about $425. In addition, the program is 
expected to reach about 1 million households for cooling assistance, 
the same level that received assistance in fiscal year 2015.
    Program funding for LIHEAP has been significantly cut from $5.1 
billion in fiscal year 2010 to the current level of $3.3 billion. As a 
result, States have had to reduce the number of households receiving 
assistance by 1.3 million, from 8 million to the current level of 6.7 
million. Program cuts have hurt the ability of States to help the 
Nation's poorest households pay their energy bills. The average grant 
has further been reduced from $520 in fiscal year 2010 to the current 
level of about $425.
    At the same time, LIHEAP is in a period of transition. Along with 
the Administration for Children and Families, the Department that 
oversees the program, LIHEAP offices are working to enhance current 
program integrity measures including developing modernized web-based 
intake systems, and instituting external verification of applicant-
submitted data. In addition, they are developing nationwide performance 
measures that will give Congress and the public a clear picture of the 
effectiveness of LIHEAP in helping low income households. NEADA 
believes these efforts will lead to a more responsive and more cost-
effective program.
                    liheap in the president's budget
    The Obama Administration released its fiscal year 2017 budget on 
February 9, 2016. This budget would reduce core block grant funding for 
LIHEAP from $3.39 billion to $3.0 billion. This represents a cut of 
$390 million or about 12 percent. The budget did not provide a 
rationale for the cut. We urge the Committee to reject this proposal.
    Weatherization.--Current law allows States to set aside up to 15 
percent of their allocation for Weatherization and up to 25 percent 
with a waiver. The Administration's proposal would allow States to set-
aside up to 40 percent without a waiver. We are recommending that the 
Committee reject this proposal. The current law provides States with 
sufficient flexibility to design their weatherization programs in 
context of other resource that might be available for this purpose, 
allowing States to strike the proper balance between bill payment 
assistance and efficiency. In addition, we believe that increasing the 
ceiling for Weatherization within the block grant would undermine the 
primary purpose of LIHEAP which is to help poor families pay their home 
energy bills.
    One aspect of the budget is potentially very positive for LIHEAP. 
It would add a new contingency fund of $560 million. We urge the 
Committee to consider this proposal assuming it would not detract from 
providing full funding for the base program.
             what is the impact of declining federal funds?
    Surveys of families receiving Federal assistance have been 
consistent over the years. Poor families struggle to pay their home 
energy bills. When they fall behind, they risk shut-off of energy 
services or they are not able to afford the purchase of delivered 
fuels. In fiscal year 2011, NEADA conducted a survey of approximately 
1,800 households that received LIHEAP benefits.
    The results show that LIHEAP households are among the most 
vulnerable in the country.
  --40 percent have someone age 60 or older
  --72 percent have a family member with a serious medical condition
  --26 percent use medical equipment that requires electricity
  --37 percent went without medical or dental care
  --34 percent did not fill a prescription
  --85 percent of people with a medical condition are seniors
    LIHEAP's impact in many cases goes beyond providing bill payment 
assistance by playing a crucial role in maintaining family stability. 
It enables elderly citizens to live independently and ensures that 
young children have safe, warm homes to live in.
        energy prices and their impact on low income households
    While energy prices have stabilized in some cases declined from 
previous year highs they remain unaffordable for millions of low income 
households. According to the U.S. Energy Information Administration, 
the cost of home heating this winter with natural gas was $525, 
electricity $903, heating oil, $1,033, propane $1,696 in the Northeast 
and $1,015 in the Midwest. EIA also reported that the average summer 
electricity expenditures is expected to remain at an unaffordable $407, 
about the same as last year.
    Energy prices fall hardest on lower income households. In fiscal 
year 2014, mean burden for low-income was 10 percent almost four times 
the rate for non-low income households (2.4 percent). Of even greater 
concern about one-third of lower income households have energy burden 
greater than 15 percent of income and one in six have an energy burden 
greater than 25 percent of income.
    Source: Fiscal Year 2014 Home Energy Notebook, Administration for 
Children and Families.
                            faces of liheap
    Alabama: A single mother in Alabama supporting three children on 
minimum wage was often forced to decide whether to pay utility bills or 
rent. She received LIHEAP to help pay her bill and was enrolled in an 
energy education class to help manage her energy usage. In addition to 
the LIHEAP benefit, she was able to bring down her energy bill from 
about $570 a month to $495 month, a savings of $75, as a result of the 
class.
    California: A young mother of three lived in an older all-electric 
home and had their electricity shut off due to a past-due bill of about 
$800. She worked full time making minimum wage and her husband worked 
as a seasonal laborer. With no electricity, the family could not heat 
their home, access hot water, or operate appliances. LIHEAP was able to 
assist the family by paying their past due bill to get the electricity 
turned back on. She was also referred to the County's Weatherization 
Program, which assists families in making their homes more energy 
efficient.
    Connecticut: A single mother of two facing the challenges of being 
homeless came to the State for help. Through Connecticut's connected 
services, she received a housing subsidy, $505 in LIHEAP funds, and was 
enrolled in the utility company's Matching Payment Program.
    Georgia: A 77 year-old disabled senior living on SSI was facing 
shut-off due to unaffordable winter energy bills. During the winter 
months every year her heating bills peaked as the result of having to 
maintain a consistence home heating temperature due to her disability 
and other illnesses. Her gas bill was in danger of disconnection with a 
balance of $612 and an additional past due portion of $355. With the 
senior meeting the eligibility requirement for both the LIHEAP maximum 
benefit $350 and Home Energy Assistance Team (H.E.A.T) program funds of 
$350 the program was able to successfully assist this senior to bring 
her home heating bill current which resulted in the senior maintaining 
home heating throughout the remainder of winter.
    While visiting the home of a senior citizen to take a LIHEAP 
application, the Program Coordinator noticed the oven and top burners 
of her stove were on, as well as that she was wearing a heavy over 
wrap. During the intake process it was discovered that her home heating 
furnace was not working. Based on the her income she received the 
maximum LIHEAP benefit of $350 and was referred to the Weatherization 
Assistance Program (WAP) to have her heating season evaluated. The 
Weatherization Program Coordinator came out and confirmed that the 
furnace needed to be replaced. A WAP team was dispatched to the senior 
home to install a new furnace, the senior could immediately feel the 
difference in the heating of the home and was extremely grateful.
    Idaho: A 90 year-old woman in rural Idaho was referred by LIHEAP to 
Weatherization after she indicated that she had a broken furnace. 
Weatherization staff found that she was using a coffee can to carry 
wood pellets from an outdoor shed to a pellet stove in her living room, 
because she was not able to carry an entire bag. With no other backup 
heat source, she would have to leave her home if the unreliable stove 
broke. Because of the referral from LIHEAP, the Weatherization program 
was able to install a new high efficiency furnace and weatherize her 
home. This saved her money on her monthly heating bill and allowed her 
to stay in her home.
    Illinois: A single man who had been living in a tent was able to 
afford an apartment for the first time in years when he discovered he 
had an old bill with the utility and would not be able to get utilities 
in his new home. LIHEAP was able to get him connected and help him get 
up-to-date on his bills.
    Oklahoma: A young single woman with medical issues was working part 
time as a cashier and taking care of her elderly grandmother. She was 
able to use LIHEAP to maintain service while she was between jobs, 
preventing her and her mother from entering a shelter. She was also 
able to use LIHEAP emergency assistance to prevent disconnect of her 
electricity when her new salary was not enough to cover the bill.
    Pennsylvania: A disabled cancer patient lost her home through 
foreclosure but was still in the residence pending eviction. Her 
furnace was shut down for safety reasons after the State weatherization 
team discovered it was leaking carbon monoxide. The property was 
acquired by an out-of-state corporation that refused to allow the 
weatherization team to repair the furnace. The State LIHEAP office was 
able to use LIHEAP weatherization funds to provide space heaters for 
the woman until she was able to make other living arrangements, saving 
her from making the choice of living in a house made hazardous from 
carbon monoxide or in freezing temperatures.
    Tennessee: A woman who is bed ridden and paralyzed from the waist 
down had to cut back on other necessities to pay her medical bills. At 
the beginning of last winter, she saved energy by only turning on the 
lights when her nurse came to visit. She also kept her thermostat on 60 
degrees and asked her nurse to layer her clothing and put extra 
blankets on her before she left. Since receiving LIHEAP, she has been 
able to leave a light on at night to make her feel more secure and to 
keep the home a comfortable temperature.
    Wyoming: An elderly woman was facing eviction because she got 
behind on her utility bills. She was having trouble stretching her 
social security check to cover her utilities, her cancer treatments, 
and the cost of travel to receive treatment. LIHEAP helped her out with 
her bill, ensuring she could stay in her home. ``We might not be able 
to eat very well or pay for medicines, but at least we can be warm in 
our own homes with the help of LIHEAP''.
                                 ______
                                 
   Prepared Statement of the National Family Planning & Reproductive 
                           Health Association
                                summary
_______________________________________________________________________

    Requesting $327 million in funding for fiscal year 2017 for the 
national family planning program (Title X of the Public Health Service 
Act).
_______________________________________________________________________

    My name is Clare Coleman; I'm the President & CEO of the National 
Family Planning & Reproductive Health Association (NFPRHA), a 
membership organization representing the Nation's safety-net family 
planning providers--nurse practitioners, nurses, physicians, 
administrators and other key healthcare professionals. Many of NFPRHA's 
members receive Federal funding from Medicaid and through Title X of 
the Federal Public Health Service Act, the only federally funded, 
dedicated family planning program for the low-income and uninsured. 
These critical components of the Nation's public health safety net are 
essential resources for those providing access to high-quality services 
in communities across the country. As the committee works on the fiscal 
year 2017 appropriations bill, NFPRHA respectfully requests that you 
make a significant investment in Title X by including $327 million, 
which would help make progress to restore the capacity of the program 
to serve those in need.
    NFPRHA was pleased to see that the administration acknowledged 
Title X's integral role in healthcare delivery by including $300 
million for the program in the President's fiscal year 2017 Budget 
Request, a $13.5 million increase over the fiscal year 2016 
appropriated level. However, that amount is insufficient to meet the 
well-documented demand for publicly funded family planning services. A 
recent analysis published in the American Journal of Public Health 
found that in order for all low-income, uninsured women of reproductive 
age to access family planning services, the program would need to be 
supported with approximately $737 million. The fiscal year 2016 
appropriated level of $286.5 million, therefore, represents only a 
fraction of what is needed to serve low-income, uninsured women across 
the country.
    Even as more individuals benefit from insurance coverage through 
the Affordable Care Act (ACA) and as additional States expand Medicaid, 
the Title X network continues to play an essential role in our Nation's 
service delivery framework. ``Churning'' and confidentiality issues, 
for example, play a role in keeping some individuals uninsured or 
unable to use the coverage they have for the full range of their family 
planning needs. More importantly, Title X-funded health centers, 
because of the quality and specialty care they provide, remain in 
demand even as low-income women gain access to health insurance. If the 
Massachusetts health reform experience were to prove representative of 
what could be expected as the ACA continues into its third full year of 
implementation, there will be a strong increase in demand for services 
at publicly funded family planning centers. According to a report by 
the Centers for Disease Control and Prevention (CDC), as health reform 
in Massachusetts expanded coverage for most people living in the State, 
Title X family planning health centers continued to have high volumes 
of patients, both insured and uninsured, and remained providers of 
choice for many.
    The failure of States to expand Medicaid eligibility for all adults 
up to 138 percent of the Federal poverty level (an income of $16,242 a 
year for an individual in 2016)--along with new barriers to coverage 
being sought by some expansion States, such as premiums and other cost-
sharing requirements--compounds the demand being placed on the Title X 
safety net. Currently, 19 States have not expanded their Medicaid 
eligibility under the ACA. Of those, only 1 State (WI) have full-
benefit Medicaid eligibility for childless adults. For working parents, 
16 of the 19 States have Medicaid eligibility equal to or less than 75 
percent of FPL (an income of $8,910 a year); 12 have eligibility at or 
below 50 percent (an income of $5,940 a year). Six States have 
eligibility set at less than 25 percent of FPL--that means individuals 
making more than $2,970 are too ``rich'' for Medicaid.
    Furthermore, emerging public health threats highlight the 
importance of the publicly funded family planning safety net and the 
need for robust Title X funding. The CDC recently reported a causal 
link between babies born with microcephaly and pregnant women infected 
with the Zika virus, and public health experts expect the Zika virus to 
continue to spread domestically. Because of the potentially devastating 
impact of the virus on the health of the developing fetus, it is 
imperative that women have the tools and resources to prevent unplanned 
pregnancies. In a time of public health emergency, women will turn to 
the Title X program for thorough counseling, risk assessment, and 
access to family planning services, and the program should be funded in 
a manner that allows the publicly funded family planning safety net to 
respond to this threat.
    Similar to other publicly funded health programs, Title X has 
suffered budget cuts despite rising patient need. Between fiscal year 
2010-fiscal year 2014, the Title X family planning program was cut a 
net $31 million (-10 percent). During the same period, approximately 
1.1 million patients were lost from the program. These findings are 
very disturbing given that four in ten women who utilize a publicly 
funded family planning center say that it is there only source of care.
    As appropriators grapple with how best to distribute limited 
Federal resources, NFPRHA encourages the Committee to continue to 
prioritize investments in programs, including Title X, that are proven 
to save critical taxpayer dollars. Every $1 invested in publicly funded 
family planning services saves $7.09 in Medicaid costs associated with 
unplanned births. Additionally, services provided in Title X-supported 
centers alone yielded $5.3 billion of the $10.5 billion in total 
savings for publicly funded family planning in 2010.
    Moreover, appropriators should invest in programs, such as Title X, 
that focus on outcomes and increasing service efficiency. Title X has 
long set the standard for high-quality family planning and sexual 
health service provision and recently doubled down on its efforts to 
lead the field by advancing best practices for clinical care. In April 
2014, the program issued ``Providing Quality Family Planning Services--
Recommendations of CDC and the U.S. Office of Population Affairs,'' 
that outlines the most up-to-date clinical recommendations for all 
providers of family planning care, including Title X-funded providers, 
to help define patient-centered, high-quality care in a family planning 
visit. Such efforts reinforce the network's dual role as safety-net 
providers and centers of excellence for family planning and sexual 
healthcare.
    Lastly, Title X supports critical infrastructure and technology 
necessary for modern service delivery that are not reimbursable under 
Medicaid and commercial insurance. Resources for electronic health 
record implementation for safety-net providers--just as for others in 
the safety net--are necessary to help achieve the ACA goal of having a 
nationwide health information technology infrastructure and more 
coordinated models of care. Increased Title X funding is essential to 
help address the gap caused by the oversight in Federal planning that 
led to most family planning health providers' ineligibility for the 
electronic health records (EHR) incentives available under the HITECH 
Act.
    Millions of low-income women and men depend on the Title X program 
for affordable access to family planning and reproductive health 
services that help them stay healthy. However, politically motivated 
attacks are jeopardizing the Title X program's ability to help these 
vulnerable individuals and families. NFPRHA urges the Committee to 
reverse this trend by making a significant investment in the Nation's 
safety-net family planning health services and requests funding for 
Title X at $327 million in fiscal year 2017.

    [This statement was submitted by Clare Coleman, President & CEO, 
National Family Planning & Reproductive Health Association.]
                                 ______
                                 
       Prepared Statement of the National Head Start Association
    Dear Chairman Blunt, Ranking Member Murray, and Members of the 
Committee, on behalf of the National Head Start Association (NHSA), 
thank you for the opportunity to submit written testimony regarding 
funding for Head Start and Early Head Start in fiscal year 2017. For 
more than 50 years, Head Start has created opportunities for 
disadvantaged children and families to succeed by providing the highest 
quality early childhood education, including health, nutrition, parent 
engagement, family support and child development services. NHSA is 
grateful for the Subcommittee's tradition of strong bipartisan support 
for early childhood education. In fiscal year 2017, NHSA respectfully 
requests the Subcommittee allocate $9,601,724,000 for Head Start and 
Early Head Start. This amount is in line with the President's fiscal 
year 2017 request and represents a $434,000,000 increase over fiscal 
year 2016 enacted levels.
    Head Start and Early Head Start directors nationwide remain 
appreciative of your leadership in preventing the return of 
sequestration in fiscal years 2016 and 2017, as well as providing a 
significant increase in funding for Head Start in fiscal year 2016. The 
fiscal year 2016 funds will expand infant-toddler access, strengthen 
quality through increased duration of services, and help enable Head 
Start programs to keep pace with rapidly rising operating costs. They 
will also allow the Head Start field to prepare for and begin 
implementation of new Head Start Program Performance Standards, which 
the Administration proposed in June 2015 and are expected to be made 
final in 2016. The entire Head Start field sincerely appreciates the 
additional investment and commitment Congress continues to make in our 
Nation's future by supporting youth and families in our most 
underserved communities.
    NHSA recognizes the restrictions and challenges of the fiscal year 
2017 budget and the top-line discretionary spending limits. However, as 
we strongly believe in continuous quality improvement and are intent on 
implementing new Head Start Program Performance Standards with minimal 
impact to the number of children and families served nationwide, we 
strongly encourage you to consider the funding needs and priorities 
necessary to strengthen and grow Head Start, as identified by the Head 
Start community. An investment of $9.6 billion will allow Head Start 
centers to continue services to the nearly one million children and 
their families from birth through age five currently enrolled in Head 
Start and Early Head Start, as well as continue to strengthen quality 
through the expanded duration of services, improved teacher retention, 
and direct quality improvement funds as identified in the 2007 Head 
Start Act.
    NHSA urges the Subcommittee to continue to build on last year's 
investments. Should the Committee have the flexibility to invest in 
Head Start programs above the fiscal year 2016 enacted level, we offer 
the following prioritized funding recommendations:
    Supporting Quality Workforce Retention: Within the sum provided, 
NHSA recommends $141,629,000 be allocated for Workforce Investments 
through a cost-of-living adjustment. Nearly every Head Start provider 
struggles to retain quality staff due to non-competitive salaries. 
Furthermore, high staff turnover rates directly impact quality of 
services to young children. Investing in workforce quality is the most 
important and pressing need for programs across the country. Recent 
Program Information Report (PIR) data strongly suggest that when Head 
Start grantees receive a Workforce Investment, there is less teacher 
turnover. For example, in the 2008-2009 school year, when there was not 
a Workforce Investment 26.5 percent of teachers who left Head Start 
cited salary as the main reason for their departure. The next 2 years, 
when Congress made a significant Workforce Investment through the 
Recovery Act and annual appropriations, that number dropped to 20.9 
percent in 2009-2010 and 19.3 percent in 2010-2011. The next year, 
2011-2012, turnover increased back to 26.2 percent when there was not a 
Workforce Investment. Teacher turnover has a direct impact on the 
quality and stability of programs and we strongly encourage Congress to 
do everything possible to help mitigate this growing concern.\1\
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services. (2015, November). 
2008-2015 Head Start Program Information Reports.
---------------------------------------------------------------------------
    Supporting Duration Expansion: Within the overall sum, NHSA 
recommends $292,000,000 be allocated for flexible Quality Improvement 
funding (QIF), without restrictions, to support the preparation and 
implementation of the new Head Start Performance Standards. Authorized 
in the 2007 Head Start Act, QIF may be used for increasing duration of 
instruction time, staff training, improving community-wide planning and 
classroom environments, strengthening transportation safety, and 
increasing hours of program operation. The QIF offers local centers 
flexibility to prepare their communities for duration expansion and 
other policies to strengthen quality as part of the new standards.
    NHSA largely concurs with the goals outlined in the proposed 
standards of ensuring continuous quality improvement, strengthening 
evidence-based practices, and expanding duration of Head Start 
programming. However, not every Head Start center and community is 
ready to immediately expand their programs--some centers require 
additional community-wide planning, classroom improvements, and safer 
transportation systems before they can increase the hours of services. 
By allocating funding through the Quality Improvement Fund, Congress 
will allow those Head Start centers who are fully prepared to expand 
services immediately, while also providing sufficient flexibility to 
assist those centers that require additional preparation before they 
can expand with quality. An increase in the Quality Improvement Fund 
will ensure that duration expansion does not come at the expense of the 
number of children and families served.
    Head Start Returns the Public's Investment: Given the constrained 
fiscal environment in fiscal year 2017, NHSA recognizes the need to 
prioritize programs with demonstrable returns on the investment in 
public dollars. Studies have proven that for every one dollar invested 
in a Head Start child, society earns at least seven dollars back 
through increased earnings, employment, and family stability; \2\ as 
well as decreased welfare dependency, \3\ healthcare costs,\4\ crime 
costs,\5\ grade retention,\6\ and special education.\7\ The latest 
science in brain development shows that the ages of zero to five are 
the most critical in a child's life. Head Start and Early Head Start 
ensure that children from the most disadvantaged communities receive 
the nurturing, engaging, and healthy education necessary for an equal 
opportunity to succeed later in life. In 2014-2015, there were 
4,770,452 children in poverty under age five.\8\ Of those, only 41 
percent of three and 4 year olds had access to Head Start. And only 4 
percent of children under age three had access to Early Head Start. 
Investments in Head Start are investments in the success of our 
Nation's future generations and, while we have made significant strides 
the past several years, we could do more.
---------------------------------------------------------------------------
    \2\ Benefits and Costs of Head Start. Social Policy Report. 21 (3: 
4); Deming, D. (2009). Early childhood intervention and life-cycle 
skill development: Evidence from Head Start. American Economic Journal: 
Applied Economics, 1(3): 111-134; Meier, J. (2003, June 20). Interim 
Report. Kindergarten Readiness Study: Head Start Success. Preschool 
Service Department, San Bernardino County, California; Deming, D. 
(2009, July). Early childhood intervention and life-cycle skill 
development: Evidence from Head Start, p. 112.
    \3\ Meier, J. (2003, June 20). Kindergarten Readiness Study: Head 
Start Success. Interim Report. Preschool Services Department of San 
Bernardino County.
    \4\ Friswold, D. (2006, February). Head Start participation and 
childhood obesity. Vanderbilt University Working Paper No. 06-WG01; 
Currie, J. and Thomas, D. (1995, June). Does Head Start Make a 
Difference? The American Economic Review, 85 (3): 360; Anderson, K.H., 
Foster, J.E., & Frisvold, D.E. (2009). Investing in health: The long-
term impact of Head Start on smoking. Economic Inquiry, 48 (3), 587-
602.
    \5\ Americans too high: Pew study; Garces, E., Thomas, D. and 
Currie, J. (2002, September). Longer-term effects of Head Start. 
American Economic Review, 92 (4): 999-1012.
    \6\ Over Head Start: What the Research Shows.; Garces, E., Thomas, 
D. and Currie, J. (2002, September). Longer-Term Effects of Head Start. 
American Economic Review, 92 (4): 999-1012.
    \7\ NHSA Public Policy and Research Department analysis of data 
from a Montgomery County Public Schools evaluation. See Zhao, H. & 
Modarresi, S. (2010, April). Evaluating lasting effects of full-day 
prekindergarten program on school readiness, academic performance, and 
special education services. Office of Shared Accountability, Montgomery 
County Public Schools.
    \8\ Kids Count Data Book. (2015). Children in poverty by age group. 
The Annie E. Casey Foundation. Retrieved from http://
datacenter.kidscount.org/data.
---------------------------------------------------------------------------
    Again, the Head Start community understands the pressure the 
Subcommittee faces in fiscal year 2017 and we are grateful for the 
commitment shown by Congress and the President to keep early learning, 
and Head Start in particular, a priority. We urge the Subcommittee to 
build on investments to Head Start and Early Head Start in fiscal year 
2017 in order to increase workforce retention, provide continuous 
quality improvement, and expand duration or services. Thank you for 
your time and consideration.

    [This statement was submitted by Yasmina Vinci, Executive Director, 
National Head Start Association.]
                                 ______
                                 
  Prepared Statement of the National Indian Child Welfare Association
    The National Indian Child Welfare Association (NICWA), located in 
Portland, Oregon, has over 35 years of experience advocating on behalf 
of American Indian and Alaska Native (AI/AN) children in child welfare 
and children's mental health systems. Thank you for the opportunity to 
provide fiscal year 2017 budget recommendations for child welfare and 
children's mental health programs administered by the Department of 
Health and Human Services (DHHS). Our recommendations and priorities 
are listed below.
                     child welfare recommendations
    A recent report from the Attorney General's Advisory Committee on 
American Indian/Alaska Native Children Exposed to Violence provided the 
following recommendation:
    Congress and the executive branch shall direct sufficient funds to 
        AI/AN Tribes to bring funding for tribal criminal and civil 
        justice systems and tribal protection systems into parity with 
        the rest of the United States (U. S. Department of Justice 
        [USDOJ], 2014, p. 51).
    Tribes, like States, rely on the Federal Government for the 
majority of their child welfare funding. Child safety and family 
stability are Tribal Governments' highest priorities, yet their 
programs remain drastically underfunded by the Federal Government. This 
underfunding has contributed to the increased risk for child 
maltreatment of AI/AN children and has stymied efforts to heal victims 
of child maltreatment and rehabilitate their families. Congress must 
prioritize the safety and well-being of these children and families in 
the budget process. NICWA provides the following recommendations:

----------------------------------------------------------------------------------------------------------------
                                                                     Fiscal year 2016        Fiscal year 2017
      Agency                          Program                            enacted              recommendation
----------------------------------------------------------------------------------------------------------------
         DHHS       Promoting Safe and Stable Families-Disc.                 $59.7m                   $79.7m
            ACF/CB                                (tribal)                  ($1.8m)        ($21.8m with $20m
                                                                                          tribal capacity funds)
rrrrrrrrrrrrrrrrrrr
         DHHS                                             Child Abuse Discret$33.0m Activities        $43.7m
            ACF/CB                                (tribal)                (unknown)                (unknown)
rrrrrrrrrrrrrrrrrrr
         DHHS                                             Community-Based Chi$39.7mse Prevention        $50m
            ACF/CB                                (tribal)                  ($416k)                  ($500k)
rrrrrrrrrrrrrrrrrrr
         DHHS                                             Child Welfare Serv$268.7m                    $280m
            ACF/CB                                (tribal)                  ($6.3m)                 ($7.1m)
rrrrrrrrrrrrrrrrrrr
         DHHS                         Payments for Foster Care and $0.0m for tribal          $37m for tribal
            ACF/CB                                                   start-up funds               Title IV-E
                                                                                              start-up funds
rrrrrrrrrrrrrrrrrrr
         DHHS                     Maternal Infant & Early Childhood Home      $400m                    $400m
         HRSA                    Visiting Program (tribal)                   ($12m)                   ($12m)
----------------------------------------------------------------------------------------------------------------

                        priority recommendations
Payments for Foster Care and Permanency
DHHS, Administration for Children and Families

    Budget Recommendation.--Increase this program's funding by $37 
million to specifically support tribal Title IV-E program start-up for 
Tribes with approved Title IV-E plans.
    The Fostering Connections to Success and Increasing Adoptions Act 
(Public Law 110-351) provided Tribal Governments with historic new 
opportunities to access foster care and permanency funding and 
technical assistance under the Title IV-E program--an area of child 
welfare services where Tribes are woefully underfunded.
    As described in a recent GAO report (2015), more Tribes are not 
running Title IV-E programs because Title IV-E does not provide the 
funding or support needed by many Tribes to actually begin 
implementation of the program. Essential to Title IV-E implementation 
is the ability to provide a substantial non-Federal match and support 
initial caregiver payments and program costs with tribal funds. Yet, 
Tribes interested in operating Title IV-E do not have the same access 
to general revenue as States. Also essential to Title IV-E 
implementation is the staffing and infrastructure necessary to support 
expanded services, additional requirements, and new accounting systems. 
Tribes--who have been chronically underfunded and only reassumed 
control over their child welfare services in 1978--do not have the same 
child welfare infrastructure or capacity as States.
    The President's fiscal year 2017 budget requests an increase of $37 
million to the Payments for Adoption and Permanency Program to allow 
for Tribes that have approved Title IV-E plans to apply for start-up 
funding. For Tribes to successfully access Title IV-E and children to 
have safe and supported foster homes this program must be funded.
Promoting Safe and Stable Families (Social Security Act Title IV-B, 
        Subpart 2)
DHHS, Administration for Children and Families

    Budget Recommendation.--Increase discretionary funding in this 
program to $89.75 million to support the President's $20 million 
initiative to increase tribal capacity and rural child welfare.
    The Promoting Safe and Stable Families Program (PSSF) provides 
funds to Tribes for coordinated child welfare services that include 
family preservation, family support, family reunification, and adoption 
support services. There is a 3 percent set-aside for Tribes based on a 
formula, however if a Tribe would qualify for less than $10,000 then it 
is not eligible to receive any funding under this program. This means 
that many Tribes, typically those Tribes with the most need, cannot 
access PSSF funding because the overall appropriation is currently too 
low and affects the individual tribal allocation. This means that 
Tribes are providing intensive family preservation and family 
reunification services in spite of inadequate funding and insufficient 
staffing. This puts incredible strain on individual workers and 
programs. This strain stands in the way of Tribes' ability to build 
capacity, expand programs, coordinate services with States, and help 
reduce disproportionate placement of AI/AN children in both State and 
tribal foster care systems.
    The President's fiscal year 2017 budget includes a $20 million 
increase to PSSF discretionary funds for a tribal child welfare 
capacity building initiative. This initiative would provide Tribes with 
the resources necessary to support the staff time, infrastructure, and 
development of child welfare departments and services, as well as 
assist States in reducing foster care rates of AI/AN children in their 
systems. NICWA recommends that this initiative be funded.
                        children's mental health
    The Attorney General's Advisory Committee on American Indian/Alaska 
Native Children Exposed to Violence provided the following 
recommendation:
    The Secretary of Health and Human Services should increase and 
        support access to culturally appropriate behavioral health 
        services in all AI/AN communities (USDOJ, 2014, p. 88).
    In order to effectively serve AI/AN children and communities, 
funding must provide flexible opportunities that allow Tribes to 
integrate culturally appropriate comprehensive mental and behavioral 
health services. NICWA provides the following recommendations:

----------------------------------------------------------------------------------------------------------------
                                                                     Fiscal year 2016        Fiscal year 2017
      Agency                          Program                            enacted              recommendation
----------------------------------------------------------------------------------------------------------------
         DHHS            Programs of Regional and National                    $6.4m                    $8.5m
                                            Significance--
SAMHSA                                                    Children and Family Pro  ams    (Reserve $6.5m for
                                                (includes Circles of Care)                                  Circles of Care)
rrrrrrrrrrrrrrrrrrr
         DHHS                                             Children's Mental He$117mServices Program--  $117m
       SAMHSA                                  Systems of Care
rrrrrrrrrrrrrrrrrrr
         DHHS       GLS State/Tribal Youth Suicide Prevention                $35.4m                   $40.5m
       SAMHSA
rrrrrrrrrrrrrrrrrrr
         DHHS                                         GLS Campus Suicide Preve$6.5m Program            $9.1m
       SAMHSA
rrrrrrrrrrrrrrrrrrr
         DHHS                     AI/AN Suicide Prevention                    $2.9m                    $3.2m
       SAMHSA
rrrrrrrrrrrrrrrrrrr
         DHHS               Tribal Behavioral Health Grant                     $30m                     $50m
       SAMHSA       (divided equally between substance abuse
                    prevention and mental health services)
rrrrrrrrrrrrrrrrrrr
         DHHS                                 Project LAUNCH                 $34.5m                   $34.5m
       SAMHSA
----------------------------------------------------------------------------------------------------------------

                        priority recommendations
Tribal Behavioral Health Program
DHHS, Substance Abuse Mental Health Services Administration

    Budget Recommendation.--Increase funding of this program to $50 
million to make this funding available across Indian Country.
    The Consolidated Appropriations Act of 2015 recommended that $5 
million be allocated to Tribal Behavioral Health Grants in the form of 
the Native Connections grant program appropriating this funding for the 
first time. These are competitive grants designed to target tribal 
entities with the highest rates of suicide per capita over the last 10 
years. These funds must be used for effective and promising strategies 
to address the problems of substance abuse and suicide, and to promote 
mental health and well-being among AI/AN young people.
    As originally conceptualized, the fiscal year 2012 budget request 
sought $50 million for a new Behavioral Health-Tribal Prevention Grant. 
Approximately half of the funding was to be allocated as a ``base 
level'' to federally recognized Tribes that applied for these funds. 
Originally, the base amount that each Tribe would be eligible for was 
at least $50,000. As eventually passed by Congress in the 2015 budget, 
funding for what is now known as the Native Connections grant program, 
focuses more specifically on youth and, due to the level of funding, 
are competitive grants available to approximately 20 Tribes. The 
President's fiscal year 2017 budget request includes a $20 million 
increase, $10 million additional dollars in the Mental Health Services 
appropriations, and $10 million new dollars in the Substance Abuse 
appropriations. This additional funding is still not enough to provide 
the program with adequate support to fulfill its initial 
conceptualization. To make it available across Indian Country NICWA 
recommends this program be funded at $50 million, as suggested by the 
initial conceptualization of the program.
    If you have any questions about this testimony please contact NICWA 
Government Affairs Director David Simmons at desimmons@nicwa.org.
References:
    U. S. Department of Justice, Office of Justice Programs, Office of 
Juvenile Justice and Delinquency Prevention. (2014). Attorney General's 
Advisory Committee on American Indian/Alaska Native Children Exposed to 
Violence: Ending violence so children can thrive. Retrieved from http:/
/www.justice.gov/sites/default/files/defendingchildhood/pages/
attachments/2014/11/18/finalaianreport.pdf.
                                 ______
                                 
         Prepared Statement of the National Indian Health Board
    Chairman Blunt, Ranking Murray and Members of the Subcommittee, 
thank you for the opportunity to offer this testimony for the record. 
On behalf of the National Indian Health Board (NIHB) and the 567 
federally recognized Tribes we serve, I submit this testimony on fiscal 
year 2017 budget for the Department of Health and Human Services (HHS).
    The Federal promise to provide Indian health services was made long 
ago. Since the earliest days of the Republic, all branches of the 
Federal Government have acknowledged the Nation's obligations to the 
Tribes and the special trust relationship between the United States and 
Tribes. The United States assumed this responsibility through a series 
of treaties with Tribes, exchanging compensation and benefits for 
Tribal land and peace.\1\ In 2010, as part of the Indian Health Care 
Improvement Act, Congress reaffirmed the duty of the Federal Government 
to American Indians and Alaska Natives (AI/ANs).
---------------------------------------------------------------------------
    \1\ The Snyder Act of 1921 (25 U.S.C. 13) legislatively affirmed 
this trust responsibility.
---------------------------------------------------------------------------
    Devastating consequences from historical trauma, poverty, and a 
lack of adequate treatment resources continue to plague Tribal 
communities. AI/ANs have a life expectancy 4.2 years less than other 
Americans, but in some areas, the life expectancy is far worse. For 
instance, in Montana, ``white men . . . lived 19 years longer than 
American Indian men, and white women lived 20 years longer than 
American Indian women.'' \2\ In South Dakota, in 2014, ``for white 
residents the median age [at death] was 81, compared to 58 for American 
Indians.'' \3\ These statistics reflect the shocking disparity that 
exists in per capita spending of the Indian Health Service (IHS) and 
other Federal healthcare programs. In 2015, the IHS per capita 
expenditures for patient health services were just $3,136, compared to 
$8,097 per person for healthcare spending nationally.
---------------------------------------------------------------------------
    \2\ ``The State of the State's Health: A Report on the Health of 
Montanans.'' Montana Department of Public Health and Human Services. 
2013. p. 11.
    \3\ ``2014 South Dakota Vital Statistics Report: A State and County 
Comparison of Leading Health Indicators.'' South Dakota Department of 
Health. 2014. P. 62.
---------------------------------------------------------------------------
    The obligation to provide healthcare to AI/ANs does not extend only 
to the IHS. The Federal trust responsibility is the responsibility of 
all government agencies, including others within HHS. Agencies like the 
Centers for Disease Control and Prevention (CDC); Substance Abuse and 
Mental Health Services Administration (SAMHSA); and Centers for 
Medicare and Medicaid Services (CMS) all must play a crucial role in 
ensuring that Indian Country receives both preventative and direct 
access to health services. Tribes may be eligible to apply for Federal 
grants that address public health and other issues, however, many of 
these programs have little penetration into Indian Country because 
Tribes have difficulty meeting the service population requirements, 
match requirements, or are under resourced to even competitively apply 
for the grants. Unlike State health departments which employ teams of 
people to write grants, few Tribes have enough staff to conduct basic 
programming, let alone work on competitive grant applications.
    NIHB respectfully requests that the committee consider providing 
additional direct funding to Tribal communities through the use of 
``set asides'' for Indian Country to ensure that Indian Country is not 
left out of Federal funding opportunities. Without direct funding, 
Tribes are unable to develop sustainable infrastructure for public 
health and behavioral health programs, leading to an inconsistent and 
unreliable service delivery system.
               centers for disease control and prevention
    Public Health Services Block Grant.--Public health infrastructure 
in Indian Country is one of the most severely underfunded and under 
developed areas of the health service delivery system. IHS services are 
largely limited to direct patient care, leaving little, if any, funding 
available for public health initiatives. Our communities are therefore 
more vulnerable to increased health risks and sickness. As independent, 
sovereign nations, Tribal Governments do not operate within the State 
regulatory structure, and often must compete with their own State 
Governments for resources. Tribes are regularly left out of statewide 
public health plans and Federal funding decisions for public health 
programs. A complex public health system exists in the U.S. that 
includes a funding stream between the Federal and State Governments 
that largely support the national public health infrastructure--Tribes 
were excluded from this system. Tribes do not receive the Federal 
funding that allows State health departments to function. It is time to 
examine how Tribes can be integrated into the U.S. public health 
system, and redress this wrong.
    Tribal communities must cobble together public health funding from 
a variety of Federal, State, local and private funding sources. State 
Governments receive base operational systems and programmatic funding 
through the large flagship Federal grants and the Public Health and 
Health Services Block (PHHS) grant program, while Tribes are either not 
eligible to compete for the funding or are woefully underrepresented in 
the grantee pool. This leads to rampant unpredictability and 
inconsistency among Tribal public health initiatives. Consequently, 
significant gaps exist when it comes to health education, emergency 
preparedness, community healthcare services and basic healthcare 
screenings. Therefore, NIHB requests that, in fiscal year 2017, 
Congress create base funding for Tribal communities through the PHHS 
grant program by allocating at least 5 percent to Indian Tribes 
directly. This will enable public health systems in Indian Country to 
access consistent, sustainable, public health infrastructure dollars so 
that Tribal communities can begin to catch up to other Americans when 
it comes to public health.
    Hepatitis C Treatment in Indian Country.--According to the CDC's 
most recent surveillance report on hepatitis C, in 2013, AI/ANs were 
the population with the highest hepatitis C-related mortality rate at 
12.2 deaths per 100,000 people. This is 46 percent higher than the next 
highest population death rate. And between 2009 and 2013, the hepatitis 
C-related mortality rate among American Indians and Alaska Natives 
increased by 23.2 percent. The hepatitis C (HCV) scourge among AI/AN 
communities continues to grow out of control with no substantial 
dedication of resources or commitment by HHS to provide for targeted 
prevention, capacity building, and treatment. Treatment, that very 
nearly mirrors a cure, is readily available; however, community members 
may not be sure how to access the treatments, and Tribes have competing 
priorities and are reticent to utilize scarce IHS resources to secure 
the treatment. Even more so, prevention efforts to promote HCV 
screening have not been bolstered in Tribal communities, service 
providers have not been trained to talk to their patients about 
hepatitis risks and testing options, nor have efforts existed to 
educate the community and high risk populations about their ability to 
minimize their risks for exposure to HCV.
    Therefore, NIHB recommends that Congress direct the CDC to create a 
grant program specifically for AI/ANs that will provide monies for 
community-based prevention and screening efforts for HCV. Furthermore, 
we request that CDC be instructed to work with IHS to construct a 
targeted action plan for promoting the prevention of hepatitis C, 
increasing screening efforts and increasing access to treatment.
    Public Health Emergency Preparedness.--The Public Health Emergency 
Preparedness (PHEP) Cooperative Agreements at CDC provide base funding 
to States, territories and major cities to upgrade their ability to 
respond to a public health crises. But again, Tribal communities do not 
receive this funding directly, see little support from their State 
programs. Without federally-supported infrastructure support for 
prevention and rapid response to natural disasters, bioterrorism and 
outbreaks in Indian Country, the impacts on American Indians and Alaska 
Natives (and others) could be enormous. And with the looming threat of 
the Zika Virus, this is even more urgent--as a significant percentage 
of Tribes occupy those lands projected to be in danger due to the 
habitat of the mosquito that transmits the virus. Failure to fund 
Tribal communities and reservations could mean that large land areas of 
this country are not covered for emergency infrastructure support, 
causing a domino effect throughout the rest of the Nation when it comes 
to disease outbreaks or natural disasters. NIHB requests that Congress 
direct 5 percent of PHEP funds to Tribes so that they can develop 
serious and achievable response plans for public health crises.
       substance abuse and mental health services administration
    Nowhere is the issue of lack of solid infrastructure support more 
acute than mental and behavioral health services. AI/AN children and 
communities grapple with complex behavioral health issues at higher 
rates than any other population. Destructive Federal Indian policies 
and unresponsive or harmful human service systems have left AI/AN 
communities with unresolved historical and generational trauma.\4\ But 
access to behavioral health services is limited. In a study of 514 IHS 
and Tribal facilities, 82 percent report providing some type of mental 
health service such as psychiatric services, behavioral health 
services, substance abuse treatment, or traditional healing practices, 
and to improve access 17 percent (87) have implemented telemedicine for 
mental health services.\5\ However, none provide inpatient psychiatric 
services.\6\ Without access to care, persons in psychiatric distress 
often end up at the hospital emergency room.\7\
---------------------------------------------------------------------------
    \4\ Braveheart, M. Y. A., & DeBruyn, I. M. (1998). The American 
Indian Holocaust: healing historical unresolved grief. American Indian 
and Alaska Native Mental Health Research, 8(2).
    \5\ Urban Indian Health Institute. (2012). Addressing depression 
among American Indians and Alaska Natives: A literature review. 
Seattle, WA: Urban Indian Health Institute.
    \6\ Indian Health Service. (2011). Inpatient mental health 
assessment. Retrieved from http://www.ihs.gov/newsroom/includes/themes/
newihstheme/display_objects/documents/
FINAL_IHCIA_InpatientMH_Assessment_Final.pdf.
    \7\ Ibid.
---------------------------------------------------------------------------
    Tribal Behavioral Health Grants and Zero Suicide.--At the Substance 
Abuse and Mental Health Services Administration, several programs 
specifically target Tribal communities. NIHB was pleased to see that 
Tribal Behavioral Health Grants (TBHG) received a substantive increase 
in the final fiscal year 2016 appropriation. This critical program is 
designed to address the high incidence of substance use and suicide 
among AI/AN populations and it is a vital component of ensuring that 
behavioral health challenges are addressed across Indian Country. In 
fiscal year 2017, NIHB requests funding of $50 million for the TBHG 
program. NIHB also supports the Administration's fiscal year 2017 
request for $5.2 million in a Tribal set-aside to implement the Zero 
Suicide Initiative.
    Circles of Care.--NIHB continues to support the Circles of Care 
Program which offers 3-year infrastructure/planning grants and seeks to 
eliminate mental health disparities by providing AI/AN communities with 
tools and resources to design and sustain their own culturally 
competent system of care approach for children. Behavioral health 
infrastructure is one of the key challenges for many Tribal communities 
when it comes to creating sustainable change for their communities. 
Circles of Care represents a critical part of this work. In fiscal year 
2017, we recommend increasing Circles of Care funding by $2 million for 
a program total of $8.5 million.
               centers for medicare and medicaid services
    Definition of Indian in the Affordable Care Act.--The Affordable 
Care Act (ACA) (PL 111-148) contains several important provisions for 
American Indians and Alaska Natives including permanent reauthorization 
of the Indian Health Care Improvement Act. However, certain portions of 
healthcare reform contain different definitions of ``Indian'' which led 
to conflicting interpretations of eligibility for benefits and 
requirements for coverage. These definitions are different than those 
used by IHS and the Centers for Medicare and Medicaid Services and 
require that an individual be a member of a federally recognized Tribe. 
NIHB requests a legislative fix to streamline these definitions. 
Specifically, we request that Congress insert the text of S. 2114 into 
the fiscal year 2017 Labor, HHS, Education and Related Agencies 
Appropriations bill. Despite efforts by Congress to provide 
instructions to the agency in fiscal year 2016, the Administration has 
refused to correct this inconsistency through regulation. This fix will 
not change who is eligible to receive IHS services, but will ensure 
that the benefits and protections in the law are provided to those for 
whom they were intended. Without a fix, the Federal Government will 
essentially create class of ``sometimes Indians'' who are eligible for 
some benefits (e.g. IHS) but not others (those in the ACA). This fix is 
also supported in the fiscal year 2017 President's Budget request to 
Congress.
    American Indian/Alaska Native Call Center for the Health Insurance 
Marketplace.--AI/ANs continue to experience poor assistance when 
contacting the marketplace call center for help. Issues range from 
technicians having no knowledge of the Indian-specific protections like 
exemptions and tax credits, to technicians being rude and having no 
patience to walk elderly consumers through the troubleshooting process. 
Because AI/AN consumers continue to receive such poor customer service 
that exhibit little or no knowledge about AI/AN-specific provisions in 
the ACA, NIHB has requested that the Center for Consumer Information 
and Insurance Oversight establish an Indian-specific call center to 
respond to questions and provide technical assistance to AI/ANs. NIHB 
recommends that Congress provide funding, as detailed in the 
President's Request, for the Tribal Resource Center at the Center for 
Medicare and Medicaid Services at $500,000 as requested by CMS.
                               conclusion
    Thank you again for the opportunity to offer this written 
statement. As noted above, the Federal trust responsibility for health 
extends beyond the IHS to all agencies of the Federal Government. While 
Tribes have made important gains in recent years in terms of funding, 
consultation and increased awareness throughout all of HHS, there is 
still a long way to go before health systems in Indian Country are on 
par with those enjoyed by other Americans.

    [This statement was submitted by Lester Secatero, Chairman, 
National Indian Health Board.]
                                 ______
                                 
          Prepared Statement of the National Kidney Foundation
    The National Kidney Foundation (NKF) is America's largest and 
oldest health organization dedicated to the awareness, prevention and 
treatment of kidney disease for hundreds of thousands of healthcare 
professionals, millions of patients and their families, and tens of 
millions of people at risk. NKF works with volunteers to offer the 
scientific, clinical and kidney patient perspective on what needs to be 
done to prevent kidney disease, delay progression, and better treat 
kidney disease and kidney failure. In addition, NKF has provided 
evidence-based clinical practice guidelines for all stages of chronic 
kidney disease (CKD), including transplantation since 1997 through the 
NKF Kidney Disease Outcomes Quality Initiative (NKF KDOQI). NKF has 
local division and affiliate offices serving our constituents in all 50 
States.
    NKF is pleased to submit testimony regarding the impact of Chronic 
Kidney Disease (CKD), and steps that can be taken by Congress to build 
upon the success of the existing programs at the National Institutes of 
Health, Centers for Disease Control, and Health Resources and Services 
Administration to improve early detection and treatment of the disease.
                               about ckd
    Chronic Kidney Disease (CKD) is a condition characterized by a 
gradual loss of kidney function over time. CKD impacts 26 million 
American adults, while 1 in 3 (73 million) American adults are at risk 
for kidney disease. Diabetes and high blood pressure are responsible 
for up to two-thirds of all cases of irreversible kidney failure (end 
stage renal disease). Kidney disease can be detected through a simple 
urine test, yet the disease can go undetected until very advanced 
because kidney disease often has no symptoms. When kidney disease 
progresses, it may lead to kidney failure, which requires dialysis or a 
kidney transplant to maintain life. Rates of kidney failure are higher 
among minorities, with African Americans developing ESRD at a rate of 3 
to 1 compared to Whites and Hispanic Americans developing it at a rate 
of 2 to 1.
                the importance of early detection of ckd
    Only 10 percent of individuals with CKD are aware they have it.\1\ 
CKD is often asymptomatic--especially in the early stages--and 
therefore goes undetected without laboratory testing. Some people are 
not diagnosed until they have reached end-stage renal disease (ESRD) 
and must begin dialysis immediately.
---------------------------------------------------------------------------
    \1\ Tuot DS, Plantinga LC, Hsu CY, et al. Chronic kidney disease 
awareness among individuals with clinical markers of kidney 
dysfunction. Clin J Am Soc Nephrol. Aug 2011;6(8):1838-1844.
---------------------------------------------------------------------------
    At the end of 2014, 661,648 Americans had End Stage Renal Disease 
(ESRD), including 468,386 dialysis patients and 193,262 kidney 
transplant recipients. Complicating the cost and human toll is the fact 
that it is a disease multiplier, with patients very likely to be 
diagnosed with cardiovascular disease. ESRD was present in less than 2 
percent of Medicare beneficiaries but responsible for nearly 6 percent 
of Medicare expenditures.
    Cost-effective early identification and treatment options exist 
which can slow the progression of kidney disease, delay complications, 
and prevent or delay kidney failure. Intervention at the earliest stage 
is vital to improving outcomes, lowering healthcare costs, and 
improving patient experience, yet in a recent clinical study only 12 
percent of primary care clinicians were properly detecting CKD in their 
patients with diabetes who are at the highest risk of kidney 
disease.\2\ There often is a misconception that once someone is 
diagnosed with CKD, there must be a referral to a nephrologist. 
However, it is not necessary in most instances for referral to a 
nephrologist in early stages.
---------------------------------------------------------------------------
    \2\ Szczech LA, et al. Primary Care Detection of Chronic Kidney 
Disease in Adults with Type-2 Diabetes: The ADD-CKD Study (Awareness, 
Detection and Drug Therapy in Type 2 Diabetes and Chronic Kidney 
Disease), PLOS One November 26, 2014.
---------------------------------------------------------------------------
                      the ckd intercept initiative
    NKF is moving forward on an initiative we announced 2 years ago to 
help improve early detection and diagnosis of CKD by primary care 
practitioners (PCP). Our CKD Intercept initiative aims to transform PCP 
detection and care of the growing numbers of Americans with CKD by 
deploying evidence based clinical guidelines into primary care settings 
through education programs, symposia and practical implementation 
tools.
    In support of this effort, NKF is advocating for Congress to enact 
legislation to remove the reimbursement barriers to earlier, better CKD 
care management by directing the Secretary of Health and Human Services 
to create a Medicare bundled payment demonstration for CKD management 
to primary care practitioners and nephrologists. Given the high costs 
and comorbidities associated with late diagnosis of CKD, this 
demonstration is expected to improve patient outcomes, lower 
hospitalizations and result in savings to Medicare. NKF commissioned a 
study to develop a cost estimate model on improving earlier detection 
and management of CKD. Through early intervention, Medicare could 
reduce spending by $4.8 billion in year 10 and $8.2 billion in year 20, 
for a total reduction in spending of $93 billion over 20 years.
    While progression of CKD can lead to ESRD, CKD patients are at a 
greater risk of death, cardiovascular events and adverse drug events. 
In a most recent study conducted by The Johns Hopkins University, 
testing for kidney disease--in those with the disease--may be a 
stronger risk predictor of heart attack and stroke than tobacco use, 
blood pressure, or high cholesterol.\3\ Testing for kidney disease in 
at-risk populations provides the opportunity for interventions to 
foster awareness, foster adherence to medications and control risk 
factors. Therefore, NKF's initiatives address three priorities in the 
National Strategy for Quality Improvement in Health Care, including (1) 
making care safer by reducing harm caused in the delivery of care, (2) 
promoting the most effective prevention and treatment of the leading 
causes of mortality, starting with cardiovascular disease, and (3) 
working with communities to promote widespread use of best practices to 
enable healthy living.
---------------------------------------------------------------------------
    \3\ Matsushita, Kunihiro, Estimated glomerular filtration rate and 
albuminuria for prediction of cardiovascular outcomes: a collaborative 
meta-analysis of individual participant data, Lancet Diabetes 
Endocrinol. Published online May 29, 2015, http://dx.doi.org/10.1016/
S2213-8587(15)00040-6.
---------------------------------------------------------------------------
    With the continued support of Congress, NKF is confident a feasible 
detection, surveillance and treatment program can be advanced to as a 
first step to slow the progression of kidney disease. These initiatives 
will help build on the CDC's investment in the Chronic Kidney Disease 
Program.
                   cdc chronic kidney disease program
    NKF urges the Committee to provide $2.31 million for the CKD 
program for fiscal year 2017, an increase of $200,000. Prior to the 
creation of the Chronic Kidney Disease Program at CDC in fiscal year 
2006, no national public health program focusing on early detection and 
treatment of CKD existed. The CDC CKD program has consisted of three 
projects to promote kidney health by identifying and controlling risk 
factors, raising awareness, and promoting early diagnosis and improved 
outcomes and quality of life for those living with CKD. These projects 
include (1) demonstrating approaches for identifying individuals at 
high risk for CKD through state-based screening; (2) conducting an 
economic analysis on the economic burden of CKD and the cost-
effectiveness of interventions; and (3) establishing a surveillance 
system for CKD by analyzing and interpreting information to assist in 
prevention and health promotion efforts for kidney disease. The 
surveillance project includes a CDC website program containing 
information on risk factors, early diagnosis, and strategies to improve 
outcomes.
    As a result of consistent congressional support, the National 
Center for Chronic Disease Prevention and Health Promotion at CDC has 
instituted a series of projects that could assist in attaining the 
Healthy People 2020 objectives. However, increasing the proportion of 
persons with CKD who know they are affected requires acquiring 
additional data sources beyond Medicare claims and NHANES survey 
analyses to identify the undiagnosed population and assess the burden 
of CKD across the country to better understand the CKD impact at a 
State and local level. This momentum will be stifled and CDC's 
investment in CKD to date jeopardized if line-item funding is not 
increased.
    A study published by researchers leading the program shows that the 
burden of kidney disease is increasing and that over half of U.S. 
adults age 30-64 are likely to develop CKD.\4\ Congressional support 
for an increase in funding to the CDC program will benefit kidney 
patients and those at risk for kidney disease, advance the objectives 
of Healthy People 2020 and the National Strategy for Quality 
Improvement in Health Care, and fulfill the mandate created by Sec. 152 
of the Medicare Improvement for Patients and Providers Act. Agency 
priorities going forward include assessing disparities among racial and 
socioeconomic populations and adding new and local data on CKD 
including additional risk factors.
---------------------------------------------------------------------------
    \4\ Hoeger, Thomas, et al. The Future Burden of CKD in the United 
States: A Simulation Model for the CDC CKD Initiative, Am J Kidney Dis. 
2015;65(3):403-411.
---------------------------------------------------------------------------
                                 niddk
    NKF supports the Friends of NIDDK request of $2.16 billion for the 
Institute in fiscal year 2017. Medicare spent $99 billion in 2014 
caring for patients with kidney disease, $68 billion of which was for 
individuals who do not have kidney failure, yet NIH funding for kidney 
disease research is only about $600 million annually. Many research 
proposals with the potential to lead to improved treatments, including 
reconstructing the kidney to restore function, remain unfunded. 
Patients deserve better and we cannot allow these opportunities to slip 
away.
    In March, NKF hosted the Third Annual Kidney Patient Summit that 
included participation from nearly 100 advocates from NKF and four 
other kidney patient organizations. Increased Federal support for 
kidney disease research was a top priority in meetings with the 
advocates' congressional delegations. This is particularly important 
for individuals whose kidney disease is the result of genetic factors. 
America's scientists are at the cusp of many potential breakthroughs in 
improving our understanding of CKD and providing new therapies to delay 
and treat various kidney diseases. With the unique status of ESRD in 
the Medicare program, CKD research has the potential to provide cost 
savings to the Federal Government like that of no other chronic 
disease. We urge Congress to again provide strong bipartisan support 
for NIH to continue building on the success of the fiscal year 2016 
efforts, and fund NIDDK at this requested level.
                       hrsa organ transplantation
    NKF urges the Committee to provide $28.5 million for organ donation 
and transplantation programs in the HRSA DoT. This request is broadly 
supported by patient and professional members of the transplant 
community to restore the program's purchasing power to the fiscal year 
2010 level. Activities supported by DoT include initiatives to increase 
the number of donor organs, and the National Donor Assistance Program 
which helps individuals obtain a transplant by assisting living organ 
donors with expenses such as travel and subsistence that are not 
reimbursed by insurance, a health benefit program, or any other State 
or Federal program.
    As of April 8, 2016, the kidney transplant wait list consisted of 
100,269 individuals plus an additional 1,927 waiting for a combined 
kidney/pancreas donation. Transplantation remains the treatment of 
choice for most patients with kidney failure yet few will be given this 
opportunity. Kidney recipients often have an improved quality of life 
(and are more likely to stay in or return to the work force) and 
transplantation is tremendously cost effective--Medicare spends $29,920 
per year on a kidney recipient after the year of transplant, compared 
to more than $84,450 annually on a dialysis patient.
    In 2014, NKF established an organ donation task force to review the 
state of organ donation and identify opportunities to expand the number 
of transplants. While the task force continues to develop its 
recommendations, some activities are being implemented, one example of 
which is NKF's ``The Big Ask/The Big Give'' campaign. This initiative, 
currently in the pilot phase, promotes and supports awareness of living 
kidney donation. It is designed for both those waiting for a kidney 
transplant who have trouble asking somebody to consider donation (The 
Big Ask) and potential kidney donors (The Big Give). The Big Ask/The 
Big Give provides the necessary education and platform to take the 
misconceptions and confusion out of what can be a very complex process. 
We intend to offer the program nationwide in transplant centers, 
dialysis centers and nephrology practices.
    Thank you for your consideration of our funding requests for fiscal 
year 2017.
                                 ______
                                 
         Prepared Statement of the National League for Nursing
    The NLN promotes excellence in nursing education to build a strong 
and diverse nursing workforce to advance the health of the Nation and 
the global community. The League represents more than 1,200 nursing 
schools, 40,000 members, and 25 regional constituent leagues. The NLN 
urges the subcommittee to fund the Health Resources and Services 
Administration's (HRSA) Title VIII nursing workforce development 
programs at $244 million in fiscal year 2017. This amount is equal to 
the fiscal year 2010 funding level for the Title VIII programs.
                           nursing education
    Health inequities, inflated costs, and poor healthcare outcomes are 
intensifying because of today's shortfall of appropriately prepared 
registered nurses (RNs) and licensed vocational/practical nurses (LVN/
LPNs). With 4.6 million active, licensed RNs/LPNs, nurses are the 
primary professionals delivering quality healthcare in the Nation. 
According to the Bureau of Labor Statistics (BLS), the RN workforce is 
projected to grow by 16 percent from 2014-2024, resulting in 1,088,400 
job openings due to growth and replacement needs. BLS also calculates 
the LVN/LPN workforce will grow by 16.3 percent resulting in 322,200 
job openings during the same timeframe. This increase is fueled by an 
increased demand for healthcare services for the aging population. 
Nurses will also be needed to educate and care for patients with 
various chronic conditions, such as arthritis, dementia, diabetes, and 
obesity. The situation is further affected by the needed replacement of 
some 439,300 jobs vacated by RNs and 117,000 vacated by LVN/LPNs who 
will leave the profession and/or retire by 2024.
    The nursing shortage continues to outpace the level of Federal 
resources allocated by Congress to help alleviate it. Appropriations 
for nursing education are inconsistent with the healthcare reality 
facing our Nation today. For the last 50 years, the Title VIII nursing 
workforce development programs have provided training for entry-level 
and advanced practice registered nurses (APRNs) to improve the access 
to, and quality of, healthcare in underserved communities. The Title 
VIII programs are fundamental to the infrastructure delivering quality, 
cost-effective healthcare. The NLN applauds the subcommittee's 
bipartisan efforts to recognize that a strong nursing workforce is 
essential to health policy that provides high-value care for every 
dollar invested in capacity building for a 21st century nurse 
workforce. Insufficient Federal investments in the nursing workforce 
are a shortsighted course of action that further jeopardizes access to, 
and the quality of, the Nation's healthcare delivery. Absent consistent 
support, slight boosts to Title VIII programs will not fulfill the 
expectation of generating quality health outcomes, nor will episodic 
increases in funding fill the gap generated by a 15-year nurse and 
nurse faculty shortage felt throughout the U.S. health system.
               the nurse pipeline and education capacity
    Although the recession resulted in some stability in the short-term 
for the nurse workforce, policy makers must not lose sight of the long-
term growing demand for nurses in their districts and States. As the 
United States tackles the workforce shortage that exacerbates the 
stress in the healthcare system, nursing programs across the country 
are rejecting qualified candidates because there is not enough faculty 
to teach them. The percentage of LPN/LVN pre-licensure programs that 
turned away qualified applicants dropped by 11 percent according to the 
NLN's survey of schools of nursing for academic year 2013-2014. The 
percentage for BSN programs remained unchanged between 2012 and 2014, 
while the percentage for BSRN (RN to BSN), masters, and doctorate 
programs increased by 6 percent, 8 percent, and 4 percent, 
respectively. If BSN programs remain the same as from 2012 to 2014, 
this could have a potential impact on the Institute of Medicine's (IOM) 
recommendation in The Future of Nursing: Leading Change, Advancing 
Health (2011) for an increase in the proportion of nurses with 
baccalaureate degrees from 50 to 80 percent by 2020.
    While the proportion of programs that turn away qualified 
applicants in prelicensure programs is declining, the NLN survey still 
indicates that a number of qualified applications are being rejected 
due to various constraints encountered by nursing programs. A lack of 
clinical placement settings continues to be a critical constraint as 
well as lack of faculty to expanding the capacity of nursing programs 
in almost all programs. NLN research on America's nearly 60,000 nurse 
educators shows that a core cause of the shortage is an aging and 
overworked faculty who earn less than nurses entering clinical 
practice. Sixty percent of all full-time nurse faculty members are 45- 
to 60-years old. Fifty-five percent of nurse faculty say they are 
likely to leave academic nursing by 2020. BLS projects a need of 25,400 
new nursing instructors by 2024 due to the expected increase in demand 
as well as the expected retirement of 12,200 current faculty members.
                 equally pressing is lack of diversity
    Besides representing an untapped talent pool to remedy the 
nationwide nursing shortage, diversity in nursing is essential to 
developing a healthcare system that understands and addresses the needs 
of our rapidly changing population. Our Nation is enriched by cultural 
complexity--37 percent of our population identify as racial and ethnic 
minorities. Yet diversity eludes the nursing student and nurse educator 
populations. Minorities only constitute 28 percent of the student 
population and males only 15 percent of pre-licensure RN students. A 
survey of nurse educators conducted by the NLN and the Carnegie 
Foundation's Preparation for the Professions Program found that only 7 
percent of nurse educators were minorities compared with 16 percent of 
all U.S. faculty. The lack of faculty diversity limits nursing schools' 
ability to deliver culturally appropriate health professions education. 
Workforce diversity is needed where research indicates that factors 
such as societal biases and stereotyping, communication barriers, 
limited cultural sensitivity and competence, and system and 
organizational determinants contribute to healthcare inequities.
                   title viii federal funding reality
    Today's undersupply of appropriately prepared nurses and nurse 
faculty, as well as the projected loss of experienced nurses over the 
next decade, does not bode well for our Nation. The Title VIII nursing 
workforce development programs are a comprehensive system of capacity-
building strategies that provide students and schools of nursing with 
grants to strengthen education programs, including faculty recruitment 
and retention efforts, facility and equipment acquisition, clinical lab 
enhancements, loans, scholarships, and services that enable students to 
overcome obstacles to completing their nursing education programs. 
HRSA's Title VIII data below from the agency's fiscal year 2017 budget 
justification of estimates provide a perspective on current Federal 
investments.
    The Advanced Nursing Education (ANE) program supports 
infrastructure grants to schools of nursing for advanced practice 
programs preparing nurse-midwives, nurse anesthetists, nurse 
practitioners, clinical nurse specialists, nurse administrators, nurse 
educators, public health nurses, or other advanced level nurses. In 
academic year 2014-2015, ANE program grantees trained 8,735 nursing 
students and produced 2,148 graduates. In addition, 30 percent of 
students trained were underrepresented minorities and/or from 
disadvantaged backgrounds.
    Nursing Workforce Diversity (NWD) grants increase educational 
opportunities for individuals from disadvantaged backgrounds (including 
racial and ethnic minorities underrepresented in nursing) through 
scholarship or stipend support, pre-entry preparation, and retention 
activities. In academic year 2014-2015, the number of nursing program 
students trained was 4,400.
    Nurse Education, Practice, Quality, and Retention Grants (NEPQR) 
address the critical nursing shortage via projects to expand the 
nursing pipeline, promote career mobility, provide continuing 
education, and support retention. The NEPQR program funded the 
Veterans' Bachelor of Science in Nursing (VBSN) program and made awards 
to 17 schools. Four hundred seventy-two veterans were enrolled in BSN 
degree programs and 82 graduated with a BSN degree. It is estimated 
that 33 percent of participating veterans were underrepresented 
minorities in the field of nursing, and 24 percent reported coming from 
a financially and/or educationally disadvantaged background.
    The Nurse Faculty Loan Program (NFLP) supports the establishment 
and operation of a loan fund at participating schools of nursing to 
assist nurses in completing their graduate education to become 
qualified nurse faculty. In academic year 2014-2015, the NFLP supported 
2,399 students pursuing faculty preparation. Twenty percent of students 
who received a loan reported coming from a disadvantaged background and 
nearly 25 percent of students are considered underrepresented 
minorities in their prospective professions.
    The NURSE Corps Scholarship and Loan Repayment Program (NURSE 
Corps) offers to individuals, who are enrolled or accepted for 
enrollment as full-time or part-time nursing students, the opportunity 
to apply for funds. The NURSE Corps repays up to 85 percent of nursing 
student loans in return for at least 3 years of practice in a 
designated nursing shortage area. In fiscal year 2015, the NURSE Corps 
loan repayment program made 590 loan repayment awards and 319 
continuation awards. The NURSE Corps scholarship program made 257 new 
scholarship awards and 12 continuation awards during the same time 
period.
    The NLN urges the subcommittee to fund the Title VIII nursing 
workforce development programs at the fiscal year 2010 funding level of 
$244 million in fiscal year 2017.

    [This statement was submitted by Anne R. Bavier, PhD, RN, FAAN, 
President, and Beverly Malone, PhD, RN, FAAN, Chief Executive Officer, 
National League for Nursing.]
                                 ______
                                 
         Prepared Statement of the National Minority Consortia
    The National Minority Consortia (NMC) submits this statement on 
fiscal year 2019 advance appropriations for the Corporation for Public 
Broadcasting (CPB) We represent a coalition of five national 
organizations, who, with modest support from CPB, bring authentic 
stories of diversity to the Nation. We bring unique voices and 
perspectives from America's diverse communities into all aspects of 
public broadcasting and other media, including content transmitted 
digitally over the Internet. Our requests are two: (1) That Congress 
direct CPB to meaningfully increase its commitment to diverse 
programming and serving underserved communities; and (2) that at least 
$445 million be provided in advance fiscal year 2019 funding for CPB. 
We ask the Committee to:
  --Direct CPB to increase its efforts for diverse programming with a 
        commitment for minority programming and for organizations and 
        stations located within underserved communities. We urge 
        Congress in bill and/or report language to recognize that CPB, 
        while it has enabled diversity in public broadcasting, still 
        has very far to go. We suggest language such as:

    The Committee recognizes the importance of the partnership CPB has 
        with the National Minority Consortia, which helps develop, 
        acquire, and distribute diverse content to Public Media 
        entities to serve underrepresented communities. These stories 
        of diversity transcend statistics and bring universal American 
        stories to all U.S. citizens. As populations of diverse ethnic 
        backgrounds are increasing in cities and towns across the 
        Nation, Public Media entities, TV and Radio stations and 
        digital platforms must strive to meet this audience's needs. 
        The Committee encourages CPB to support and expand this 
        critical partnership, including instituting funding guidelines 
        that encourage and reward public media that represent and reach 
        a diverse American public.
    CPB has a big responsibility with regard to diversity, yet the five 
NMC organizations combined receive only $6.5 million in discretionary 
funds from CPB, an amount less than 2 percent of the CPB budget. A 
previous amount of $7.5 million had been decreased by 10 percent in 
2013 due to the sequestration and was never reinstated.
  --Provide fiscal year 2019 advance appropriation for CPB of $445 
        million, in order to develop content that reaches across 
        traditional media boundaries, such as those separating 
        television and radio.
    While public broadcasting continues to uphold strong ethics of 
responsible journalism and thoughtful examination of American history, 
life and culture, it has not kept pace with our rapidly changing 
demographics. Members of minority groups continue to be 
underrepresented on programming and oversight levels within and in 
content production. This is unacceptable in America today, where 
minorities comprise 34.7 percent of the population. This becomes more 
urgent now that racial and ethnic minorities make up more than half of 
all children born in the United States today.
    Public broadcasting has the potential to be particularly important 
for our growing minority and ethnic communities, especially as we 
transition to a broadband-enabled, 21st century workforce that relies 
on the skills and talent of all of our citizens. While there is a niche 
in the commercial broadcast and cable world for quality programming 
about our communities, it is in the public broadcasting sphere where 
minority communities and producers should have more access and capacity 
to produce diverse high-quality programming for national audiences. We 
therefore, urge Congress to insert strong language in this act to 
ensure that this is the case and that these opportunities are made 
available to minorities and other underserved communities.
                 about the national minority consortia
    The NMC is made up of five separate and distinct organizations that 
address the need for programing that reflects American's growing ethnic 
and cultural diversity. With primary funding from the CPB, the NMC 
serves as an important component of Public Media content--on air and/or 
digitally. By developing and funding diverse content, training and 
mentoring the next generation of minority media makers, as well as 
brokering relationships between content creators and content 
aggregators, we are in a position to ensure the future strength and 
relevance of Public Media content from and to our communities.
    Each Consortia organization is engaged in cultivating ongoing 
relationships with the independent producer community by providing 
technical assistance and program funding, support and distribution. 
Often the funding we provide is the initial seed money for a project, 
that is matched by other public and private sources, providing true 
economic development. We also provide numerous hours of programming to 
individual Public Television and Radio stations--programming that is 
beyond the reach of most local stations. To have a real impact, we need 
funding that recognizes and values the full extent of minority 
participation in public life. Below is information regarding each of 
the five NMC organizations.
    Center for Asian American Media (CAAM).--CAAM's mission is to 
present stories that convey the richness and diversity of Asian 
American experiences to the broadest audience possible. They do this by 
funding, producing, distributing and exhibiting works in film, 
television and digital media. CAAM's award-winning public TV programs 
are seen by millions of viewers a year across the United States, 
including 47 documentary shows in the last 4 years. Since launching the 
groundbreaking Asian American anthology series Silk Screen (1982-1987) 
on PBS, CAAM has continued to bring works to millions of viewers 
nationwide. CAAM is widely recognized for its artistic and programmatic 
excellence. Films supported by CAAM include, Jake Shimabukuro: Life on 
Four Strings winner of the Gotham Audience Award and Peabody Award 
winner American Revolutionary: The Evolution of Grace Lee Boggs (2014) 
by Grace Lee. These and other CAAM supported films have formed the 
canon of Asian American studies programs and virtually defined the 
development and evolution of a distinctive Asian American voice in the 
media for over three generations.
    CAAM presents the annual CAAMFest (formerly known as the San 
Francisco International Asian American Film Festival) and distributes 
Asian American media to schools, libraries and colleges. CAAM's newest 
department, Digital Media, is becoming a respected leader in bringing 
innovative content and audience engagement to public media.
    Latino Public Broadcasting (LPB).--Latino Public Broadcasting (LPB) 
is the leader in the development, production, acquisition and 
distribution of non-commercial educational and cultural media that is 
representative of Latino people, or addresses issues of particular 
interest to Latino Americans. These programs are produced for 
dissemination to public broadcasting stations and other public 
telecommunication entities. Between 2009 and 2015, LPB programs won 85 
awards, including the prestigious George Foster Peabody Award, two 
Emmys, two Imagen Awards and the Sundance Film Festival Award for Best 
Director, Documentary. In addition, LPB has been the recipient of the 
Norman Lear Legacy Award and the NCLR Alma Award for Special 
Achievement--Year in Documentaries.
    Latino Public Broadcasting provides a voice to the diverse Latino 
community throughout the United States. Latinos have helped shape the 
Nation over the last 500-plus years and have become, with more than 50 
million people, the largest minority group in the Nation.
    National Black Programming Consortium/Black Public Media (NBPC) 
works to increase capacity in diverse communities to create, distribute 
and use public media. Throughout its history, its mission has been two-
fold: building capacity in new generations of creators of social issue 
media and broadening the pool of stakeholders in public media 
institutions. NBPC is dedicated to developing black digital authorship 
and distributing unique stories of the black experience in the new 
media age. Since 1979 NBPC has invested over $7 million dollars in 
iconic documentary productions for public television; trained, 
mentored, and supported a diverse array of producers who create content 
about contemporary black experiences; and emerged as a leader in the 
evolving next-media landscape through its annual New Media Institute 
and New Media Institute: Africa programs. NBPC also distributes 
engaging content online through its social media portal 
BlackPublicMedia.org, an online home for enlightening black digital 
content and engagement.
    Pacific Islanders in Communications (PIC).--PIC's mission is to 
support, advance, and develop Pacific Island media content and talent 
that results in a deeper understanding of Pacific Island history, 
culture, and contemporary challenges. In keeping with the mission, PIC 
helps Pacific Islander stories reach national audiences through funding 
support for productions, training and education, broadcast services, 
and community engagement. Last year alone, PIC provided 17.5 hours of 
Pacific Islander content to Public Media. In the past 10 years, PIC has 
produced over 100 hours of programming for national broadcast, trained 
over 400 Pacific Islander filmmakers, and have had over 200 community 
screenings worldwide reaching more than 60,000 people in attendance. 
This summer, PIC will present their new, Emmy award winning, six- part 
series Family Ingredients on PBS. In the last 2 years PIC has had two 
films in the award-winning series Independent Lens, Kumu Hina and In 
Football We Trust. PIC's seminal series Pacific Heartbeat, reached over 
24 million households last year, and will begin its fifth season in 
May.
    Vision Maker Media (VMM) (formerly Native American Public 
Telecommunications) empowers and engages Native People to tell stories. 
They serve Native producers and Indian country in partnership with 
public television and radio by working with Native producers to 
develop, produce and distribute educational telecommunications programs 
for all media including public television and public radio. Vision 
Maker Media supports training to increase the number of American 
Indians and Alaska Natives producing quality public broadcasting 
programs, which includes advocacy efforts promoting increased control 
and use of information technologies and the policies to support this 
control by American Indians and Alaska Natives. A key strategy for this 
work is the development of strong partnerships with Tribal nations, 
Indian organizations and Native communities. Reaching the general 
public and the global market is the ultimate goal for the dissemination 
of Native produced media that shares Native perspectives with the 
world.
    In the past 2 years, VMM has presented over 20 hours of programming 
to Public Media. 90 percent of public television stations utilized 
their content for programming needs. The Medicine Game was released in 
April 2015 and stations continue to use this program to inspire 
students, teachers and parents. Two brothers from the Onondaga Nation 
pursue their dreams of playing lacrosse for Syracuse University. Their 
dream nearly in reach, the boys are caught in a constant struggle to 
define their Native identity, live up to their family's expectations 
and balance challenges on and off the Reservation. Stories of hope, 
like The Medicine Game, can shine light in dark places, helping solve 
some of the toughest issues Native Americans face.
    Thank you for your consideration of our recommendations. We see new 
opportunities to increase diversity in programming, production, 
audience, and employment in the new media environment, and we thank 
Congress for support of our work on behalf of our communities.
                                 ______
                                 
  Prepared Statement of the National Network to End Domestic Violence
    Labor, Health and Human Services Appropriations Subcommittee 
Chairman Blunt, Ranking Member Murray, Chairman Cochran, Vice 
Chairwoman Mikulski and distinguished members of the Appropriations 
Committee, thank you for this opportunity to submit testimony on the 
importance of investing in Family Violence Prevention and Services Act 
(FVPSA) and Violence Against Women Act (VAWA) programs. I sincerely 
thank the Committee for its ongoing support of these lifesaving 
programs.
    I am the President and CEO of the National Network to End Domestic 
Violence (NNEDV), the Nation's leading voice for domestic violence 
survivors and their advocates. We represent the 56 State and 
territorial domestic violence coalitions, their nearly 2,000 member 
domestic violence and sexual assault programs, and the millions of 
victims they serve. Our direct connection with victims and victim 
service providers gives us a unique understanding of their needs and 
the vital importance of continued Federal investments. I am submitting 
this testimony to request a targeted investment of $260 million in 
Family Violence Prevention and Services Act (FVPSA), Violence Against 
Women Act (VAWA) and related programs administered by the U.S. 
Department of Health and Human Services fiscal year 2017 Budget 
(specific requests detailed below).
    Incidence, Prevalence, Severity and Consequences of Domestic and 
Sexual Violence.--The crimes of domestic and sexual violence are 
pervasive, insidious and life-threatening. Recently, the Centers for 
Disease Control and Prevention (CDC) released the first-ever National 
Intimate Partner and Sexual Violence Survey (NISVS) which found that 
domestic violence, sexual violence, and stalking are widespread. 
Domestic violence affects more than 12 million people each year and 
nearly three in ten women and one in four men have experienced rape, 
physical, violence, or stalking in his or her lifetime. Female victims 
of rape, physical violence, or stalking by an intimate partner 
experienced severe impacts such as fear, concern for their safety, need 
for medical care, injury, need for housing services, and missing work 
or school.
    The CDC has estimated that 854,000 women in Missouri and 1,094,000 
women in Washington State have experienced rape, physical violence, or 
stalking by an intimate partner in their lifetime.\1\ The terrifying 
conclusion of domestic violence is often murder, and every day in the 
United States, an average of three women are killed by a current or 
former intimate partner.\2\ The cycle of intergenerational violence is 
perpetuated as children are exposed to violence. Approximately 15.5 
million children are exposed to domestic violence every year.\3\ One 
study found that men exposed to physical abuse, sexual abuse and 
witnessing adult domestic violence as children were almost 4 times more 
likely than other men to have perpetrated domestic violence as adults.
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    \1\ Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., 
Walters, M.L., Merrick, M.T., Chen, J., & Stevens, M.R. (2011). The 
National Intimate Partner and Sexual Violence Survey (NISVS): 2010 
Summary Report. Atlanta, GA: National Center for Injury Prevention and 
Control, Centers for Disease Control and Prevention.
    \2\ Bureau of Justice Statistics (2008). Homicide Trends in the 
U.S. from 1976-2005. U.S. Dept. of Justice.
    \3\ McDonald, R., et al. (2006). ``Estimating the Number of 
American Children Living in Partner-Violence Families.'' Journal of 
Family Psychology, 30(1), 137-142.
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    In addition to the terrible cost domestic and sexual violence has 
on the lives of individual victims and their families, these crimes 
also cost taxpayers and communities. The cost of intimate partner 
violence exceeds $5.8 billion each year, $4.1 billion of which is for 
direct healthcare services.\4\ Translating this into 2016 dollars, 
based on the Bureau of Labor Statistics Consumer Price Index, the 
annual cost to the Nation is over $9 billion per year. Domestic 
violence costs U.S. employers an estimated $3 to $13 billion 
annually.\5\
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    \4\ National Center for Injury Prevention and Control. Costs of 
Intimate Partner Violence Against Women in the United States. Atlanta 
(GA): Centers for Disease Control and Prevention; 2003.
    \5\ Bureau of National Affairs Special Rep. No. 32, Violence and 
Stress: The Work/Family Connection 2 (1990); Joan Zorza, Women 
Battering: High Costs and the State of the Law, Clearinghouse Rev., 
Vol. 28, No. 4, 383, 385.
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    Despite this grim reality, we know that when a coordinated response 
is developed and immediate, and essential services are available, 
victims can escape from life-threatening violence and begin to rebuild 
their lives. To address unmet needs and build upon its successes, FVPSA 
and VAWA programs should receive significant increases in the fiscal 
year 2017 Labor, Health and Human Services Appropriations bill.
    Family Violence Prevention and Services Act (FVPSA) (Administration 
for Children and Families)--$175 million request.--Since its passage in 
1984 as the first national legislation to address domestic violence, 
FVPSA has remained the only Federal funding directly for shelter 
programs. Now in its 32nd year, FVPSA has made substantial progress 
toward ending domestic violence. Despite the progress and success 
brought by FVPSA, an unconscionable need remains for FVPSA-funded 
victim services.
    There are more than 2,000 community-based domestic violence 
programs for victims and their children (approximately 1,500 of which 
are FVPSA-funded through State formula grants). These programs offer 
services such as emergency shelter, counseling, legal assistance, and 
preventative education to millions of adults and children annually and 
are at the heart of our Nation's response to domestic violence. A 2008 
multi-State study conclusively shows that the Nation's domestic 
violence shelters are addressing victims' urgent and long-term needs 
and are helping victims protect themselves and their children.
    This same study found that, if shelters did not exist, the 
consequences for victims would be dire, including ``homelessness, 
serious losses including [loss of] children [or] continued abuse or 
death.'' \6\ Additionally, non-residential domestic violence services 
are essential to addressing victims' needs. Such programs provide a 
wide variety of services to victims including counseling, child care, 
financial support, and safety planning. Without the counseling services 
she received from her local domestic violence program, one victim said, 
``I would not be alive, I'm 100 percent certain about that.'' \7\
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    \6\ Lyon, E. & Lane, S. (2009). Meeting survivors' needs: A multi-
State study of domestic violence shelter experiences. Harrisburg, PA: 
National Resources Center on Domestic Violence.
    \7\ Lyon, Eleanor, Bradshaw, Jill, Menard, Anne. Meeting Survivors' 
Needs through Non-Residential Services & Supports: Results of a Multi-
State Study. Harrisburg, PA: National Resource Center on Domestic 
Violence. November, 2011.
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    The Increased Need for Funding: to Maintain Programs and Bridge the 
Gap. .--Many programs across the country use their FVPSA funding to 
keep the lights on and their doors open. We cannot overstate how 
important this funding is: victims must have a place to flee to when 
they are escaping life-threatening violence. As increased training for 
law enforcement, prosecutors and court officials has greatly improved 
the criminal justice system's response to victims of domestic violence, 
there is a corresponding increase in demand for emergency shelter, 
hotlines and supportive services. Additionally, demand has increased as 
a result of the economic downturn, and victims with fewer personal 
resources become increasingly vulnerable. Since the economic crisis 
began, eight out of ten domestic violence shelters have reported an 
increase in women seeking assistance from abuse. \8\ As a result, 
shelters overwhelmingly report that they cannot fulfill the growing 
need for these services.
---------------------------------------------------------------------------
    \8\ Mary Kay's Truth About Abuse Report. Mary Kay Inc. (2012).
---------------------------------------------------------------------------
    Each year NNEDV releases a report entitled Domestic Violence 
Counts: A 24-hr National Census of Domestic Violence Services (Census). 
The report revealed that in just one day in 2015, while 71,828 victims 
of domestic violence received services, over 12,197 requests for 
services went unmet, due to lack of funding and resources. Of those 
unmet requests, 63 percent were for safe shelter. In 2015, domestic 
violence programs reported that they had laid off nearly 1,235 staff 
positions in addition to reducing or eliminating 1,936 services in the 
past year, including prevention services, therapy, and child welfare 
advocacy. I strongly encourage you to read NNEDV's DV Counts Census 
(www.nnedv.org/census) to learn more about the desperate needs of 
victims State-by-State and nationally.
    In 2013, domestic violence programs funded by the Family Violence 
Prevention & Services Act (FVPSA) provided shelter and nonresidential 
services to more than 1.3 million victims. Due to lack of capacity, 
however, an additional 186,552 requests for shelter went unmet. Since 
2011, at least 19 local domestic violence programs across the country 
have been forced to close entirely.
    For those individuals who are not able to find safety, the 
consequences can be extremely dire, including continued exposure to 
life-threatening violence or homelessness. It is absolutely 
unconscionable that victims cannot find safety for themselves and their 
children due to a lack of adequate investment in these services. In 
order to help meet the immediate needs of victims in danger and to 
continue this work to prevent and end domestic violence, FVPSA funding 
must be increased to its authorized level of $175 million.
                          additional requests
    National Domestic Violence Hotline (Administration for Children and 
Families)--$12 million; DELTA Prevention Program (Centers for Disease 
Control and Injury Prevention)--$6 million; Rape Prevention and 
Education (RPE) (Centers for Disease Control and Injury Prevention)--
$50 million; Preventative Health and Health Services Block Grant, Rape 
Set-Aside--$7 million; Violence against Women Health Initiative, 
(Office On Women's Health)--$10 million.

    [This statement was submitted by Kim Gandy, President and CEO, 
National Network to End Domestic Violence.]
                                 ______
                                 
          Prepared Statement of the National Respite Coalition
    Mr. Chairman, I am Jill Kagan, Chair of the National Respite 
Coalition (NRC), a network of State respite coalitions, respite 
providers, family caregivers, and national, State and local 
organizations that support respite. The NRC also facilitates the 
Lifespan Respite Task Force, a coalition of over 100 national, State 
and local groups. The NRC is requesting that the Subcommittee include 
$5.0 million for the Lifespan Respite Care Program in the fiscal year 
2017 Labor, HHS, and Education Appropriations bill as recommended in 
the President's fiscal year 2017 budget. This will enable:
  --State replication of best practices in Lifespan Respite to allow 
        family caregivers, regardless of the care recipient's age or 
        disability, to have access to affordable respite, and to be 
        able to continue to play the significant role in long-term care 
        that they are fulfilling today, saving Medicaid billions;
  --Improvement in the quality of respite services currently available;
  --Expansion of respite capacity to serve more families by building 
        new and enhancing current respite options, including 
        recruitment and training of respite workers and volunteers; and
  --Greater consumer direction by providing family caregivers with 
        training and information on how to find, use and pay for 
        respite services.
    Who Needs Respite?--More than 43 million adults in the U.S. are 
family caregivers of an adult or a child with a disability or chronic 
condition (National Alliance for Caregiving (NAC) and AARP Public 
Policy Institute, 2015). The estimated economic value of family 
caregiving of adults alone is approximately $470 billion annually (AARP 
Public Policy Institute, 2015). Eighty percent of those needing long-
term services and supports (LTSS) are living at home. Two out of three 
(66 percent) older people with disabilities who receive LTSS at home 
get all their care exclusively from family caregivers (Congressional 
Budget Office, 2013). This percentage will only rise in the coming 
decades with greater life expectancies of individuals with disabling 
and chronic conditions living at home with their aging parents or other 
caregivers, the aging of the baby boom generation, and the decline in 
the percentage of the frail elderly who are entering nursing homes.
    Immediate concerns about how to provide care for a growing aging 
population are paramount. However, caregiving is a lifespan issue with 
the majority of family caregivers caring for someone between the ages 
of 18 and 75 (53 percent) (NAC and AARP, 2015). The most recent 
National Survey of Children with Special Health Care Needs found that 
11 million children under age 18 have special healthcare needs \1\ 
(Health Resources and Services Administration, 2013).
---------------------------------------------------------------------------
    \1\ The U.S. Department of Health and Human Services, Health 
Resources and Services Administration, Maternal and Child Health Bureau 
(MCHB) defines children with special healthcare needs (CSHCN) as 
``...those who have or are at increased risk for a chronic physical, 
developmental, behavioral, or emotional condition and who also require 
health and related services of a type or amount beyond that required by 
children generally.''
---------------------------------------------------------------------------
    National, State and local surveys have shown respite to be the most 
frequently requested service by family caregivers (The Arc, 2011; 
National Family Caregivers Association, 2011). Yet, 85 percent of 
family caregivers of adults are not receiving respite services at all 
(NAC and AARP, 2015). Nearly half of family caregivers of adults (44 
percent) identified in the National Study of Caregiving were providing 
substantial help with healthcare tasks. Of this group, despite their 
high level of care, fewer than 17 percent used respite (Wolff, J., et 
al. 2016).
    Families of the wounded warriors, military personnel who returned 
from Iraq and Afghanistan with traumatic brain injuries and other 
serious chronic and debilitating conditions, don't have full access to 
respite. Even with enactment of the VA Family Caregiver Support Program 
which serves only veterans since 9/11, the need for respite remains 
high for all veterans and their family caregivers. A 2014 Rand 
Corporation report prepared for the Elizabeth Dole Foundation, Hidden 
Heroes: America's Military Caregivers, recommended that respite care 
should be more widely available to military caregivers (Ramchand, et 
al., 2014). The Dole Foundation's Respite Impact Council found that 
traditional respite services do not address the needs of military 
caregivers and the Lifespan Respite Care program should be fully funded 
to help meet those needs.
    Respite Barriers and the Effect on Family Caregivers.--While most 
families want to care for family members at home, research shows that 
family caregivers are at risk for serious emotional stress and mental 
and physical health problems (NAC and AARP; 2015; American 
Psychological Association, 2012; Spillman, et al., 2014). When 
caregivers lack effective coping styles or are depressed, care 
recipients may be at risk for falling, developing preventable secondary 
health conditions or limitations in functional abilities. The risk of 
abuse from caregivers among care recipients with significant needs 
increases when caregivers themselves are depressed or in poor health 
(American Psychological Association, nd). Parents of children with 
special healthcare needs report poorer general health, more physical 
health problems, worse sleep, and increased depressive symptoms 
compared to parents of typically developing children (McBean, A, et 
al., 2013).
    Respite, that has been shown to ease family caregiver stress, is 
too often out of reach or completely unavailable. Restrictive 
eligibility criteria preclude many families from receiving services. 
Many children with disabilities age out of the system when they turn 21 
and lose services, such as respite. A survey of nearly 5000 caregivers 
of individuals with intellectual and developmental disabilities (I/DD) 
found the vast majority of caregivers report physical fatigue (88 
percent), emotional stress (81 percent) and emotional upset or guilt 
(81 percent); 1 out of 5 families (20 percent) report that someone in 
the family quit their job to provide care; and more than 75 percent of 
family caregivers could not find respite services (The Arc, 2011). 
Despite their higher burden of care, caregivers of persons with 
dementia are more prone to underutilizing and/or delaying respite. The 
2013 Johns Hopkins Maximizing Independence at Home Study, in which 
researchers surveyed persons with dementia residing at home with their 
informal caregivers, found that nearly half of the caregivers had unmet 
needs for mental healthcare and most of these, according to the 
researchers, needed emotional support or respite care (Black, B, et 
al., 2013). Respite may not exist at all for individuals with 
conditions such as ALS, MS, spinal cord or traumatic brain injuries, or 
children with serious emotional conditions or autism.
    Barriers to accessing respite include fragmented and narrowly 
targeted services, cost, and the lack of information about respite or 
how to find or choose a provider. A critically short supply of well-
trained respite providers may prohibit a family from making use of a 
service they so desperately need. Lifespan Respite is designed to help 
States eliminate barriers through improved coordination and capacity 
building.
    Respite Benefits Families and is Cost Saving.--Respite has been 
shown to help reduce the stress that can lead poor health among family 
caregivers. In turn, respite helps avoid or delay out-of-home 
placements, minimizes precursors that can lead to abuse and neglect, 
and strengthens marriages and family stability. While limitations in 
respite research exist, these findings were recently corroborated by a 
review of the literature conducted by an Expert Panel on Respite 
Research, convened by ARCH with support from ACL (Kirk, 2015). For 
example, a study of parents of children with autism found that respite 
was associated with reduced stress and improved marital quality 
(Harper, et al., 2013). A U.S. Department of Health and Human Services 
report found that reducing key stresses on caregivers through services 
such as respite would reduce nursing home entry (Spillman and Long, 
USDHHS, 2007). In a survey of caregivers of individuals with Multiple 
Sclerosis, two-thirds said that respite would help keep their loved one 
at home. When the care recipient with MS also has cognitive impairment, 
the percentage of those saying respite would be helpful to avoid or 
delay nursing home placement jumps to 75 percent (NAC, 2012).
    Compelling budgetary benefits accrue because of respite. Delaying a 
nursing home placement for one person with Alzheimer's or avoiding 
hospitalization for a child with autism can save Medicaid and other 
government programs thousands of dollars. Researchers at the University 
of Pennsylvania studied the records of 28,000 children with autism 
enrolled in Medicaid in 2004. They concluded that for every $1,000 
States spent on respite, there was an 8 percent drop in the odds of 
hospitalization (Mandell, D., et al., 2012). In the private sector, 
U.S. businesses lose from $17.1 to $33.6 billion per year in lost 
productivity of family caregivers (MetLife Mature Market Institute, 
2006). Higher absenteeism among working caregivers costs the U.S. 
economy an estimated $25.2 billion annually (Witters, D., 2011). 
Respite for working family caregivers could improve job performance, 
saving employers billions.
    Lifespan Respite Care Program Helps.--The Federal Lifespan Respite 
program, administered by the Administration for Community Living (ACL) 
provides competitive grants to eligible State agencies. Congress 
appropriated $2.5 million each year from fiscal year 2009--fiscal year 
2012 and slightly less in fiscal year 2013-fiscal year 2015. Since 
2009, 33 States and DC have received Lifespan Respite Grants. In fiscal 
year 2016, the program received $3.3 million. While current or past 
grantees will receive no new funding this year, an additional 2-3 new 
States are expected to be funded. States are required to establish 
State and local coordinated Lifespan Respite care systems to serve 
families regardless of age or special need, provide new planned and 
emergency respite services, train and recruit respite workers and 
volunteers and assist caregivers in gaining respite access. Lifespan 
Respite helps States maximize use of limited resources across age and 
disability groups and deliver services more efficiently. Increasing 
funding, even slightly, for the program in fiscal year 2017 could allow 
funding of several new States and help current grantees complete their 
ground-breaking work.
    How is Lifespan Respite Program Making a Difference?--With limited 
funds, Lifespan Respite grantees are engaged in innovative activities 
such as:
  --Alabama, Arizona, Delaware, Montana, Nebraska, Nevada, North 
        Carolina, Oklahoma, Rhode Island, South Carolina, Tennessee, 
        Virginia, and Washington have successfully used consumer-
        directed respite vouchers for serving underserved populations, 
        such as individuals with MS or ALS, adults with intellectual or 
        developmental disabilities (I/DD), or those on waiting lists 
        for services.
  --Idaho, Illinois, Iowa, and Nebraska offer emergency respite 
        support.
  --Alabama, Arizona, Colorado, Massachusetts, Nebraska, New York, 
        Ohio, Pennsylvania, South Carolina and Tennessee are providing 
        new volunteer or faith-based respite.
  --Innovative and sustainable respite services, funded in Colorado, 
        Massachusetts, North Carolina and Ohio through mini-grants to 
        community-based agencies, have documented benefits to family 
        caregivers.
  --Respite provider recruitment and training are priorities in New 
        Hampshire, Virginia, and Wisconsin.
    Additional partnerships between State agencies are changing the 
landscape. The AZ Lifespan Respite program housed in Aging and Adult 
Services partnered with AZ's Children with Special Health Care Needs 
Program to provide respite vouchers to families across the age and 
disability spectrum. The OK Lifespan Respite program partnered with the 
State's Transit Administration to develop mobile respite to serve 
isolated rural areas of the State. States are building respite 
registries and ``no wrong door systems'' in partnership with Aging and 
Disability Resource Centers to help family caregivers access respite 
and funding sources. Funding must be maintained to help sustain these 
innovative State efforts. States are developing long-term 
sustainability plans, but without Federal support, many of the grantees 
will be cut off before these initiatives achieve their full impact.
    No other Federal program mandates respite as its sole focus, helps 
ensure respite quality or choice, and allows funds for respite start-
up, training or coordination to address accessibility and affordability 
issues for families. With tens of millions of families affected, 
caregiving is a public health issue requiring an immediate proven 
preventive response, such as respite. We urge you to include $5 million 
in the fiscal year 2017 Labor, HHS, and Education appropriations bill. 
This will allow Lifespan Respite Programs to be replicated and 
sustained. Families, with access to respite, will be able to keep their 
loved ones at home, saving Medicaid and other Federal programs, 
billions of dollars.
    Complete references available upon request. Please contact the NRC 
for more information. Http://archrespite.org/national-respite-
coalition.

    [This statement was submitted by Jill Kagan, Chair, National 
Respite Coalition.]
                                 ______
                                 
      Prepared Statement of the National Rural Health Association
    The National Rural Health Association (NRHA) is pleased to provide 
the Senate Subcommittee on Labor, Health and Human Services, Education 
and Related Agencies with a statement for the record on fiscal year 
2017 funding levels for programs with a significant impact on the 
health of rural Americans.
    NRHA is a national nonprofit membership organization with a diverse 
collection of 21,000 individuals and organizations who share a common 
interest in rural health. The Association's mission is to improve the 
health of rural Americans and to provide leadership on rural health 
issues through advocacy, communications, education and research.
    NRHA is advocating support for a group of rural health program that 
assist rural communities in maintaining and building a strong 
healthcare delivery system into the future. Most importantly, these 
programs help increase the capacity of the rural healthcare delivery 
system and true safety net providers. Rural Americans, on average, are 
poorer, sicker and older than their urban counterparts. Programs in the 
rural health safety net increase access to healthcare, help communities 
create new health programs for those in need and train the future 
health professionals that will care for the 62 million rural Americans. 
With modest investments, these programs evaluate, study and implement 
quality improvement programs and health information technology systems.
    Funding for the rural health safety net is more important than ever 
as rural Americans are facing a hospital closure crisis. Seventy-one 
rural hospitals have closed, 10,000 rural jobs lost and 1.2 million 
rural patients have lost access to their nearest hospital since 2010. 
Even more concerning is that 673 rural hospitals are at risk of 
closure, meaning sustained Medicare cuts threaten the financial 
viability of 1 in 3 rural hospitals. The loss of these hospitals would 
mean 11.7 million patients would lose access to care in their 
community.
    Important rural health programs supported by NRHA are outlined 
below.
    The National Health Service Corps (NHSC) plays an important role in 
maintaining the healthcare safety net by placing primary healthcare 
providers in the most undeserved rural communities. NHSC is a network 
of 8,000 primary healthcare professionals, and 10,000 sites (September 
2010). However, the demand for primary care providers far exceeds the 
supply, and the needs of rural communities continue to row. Rural 
communities must have the resources necessary to hire primary care, 
dental and behavioral health providers. Request: $278.3 million.
    Rural Health Outreach and Network Grants provide capital investment 
for planning and launching innovative projects in rural communities 
that will become self-sufficient. These grants are unique Federal 
grants in that they allow a great deal of flexibility for the community 
to build a program around their community's specific needs. Grant funds 
are awarded for communities to develop needed formal, integrated 
networks of providers that deliver primary and acute care services. The 
grants have led to successful projects including information technology 
networks, oral screenings, and preventative care. Due to the community 
nature of the grants and the focus on sustainability after the grant 
term has run out--85 percent of the grantees continue to deliver 
services a full 5 years after Federal funding ends. Request: $69 
million.
    Rural Health Research and Policy Grants form the Federal 
infrastructure for rural health policy. These grants provide policy 
makers with policy-relevant research on problems facing rural 
communities in providing access to quality affordable care and to 
improving population health in rural America. By funding rural health 
research centers across the country these grants produce a mix of 
health services research, epidemiology, public health, geography, 
medicine, and mental health. These funds allow rural America to have a 
coordinated voice in the Department of Health and Human Services (HHS), 
in addition to providing expertise to agencies such as the Centers for 
Medicare and Medicaid Services. As a part of this request, we urge the 
Subcommittee to include in report language instructions to the Office 
of Rural Health Policy to direct additional funding to the State rural 
health associations. Request: $10.3 million.
    State Offices of Rural Health provide State specific infrastructure 
for rural health policy. These State offices are the counterpart to the 
Federal rural health research and policy framework. State offices form 
an essential link between small rural communities and the State and 
Federal resources to develop long term solutions to rural health 
problems. These funds provide necessary capacity to States for the 
administration of critical rural health programs, assist in 
strengthening rural healthcare delivery systems, and maintaining rural 
health as a focal point within each State. The State offices play a key 
role in assisting rural health clinics, community health centers, and 
small, rural hospitals assess community healthcare needs. This program 
creates a State focus for rural health interests, brings technical 
assistance to rural areas, and helps frontier communities tap State and 
national resources available for healthcare and economic development. 
State offices form an essential connection to other State agencies and 
local communities; allowing Federal resources to best address the 
unique needs of rural communities. Request: $15 million.
    Rural Hospital Flexibility Grants fund quality improvement and 
emergency medical service projects at Critical Access Hospitals (CAHs). 
These grants allow rural communities to improve access to care, develop 
increased efficiencies, and improved quality of care by leveraging the 
services of CAHs, Emergency Medical Services (EMS), clinics, and health 
practitioners. These grants serve an important function in increasing 
information technology activities in rural America. Also funded in this 
line is the Small Hospital Improvement Program (SHIP), which provides 
grants to more than 1,500 small rural hospitals (50 beds or less) 
across the country to improve business operations, focus on quality 
improvement, and ensure compliance with health information privacy 
regulations. Request: $46 million.
    Rural and Community Access to Emergency Devices Grants help 
communities afford the purchase of emergency devices, such as 
defibrillators, and the necessary training for community members and 
first responders in the proper use of these devices. The proper and 
timely use of a defibrillator following a sudden cardiac arrest doubles 
a victim's change of survival. Placement of devices within the 
community where cardiac arrest is likely to occur allows for greater 
success. Such immediate intervention are particularly important in 
rural America where follow on medical care may require longer wait 
times due to long distances to a hospital, mountainous terrain, or 
inclement weather. Request: $4.5 million.
    The Office for the Advancement of Telehealth (OAT) supports the 
provision of clinical services at a distance, reduces rural provider 
isolation, fosters integrated delivery systems through network 
development, and tests a broad range of telehealth applications. Long-
term, telehealth promises to improve the health of millions of 
Americans, save money by reducing unnecessary office visits and 
hospital stays, and provide continuing education to isolated rural 
providers. The OAT coordinates and promotes the use of telehealth 
technologies by fostering partnerships between Federal and State 
agencies and private sector groups. Since telehealth is still an 
emerging field with new approaches and technologies; continued 
investment in the infrastructure and development is needed. Request: 
$18.5 million.
Title VII Health Professions Training Programs (with a significant 
        rural focus):
  --Area Health Education and Centers (AHECs) encourage and provide 
        financial support to those training to become healthcare 
        professionals in rural areas. Without this experience and 
        support in medical school, far fewer professionals would be 
        aware of the needs of rural communities and even fewer would 
        make the commitment to practice in rural areas. AHECs support 
        the recruitment and retention of physicians, students, faculty 
        and other primary care providers in rural and medically 
        underserved areas. It has been estimated that nearly half of 
        AHECs would shut down without Federal funding, placing future 
        access to healthcare in rural communities at risk. Request: $40 
        million.
  --Rural Physician Pipeline Grants help medical colleges develop rural 
        specific curriculum and to recruit students from rural 
        communities that are likely to return to their home regions to 
        practice. This ``grow-your-own'' approach is one of the best 
        and most cost-effective ways to ensure a robust rural workforce 
        into the future. Request: $5.3 million.
  --Geriatric Programs train health professionals in geriatrics, 
        including funding for Geriatric Education Centers (GEC). There 
        are currently 47 GECs nationwide that ensure access to 
        appropriate and quality healthcare for seniors. Rural America 
        has a disproportionate share of our Nation's elderly and is 
        more likely to have physician shortages than urban locations. 
        Without this program, rural healthcare provider shortages would 
        grow. Request: $42 million.
    The National Rural Health Association appreciates the opportunity 
to provide our recommendations to the Subcommittee. These programs are 
critical to the rural health delivery system and help maintain access 
to high quality care in rural communities. We greatly appreciate the 
support of the Subcommittee and look forward to working with Members of 
the Subcommittee to continue making these important investments in 
rural health.
                                 ______
                                 
Prepared Statement of the National Technical Institute for the Deaf and 
                   Rochester Institute of Technology
    Mr. Chairman and Members of the Committee: I am pleased to present 
the fiscal year 2017 budget request for NTID, one of nine colleges of 
RIT, in Rochester, N.Y. Created by Congress by Public Law 89-36 in 
1965, NTID provides a university-level technical and professional 
education for students who are deaf and hard of hearing, leading to 
successful careers in high-demand fields for a sub-population of 
individuals historically facing high rates of unemployment and under-
employment. NTID students study at the associate, baccalaureate, 
master's and doctoral levels as part of a university (RIT) that 
includes more than 17,000 hearing students. NTID also provides 
baccalaureate and graduate-level education for hearing students in 
professions serving deaf and hard-of-hearing individuals.
                             budget request
    On behalf of NTID, for fiscal year 2017 I would like to request 
$70,712,000 for Operations. NTID has worked hard to manage its 
resources carefully and responsibly. NTID actively seeks alternative 
sources of public and private support, with approximately 28 percent of 
NTID's Operations budget coming from non-Federal funds, up from 9 
percent in 1970. Since fiscal year 2006, NTID raised more than $22.5 
million in support from individuals and organizations. NTID has also 
recognized that construction funding is limited and planned for 
critical and long overdue renovations using existing Federal and non-
Federal funds.
    NTID's fiscal year 2017 request of $70,712,000 in Operations would 
allow NTID to admit all qualified students for Fall 2017 enrollment, 
keep the fiscal year 2017 tuition increase relatively low (3.9 
percent), and continue to offer Grants in Aid to more students. With 
this funding, NTID can support new academic programs, add staff (sign 
language interpreters and captionists) in student access services to 
meet unprecedented demand, and complete much needed capital and 
renovation projects.
                               enrollment
    Truly a national program, NTID has enrolled students from all 50 
States. In Fall 2015 (fiscal year 2016), NTID's enrollment was 1,413 
students. For fiscal year 2017, NTID anticipates an enrollment near 
1,400. NTID's enrollment history over the last 10 years is shown below:

                                                  NTID ENROLLMENTS: FISCAL YEAR 2007--FISCAL YEAR 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                      Deaf/Hard-of-Hearing Students                 Hearing Students
                                                              --------------------------------------------------------------------------------   Grand
                         Fiscal Year                                                                       Interpreting                          Total
                                                               Undergrad   Grad RIT     MSSE    Sub-Total     Program       MSSE    Sub-Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
2016.........................................................      1,167         53         15      1,235          151          27        178      1,413
2015.........................................................      1,153         44         16      1,213          146          28        174      1,387
2014.........................................................      1,195         42         18      1,255          147          30        177      1,432
2013.........................................................      1,269         37         25      1,331          167          31        198      1,529
D2012........................................................      1,281         42         31      1,354          160          33        193      1,547
2011.........................................................      1,263         40         29      1,332          147          42        189      1,521
2010.........................................................      1,237         38         32      1,307          138          29        167      1,474
2009.........................................................      1,212         48         24      1,284          135          31        166      1,450
2008.........................................................      1,103         51         31      1,185          130          28        158      1,343
2007.........................................................      1,017         47         31      1,095          130          25        155      1,250
--------------------------------------------------------------------------------------------------------------------------------------------------------
MSSE: Master of Science in Secondary Education of Deaf/Hard of Hearing Students.
Grad RIT: other graduate programs at RIT.

                         ntid academic programs
    NTID offers high quality, career-focused associate degree programs 
preparing students for specific well-paying technical careers. NTID 
also provides transfer associate degree programs to better serve our 
student population seeking bachelor's, master's, and doctoral degrees. 
These transfer programs provide seamless transition to baccalaureate 
and graduate studies in the other colleges of RIT. In support of those 
deaf and hard-of-hearing students enrolled in the other RIT colleges, 
NTID provides a range of access services (e.g., sign language 
interpreting, real-time speech-to-text captioning, notetaking) as well 
as tutoring services. One of NTID's greatest strengths is our 
outstanding track record of assisting high-potential students to gain 
admission to, and graduate from, the other colleges of RIT at rates 
comparable to their hearing peers.
    A cooperative education (co-op) component is an integral part of 
academic programming at NTID and prepares students for success in the 
job market. A co-op assignment gives students the opportunity to 
experience a real-life job situation and focus their career choice. 
Students develop technical skills and enhance vital personal skills 
such as teamwork and communication, which will make them better 
candidates for full-time employment after graduation. Last year, 235 
students participated in 10-week co-op experiences that augment their 
academic studies, refine their social skills, and prepare them for the 
competitive working world.
                        student accomplishments
    NTID deaf and hard-of-hearing students persist and graduate at 
higher rates than the national persistence and graduation rates for all 
students at 2-year and 4-year colleges. For NTID deaf and hard-of-
hearing graduates, over the past 5 years, an average of 93 percent have 
found jobs commensurate with their education level. Of our fiscal year 
2014 graduates (the most recent class for which numbers are available), 
94 percent were employed 1 year later, with 61 percent employed in 
business and industry, 28 percent in education and non-profits, and 11 
percent in government.
    Graduation from NTID has a demonstrably positive effect on 
students' earnings over a lifetime, and results in a notable reduction 
in dependence on Supplemental Security Income (SSI) and Social Security 
Disability Insurance (SSDI). In fiscal year 2012, NTID, the Social 
Security Administration (SSA), and Cornell University examined earnings 
and Federal program participation data for more than 16,000 deaf and 
hard-of-hearing individuals who applied to NTID over our entire 
history. The study showed that NTID graduates, over their lifetimes, 
are employed at a higher rate and earn more (therefore paying more in 
taxes) than students who withdraw from NTID or attend other 
universities. NTID graduates also participate at a lower rate in SSI 
and SSDI programs than students who withdrew from NTID.
    Using SSA data, at age 50, 78 percent of NTID deaf and hard-of-
hearing graduates with bachelor degrees and 73 percent with associate 
degrees report earnings, compared to 58 percent of NTID deaf and hard-
of-hearing students who withdrew from NTID and 69 percent of deaf and 
hard-of-hearing graduates from other universities. Equally important is 
the demonstrated impact of an NTID education on graduates' earnings. At 
age 50, $58,000 is the median salary for NTID deaf and hard-of-hearing 
graduates with bachelor degrees and $41,000 for those with associate 
degrees, compared to $34,000 for deaf and hard-of-hearing students who 
withdrew from NTID and $21,000 for deaf and hard-of-hearing graduates 
from other universities.
    An NTID education also translates into reduced dependency on 
Federal transfer programs, such as SSI and SSDI. At age 40, less than 2 
percent of NTID deaf and hard-of-hearing associate and bachelor degree 
graduates participated in the SSI program compared to 8 percent of deaf 
and hard-of-hearing students who withdrew from NTID. Similarly, at age 
50, only 18 percent of NTID deaf and hard-of-hearing bachelor degree 
graduates and 28 percent of associate degree graduates participated in 
the SSDI program, compared to 35 percent of deaf and hard-of-hearing 
students who withdrew from NTID.
                            access services
    Access services include sign language interpreting, real-time 
captioning, classroom notetaking services, captioned classroom video 
materials, and assistive listening services. NTID provides an access 
services system to meet the needs of a large number of deaf and hard-
of-hearing students enrolled in baccalaureate and graduate degree 
programs in RIT's other colleges as well as students enrolled in NTID 
programs who take courses in the other colleges of RIT. Access services 
also are provided for events and activities throughout the RIT 
community. Historically, NTID has followed a direct instruction model 
for its associate-level classes, with limited need for sign language 
interpreters, captionists, or other access services. However, the 
demand for access services has grown recently as associate-level 
students request communication based on their preferences.
    Higher enrollments have also increased the demand for access 
services. During fiscal year 2015, 140,230 hours of interpreting were 
provided--an increase of 20 percent compared to fiscal year 2010. 
During fiscal year 2015, 22,241 hours of real-time captioning were 
provided to students--a 14 percent increase over fiscal year 2010. The 
increase in demand is partly a result of the increase in the number of 
students enrolled in programs at RIT and the number of students with 
cochlear implants. In fiscal year 2016, there were 596 deaf and hard-
of-hearing students enrolled in baccalaureate or graduate programs at 
RIT, a 16 percent increase compared to fiscal year 2010, and 432 
students with cochlear implants, a 58 percent increase over fiscal year 
2010.
    As a result, NTID's fiscal year 2017 funding request recognizes the 
need to invest in additional access services staff and in research on 
technologies that might serve as an alternative to traditional access 
services.
                                summary
    It is extremely important that NTID's fiscal year 2017 funding 
request be granted in order that we might continue our mission to 
prepare deaf and hard-of-hearing people to excel in the workplace. NTID 
students persist and graduate at higher rates than national rates for 
all students. NTID graduates have higher salaries, pay more taxes, and 
are less reliant on Federal SSI/SSDI programs. NTID's employment rate 
is 93 percent over the past 5 years. Therefore, I ask that you please 
consider funding our fiscal year 2017 request of $70,712,000 for 
Operations.
    We are hopeful that the members of the Committee will agree that 
NTID, with its long history of successful stewardship of Federal funds 
and an outstanding educational record of service to people who are deaf 
and hard of hearing, remains deserving of your support and confidence. 
Likewise, we will continue to demonstrate to Congress and the American 
people that NTID is a proven economic investment in the future of young 
deaf and hard-of-hearing citizens. Quite simply, NTID is a Federal 
program that works.

    [This statement was submitted by Dr. Gerard J. Buckley, President, 
National Technical Institute for the Deaf, Vice President and Dean, 
Rochester Institute of Technology.]
                                 ______
                                 
     Prepared Statement of the National Violence Prevention Network
    Thank you for this opportunity to submit testimony in support of 
increased funding for the National Violent Death Reporting System 
(NVDRS), which is administered by the National Center for Injury 
Prevention and Control at the Centers for Disease Control and 
Prevention (CDC). The National Violence Prevention Network, a broad and 
diverse alliance of health and welfare, suicide and violence 
prevention, and law enforcement advocates supports increasing the 
fiscal year 2017 funding level to $25 million to allow for nationwide 
expansion of the NVDRS program including all 50 States, District of 
Columbia and U.S. territories. fiscal year 2016 NVDRS funding is $16 
million.
                               background
    Each year, about 57,000 Americans die violent deaths.\1\ In 
addition, an average of 117 people \2\ (22 of which are military 
veterans \3\) take their own lives each day. Violence-related death and 
injuries cost the United States $107 billion in medical care and loss 
in productivity.\4\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention . (2015, June 18 ). 
Injury Prevention & Control: Division of Violence Prevention. Retrieved 
April 14, 2016, from http://www.cdc.gov/violenceprevention/nvdrs/.
    \2\ Americans for Suicide Prevention. (n.d.). Suicide Statistics. 
Retrieved April 14, 2016, from Americans for Suicide Prevention: http:/
/afsp.org/about-suicide/suicide-statistics/.
    \3\ Kemp, J., & Bossarte, R. (2013, February). Suicide Report 2012. 
Retrieved April 14, 2016, from Department of Veterans Affairs: http://
www.va.gov/opa/docs/suicide-data-report-2012-final.pdf.
    \4\ Centers for Disease Control and Prevention . (2015, June 18). 
National Violent Death Reporting System--An Overview. Retrieved 14 
2016, April , from National Violent Death Reporting System: http://
www.cdc.gov/violenceprevention/pdf/nvdrs_overview-a.pdf.
---------------------------------------------------------------------------
    The NVDRS program makes better use of data that are already being 
collected by health, law enforcement, and social service agencies. The 
NVDRS program, in fact, does not require the collection of any new 
data. Instead it links together information that, when kept in separate 
compartments, is much less valuable as a tool to characterize and 
monitor violent deaths. With a clearer picture of why violent deaths 
occurs, law enforcement, public health officials and others can work 
together more effectively to identify those at risk and target 
effective preventive services.
    Currently, NVDRS funding levels only allow the program to operate 
in 32 States \5\ with 9 additional States having expressed an interest 
in joining once new funding becomes available. While NVDRS is beginning 
to strengthen violence and suicide prevention efforts in the 32 
participating States, non-participating States continue to miss out on 
the benefits of this important public health surveillance program.
---------------------------------------------------------------------------
    \5\ Centers for Disease Control and Prevention. (2015, December 
15). National Violent Death Reporting System--State Profiles. Retrieved 
April 14, 2016, from A CDC website: http://www.cdc.gov/
violenceprevention/nvdrs/stateprofiles.html.
---------------------------------------------------------------------------
                            nvdrs in action
    Opioid deaths are a serious public health issue. Drug overdose 
deaths are the leading cause of injury deaths in American.\6\ It is 
important to invest in surveillance of opioid addiction to determine 
the extent of the problem and implement treatment options and 
community-based prevention strategies. NVDRS has already proven to be 
an invaluable tool in many States like Alaska, Indiana and Utah that 
collect information, through toxicology reports, about prescription-
opioid overdose associated with violent deaths. Combined 2010 NVDRS 
data showed that 24 percent of violent deaths tested were positive for 
opiates.\7\ Importantly, surveillance is included as one of the primary 
recommendations in a report published by Johns Hopkins Bloomberg School 
of Public Health that promotes an evidence-based response to the 
prescription-opioid epidemic.\8\
---------------------------------------------------------------------------
    \6\ U.S. Department of Health and Human Services . (2016, April 8). 
The U.S. Opioid Epidemic. Retrieved April 14, 2016, from U.S. 
Department of Health and Human Services: http://www.hhs.gov/opioids/
about-the-epidemic/.
    \7\ Centers for Disease Control and Prevention. (2014, January 17). 
Surveillance for Violent Deaths--National Violent Death Reporting 
System, 16 States, 2010. Retrieved April 14, 2016, from Morbidity and 
Mortality Weekly Report-Surveillance Summaries/Volume 63/No.1: http://
www.cdc.gov/mmwr/pdf/ss/ss6301.pdf.
    \8\ Alexander GC, F. S. (2015). The Prescription Opioid Epidemic: 
An Evidence-Based Approach. Baltimore: Johns Hopkins Bloomberg School 
of Public Health. http://www.jhsph.edu/research/centers-and-institutes/
center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-
2015/2015-prescription-opioid-epidemic-report.pdf.
---------------------------------------------------------------------------
    Children are often the most vulnerable as they are dependent on 
their caregivers during infancy and early childhood. Sadly, NVDRS data 
has shown that young children are at the greatest risk of homicide in 
their own homes. Combined NVDRS data from 17 of the 32 States that 
currently participate in NVDRS, showed that African American children 
aged 4 years and under are more than three times as likely to be 
victims of homicide than Caucasian children,\9\ and that homicides of 
children aged four and under are most often committed by a parent or 
caregiver in the home. The data further notes that household items, or 
``weapons of opportunity,'' were most commonly used, suggesting that 
poor stress responses may be factors in these deaths. Knowing the 
demographics and methods of child homicides can lead to more effective, 
targeted prevention programs.
---------------------------------------------------------------------------
    \9\ Center for Disease Control and Prevention. (2013). National 
Violent Death Reporting System . Retrieved April 14, 2014, from A Web-
based Injury Statistics Query and Reporting System (WISQARS) Database: 
https://wisqars.cdc.gov:8443/nvdrs/nvdrsDisplay.jsp.
---------------------------------------------------------------------------
    Intimate partner violence (IPV) is another issue where NVDRS is 
proving its value. While IPV has declined along with other trends in 
crime over the past decade, thousands of Americans still fall victim to 
it every year. An analysis of intimate partner homicide based on NVDRS 
data from 16 States shows that intimate partners represented 80 percent 
of intimate partner violence-related homicides victims and corollary 
victims (family members, police officers, friends etc . . . ) 
represented the remaining 20 percent of victims.\10\
---------------------------------------------------------------------------
    \10\ Smith, S. G., Fowler, K. A., & and Niolon, P. H. (March 2014). 
Intimate Partner Homicide and Corollary Victims in 16 States--NVDRS 
2003-2009. American Journal of Public Health, 461-466.
---------------------------------------------------------------------------
    Despite being in its early stages in several States, NVDRS is 
already providing critical information that is helping law enforcement 
and public health officials target their resources to those most at 
risk of intimate partner violence. For example, NVDRS data shows that 
while occurrences are rare, most murder-suicide victims are current or 
former intimate partners of the suspect or members of the suspect's 
family. In addition, NVDRS data indicate that women are about seven 
times more likely than men to be killed by a spouse, ex-spouse, lover, 
or former lover, and most of these incidents occurred in the women's 
homes.\7\
                          nvdrs & va suicides
    Although it is preventable, every year more than 42,773 Americans 
die by suicide and another one million Americans attempt it, costing 
more than $42 billion in lost wages and work productivity.\2\ In the 
United States today, there is no comprehensive national system to track 
suicides. However, because NVDRS includes information on all violent 
deaths--including deaths by suicide--the program can be used to develop 
effective suicide prevention plans at the community, State, and 
national levels.
    A 2015 study showed that 19.9 percent of all veteran deaths between 
2001 and 2007 were suicide, with male veterans three times as likely as 
female veterans to commit suicide.\11\ The central collection of such 
data can be of tremendous value for organizations such as the 
Department of Veterans Affairs that are working to improve their 
surveillance of suicides. The types of data collected by NVDRS 
including gender, blood alcohol content, mental health issues and 
physical health issues can help prevention programs better identify and 
treat at-risk individuals.
---------------------------------------------------------------------------
    \11\ Kang, H., Bullman, T. A., & Smolenski, D. J. (2015). Suicide 
risk among 1.3 million veterans who were on active duty during the Iraq 
and Afghanistan wars. Annals of Epidemiology, 96-100.
---------------------------------------------------------------------------
    In addition to veteran suicides, NVDRS data has been crucial in 
many States like Oregon, Utah, New Jersey and North Carolina in 
understanding the circumstances surrounding elder suicide. This has 
allowed the States to collaborate locally and implement programs that 
target those populations at greatest risk.
                          federal role needed
    At an estimated annual cost of $25 million for full implementation, 
NVDRS is a relatively low-cost program that yields high-quality 
results. While State-specific information provides enormous value to 
local public health and law enforcement officials, data from all 50 
States, the U.S. territories and the District of Columbia must be 
obtained to complete the national picture. Aggregating this additional 
data will allow us to analyze national trends and also more quickly and 
accurately determine what factors can lead to violent death so that we 
can devise and disseminate strategies to address those factors.
         strengthening and expanding nvdrs in fiscal year 2017
    The 2014 Consolidated Appropriations Act recognized the public 
health utility of NVDRS in preventing violent deaths and increased 
NVDRS funding by roughly $8 million to facilitate continued expansion 
of the NVDRS program. The program received an additional $4.7 million 
in fiscal year 2016 for a total of $16 million. The additional $5 
million will allow for as many as seven new States to join the current 
32 States that participate in NVDRS. The time is now to complete the 
nation-wide expansion of NVDRS by providing an appropriation of $25 
million in fiscal year 2017 to place NVDRS in all 50 States and U.S. 
territories.
    We thank you for the opportunity to submit this statement for the 
record. The investment in NVDRS has already begun to pay off, as NVDRS-
funded States are adopting effective violence prevention programs. We 
believe that national implementation of NVDRS is a wise public health 
investment that will assist State and national efforts to prevent 
deaths from domestic violence, veteran suicide, teen suicide, gang 
violence and other violence that affect communities around the country. 
We look forward to working with you to complete the nationwide 
expansion of NVDRS by securing an fiscal year 2017 appropriation of $25 
million.

    [This statement was submitted by Paul Bonta, Chair, National 
Violence Prevention Network.]
                                 ______
                                 
     Prepared Statement of the National Viral Hepatitis Roundtable
    The National Viral Hepatitis Roundtable (NVHR) respectfully submits 
this testimony to the U.S. Senate Appropriations Subcommittee on Labor, 
Health and Human Services, and Education, and Related Agencies (LHHS) 
regarding the fiscal year 2017 Appropriations bill. As a broad national 
coalition representing approximately 350 public and private 
organizations committed to fighting, and ultimately ending, the 
hepatitis B (HBV) and hepatitis C (HCV) epidemics domestically, we are 
gravely concerned about the many missed opportunities and negative 
public health consequences resulting from the lack of urgency and 
resources available to adequately address these two communicable 
viruses in the United States.
    We therefore urge the Subcommittee to increase the appropriation 
for the Division of Viral Hepatitis (DVH) at the Centers for Disease 
Control and Prevention (CDC) to no less than $62.8 million in fiscal 
year 2017, an increase of $28.8 million over fiscal year 2016. Further, 
particularly due to the dramatic rise in HCV and, increasingly, HBV 
cases that are interconnected with the opioid and heroin addiction 
crisis, we also urge the Subcommittee to maintain modified language 
regarding the use of Federal funds as outlined in Sec.520 of the fiscal 
year 2016 LHHS Appropriations Bill, given the critical role syringe 
services programs (SSPs) play in viral hepatitis prevention and linkage 
to healthcare, social services, and drug treatment. NVHR further 
encourages the committee to appropriate additional funds specifically 
to support SSPs in fiscal year 2017 given the current crises driven by 
the syndemic of opioid and heroin addiction, overdose death, and 
chronic viral hepatitis infection (which may additionally serve as an 
early harbinger of an HIV outbreak, as seen in Scott County, Indiana in 
early 2015).
    This request is both timely and urgent, given: (1) distressing and 
preventable health disparities seen among many communities; (2) the 
vital need for a robust surveillance infrastructure; (3) the role of 
HBV and HCV infection in the rising incidence of liver cancer; and (4) 
the current state of the hepatitis C epidemic, with unique challenges 
in addressing prevalence and incidence among two distinct generations, 
and tremendous opportunity created by new curative HCV treatment.
                         scope of the epidemics
    Despite a safe, effective vaccine for HBV, and revolutionary 
curative treatments for HCV, CDC conservatively estimates that 
approximately 1.2 million Americans are living with chronic HBV, and 
3.2 million are living with chronic HCV.\1\ These are likely 
underestimates however, as surveillance systems across the Nation are 
disjointed at best, with only five States and two jurisdictions 
(Florida, Massachusetts, Michigan, New York, Washington, Philadelphia, 
and San Francisco) federally funded for such activities.\2\ Some 
experts place estimates of prevalence at approximately 2.2 million for 
chronic HBV alone and up to 5 million Americans chronically infected 
with HCV.\3\ Of primary concern is that of the nearly 4.5 million 
individuals conservatively thought to be living with HBV and/or HCV, at 
least 50-66 percent do not know they are infected with a potentially 
life-threatening, communicable virus, as both HBV and HCV most often 
present with no symptoms until the liver is already significantly 
damaged.\4\ On average, HBV and/or HCV will shorten one's lifespan by 
15-20 years.\5\
---------------------------------------------------------------------------
    \1\ Http://www.cdc.gov/hepatitis/abc/index.htm.
    \2\ Http://www.cdc.gov/hepatitis/statistics/2013surveillance/
commentary.htm.
    \3\ Http://onlinelibrary.wiley.com/doi/10.1002/hep.28026/epdf.
    \4\ Http://www.cdc.gov/hepatitis/abc/index.htm.
    \5\ Http://cid.oxfordjournals.org/content/58/8/1047.full.pdf+html.
---------------------------------------------------------------------------
                            health inequity
    There are alarming and unacceptable disparities among various 
communities for both of these viruses as well. While comprising less 
than 5 percent of the U.S. population, Asian American and Pacific 
Islander (AAPI) communities comprise over 50 percent of domestic HBV 
prevalence.\6\ As HBV is also endemic in many regions of the world, 
particularly in Asia and Africa, the foreign-born and their children 
are also at high risk.\7\ Many diverse communities are highly and 
disproportionately impacted by HCV compared to the general population, 
including veterans, especially Vietnam-era service members; the ``baby 
boomer'' birth cohort (born 1945-1965); communities of color, 
particularly Tribal communities; the incarcerated/returning citizens; 
and people who inject drugs.
---------------------------------------------------------------------------
    \6\ Http://www.cdc.gov/hepatitis/Populations/api.htm.
    \7\ Ibid.
---------------------------------------------------------------------------
                       strengthening surveillance
    Surveillance is the core public health service driving effective 
interventions, particularly for infectious disease. The current system 
of surveillance for HBV and HCV is woefully underfunded, and as such 
the available data provides merely a snapshot of the epidemics, albeit 
an alarming one. Without significantly bolstering States' ability to 
leverage existing systems of surveillance, these epidemics will remain 
ahead of our efforts to eliminate them--a goal achievable in the coming 
decades with dedicated resources. Of particular concern is that, 
despite a dearth of surveillance resources, increases in perinatal 
transmission of HCV are being identified, potentially due to the 
equalizing gender balance of people who inject drugs.\8,9\
---------------------------------------------------------------------------
    \8\ Http://slideplayer.com/slide/8867285/.
    \9\ Http://mcaap.org/wp2013/wp-content/uploads/2014-MIAP-
Conference-PM-session4_HCV-among-infants-in-MA_Kerri-Barton.pdf.
---------------------------------------------------------------------------
               hepatitis b, hepatitis c, and liver cancer
    Liver cancer is one of several potential long-term consequences of 
chronic HBV and HCV infection, and is one of the most aggressive and 
deadliest cancers with a devastatingly low 15 percent 5-year survival 
rate for all stages combined.\10\ Despite a downward trend in incidence 
of various cancers, unfortunately liver cancer rates are increasing 
faster than any other cancer site.\11\ The 2016 Annual Report to the 
Nation on the Status of Cancer further found that HCV infection alone 
accounts for 22 percent of the liver cancer burden in the United 
States.\12\ Not only can the debilitating consequences of HBV and HCV 
be avoided with effective intervention--including vaccination and 
treatment for HBV and curative treatment for HCV--addressing these 
epidemics can serve the secondary purpose of preventing a substantial 
proportion of primary liver cancer cases. Indeed, treatment for HBV and 
HCV is associated with 50-80 percent and 75 percent reductions in the 
risk of developing liver cancer, respectively. Continuing the tragic 
effects of preventable health disparities, outcomes also show that the 
AAPI community historically has been most affected by liver cancer, and 
African Americans and Latinos are the youngest to die from liver cancer 
(median age).\13\ Further, entirely preventable perinatal transmission 
of HBV stubbornly remains--a particular danger as about 90 percent of 
infected infants will develop chronic infection and experience these 
devastating consequences far earlier in life.\14\
---------------------------------------------------------------------------
    \10\ Http://www.cancer.org/cancer/livercancer/detailedguide/liver-
cancer-survival-rates.
    \11\ Http://onlinelibrary.wiley.com/doi/10.1002/cncr.29936/pdf.
    \12\ Ibid.
    \13\ Ibid.
    \14\ Https://blog.aids.gov/wp-content/uploads/
Perinatal_HBV_Report_FINAL_12-21-15-508.pdf.
---------------------------------------------------------------------------
            hepatitis c--unique challenges and opportunities

    The HCV epidemic presents in two fairly distinct waves. First is 
the majority of prevalence, existing among the baby boomer birth cohort 
which comprises about 75 percent of those currently living with HCV. 
While this population by and large is not continuing to transmit the 
virus, the majority do not know they are infected and have likely been 
living with HCV for decades. As this community ages, the long term 
impacts of the disease are going to become more apparent as patients 
increasingly present with cirrhosis (scarring) of the liver, end-stage 
liver disease, liver cancer, and the need for liver transplantation. A 
recent study suggests that nearly half of individuals in this birth 
cohort already have severe liver scarring and are in need of immediate 
treatment.\15\ As baby boomers rapidly age into Medicare, it is vital 
to identify those living with HCV and link them to appropriate care and 
treatment. Strikingly, as indicated in the chart above, CDC data 
indicate that as of 2012, mortality attributable to HCV alone now 
surpasses that of all other 59 nationally notifiable infectious 
diseases combined.
---------------------------------------------------------------------------
    \15\ Http://www.hivandhepatitis.com/hepatitis-c/hepatitis-c-topics/
hcv-disease-progression/5086-croi-2015-liver-disease-progression-is-
common-among-baby-boomers-with-hepatitis-c.
---------------------------------------------------------------------------
    Of equal concern is the issue of current and ongoing transmission 
of HCV. As Americans across the Nation have been devastated by the 
crises of opioid and heroin addiction and overdose death, there have 
been parallel increases in HCV, with CDC reporting a 151 percent 
increase in new infections from 2010-2013 (still likely a significant 
underestimate due to lack of surveillance infrastructure), 
predominantly among young people and increasingly in rural and suburban 
areas of the country.\16\ Further, HBV has also been introduced into 
some of these networks, with early 2016 CDC data indicating a 114 
percent increase in acute cases from 2009-2013 in Kentucky, West 
Virginia, and Tennessee.\17\
---------------------------------------------------------------------------
    \16\ Http://www.cdc.gov/hepatitis/statistics/2013surveillance/
commentary.htm#hepatitisC.
    \17\ Http://www.cdc.gov/mmwr/volumes/65/wr/mm6503a2.htm.
---------------------------------------------------------------------------
    Despite the many challenges currently facing us in attempting to 
catch up to this epidemic, this is also a time of tremendous 
opportunity for those living with HCV. In just the past several years, 
new direct-acting antivirals have entered the market that offer cure 
rates of over 90 percent, as well as much shorter regimens and few to 
no side effects compared to previous treatments. With this medical 
innovation has come hope for millions, and an effective intervention 
can be offered to those who test positive.
    Although these new options have revolutionized HCV treatment, and 
there is a safe and effective vaccine and treatment to successfully 
control HBV, there are a number of natural barriers to treating 
everyone who needs it; most significantly, the majority of those living 
with HBV and HCV are unaware of their status, there is a significant 
lack of provider capacity particularly in rural areas and those serving 
immigrant and refugee communities, and surveillance is still piecemeal 
at best.
    Again, we strongly urge the Subcommittee to increase the 
appropriation for CDC's DVH to no less than $62.8 million for fiscal 
year 2017, to maintain language permitting use of Federal funding under 
specific circumstances for syringe services programs as outlined in the 
fiscal year 2016 LHHS Appropriations bill, and to further appropriate 
additional funds specifically to support SSPs in fiscal year 2017. We 
thank Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee for their thoughtful consideration of our request.

    [This statement was submitted by Ryan Clary, Executive Director, 
National Viral Hepatitis Roundtable.]
                                 ______
                                 
        Prepared Statement of the Nephcure Kidney International
            summary of recommendations for fiscal year 2017
_______________________________________________________________________

  --Provide $34.5 billion for the National Institutes of Health (NIH)
  --Provide a corresponding Increase to the NIH Institutes and Centers
  --Support the expansion of the FSGS/NS research portfolio at NIDDK, 
        the Office of Rare Diseases Research (ORDR) and the National 
        Institute on Minority Health and Health Disparities (NIMHD) by 
        funding more research proposals for Primary Glomerular Disease
_______________________________________________________________________

    Thank you for the opportunity to present the views of NephCure 
Kidney International regarding research on idiopathic focal segmental 
glomerulosclerosis (FSGS) and primary nephrotic syndrome (NS). NephCure 
is the only non-profit organization exclusively devoted to fighting 
FSGS and the NS disease group. Driven by a panel of respected medical 
experts and a dedicated band of patients and families, NephCure works 
tirelessly to support kidney disease research and awareness.
    NS is a collection of signs and symptoms caused by diseases that 
attack the kidney's filtering system. These diseases include FSGS, 
Minimal Change Disease and Membranous Nephropathy. When affected, the 
kidney filters leak protein from the blood into the urine and often 
cause kidney failure, which requires dialysis or kidney 
transplantation. According to a Harvard University report, 73,000 
people in the United States have lost their kidneys as a result of 
FSGS. Unfortunately, the causes of FSGS and other filter diseases are 
poorly understood.
    FSGS is the second leading cause of NS and is especially difficult 
to treat. There is no known cure for FSGS and current treatments are 
difficult for patients to endure. These treatments include the use of 
steroids and other dangerous substances which lower the immune system 
and contribute to severe bacterial infections, high blood pressure and 
other problems in patients, particularly child patients. In addition, 
children with NS often experience growth retardation and heart disease. 
Finally, NS that is caused by FSGS, MCD or MN is idiopathic and can 
often reoccur, even after a kidney transplant.
    FSGS disproportionately affects minority populations and is five 
times more prevalent in the African American community. In a 
groundbreaking study funded by NIH, researchers found that FSGS is 
associated with two APOL1 gene variants. These variants developed as an 
evolutionary response to African sleeping sickness and are common in 
the African American patient population with FSGS/NS. Researchers 
continue to study the pathogenesis of these variants.
    FSGS has a large social impact in the United States. FSGS leads to 
end-stage renal disease (ESRD) which is one of the most costly chronic 
diseases to manage. In 2008, the Medicare program alone spent $26.8 
billion, 7.9 percent of its entire budget, on ESRD. In 2005, FSGS 
accounted for 12 percent of ESRD cases in the U.S., at an annual cost 
of $3 billion. It is estimated that there are currently approximately 
20,000 Americans living with ESRD due to FSGS.
    Research on FSGS could achieve tremendous savings in Federal 
healthcare costs and reduce health status disparities. For this reason, 
and on behalf of the thousands of families that are significantly 
affected by this disease, we encourage support for expanding the 
research portfolio on FSGS/NS at the NIH.
                   encourage fsgs/ns research at nih
    There is no known cause or cure for FSGS and scientists tell us 
that much more research needs to be done on the basic science behind 
FSGS/NS. More research could lead to fewer patients undergoing ESRD and 
tremendous savings in healthcare costs in the United States. NephCure 
works closely with NIH and has partnered with NIH on two large studies 
that will advance the pace of clinical research and support precision 
medicine. These studies are the Nephrotic Syndrome Study Network and 
the Cure Glomerulonephropathy Network.
    With collaboration from other Institutes and Centers, ORDR 
established the Rare Disease Clinical Research Network. This network 
provided an opportunity for NephCure Kidney International, the 
University of Michigan, and other university research health centers to 
come together to form the Nephrotic Syndrome Study Network (NEPTUNE). 
Now in its second 5-year funding cycle, NEPTUNE has recruited over 450 
NS research participants, and has supported pilot and ancillary studies 
utilizing the NEPTUNE data resources. NephCure urges the subcommittee 
to continue its support for RDCRN and NEPTUNE, which has tremendous 
potential to facilitate advancements in NS and FSGS research.
    NIDDK recently initiated the Cure Glomerulonephropathy Network 
(Cure GN), a multicenter 5-year cohort study of glomerular disease 
patients. Participants will be followed longitudinally to better 
understand the causes of disease, response to therapy, and disease 
progression, with the ultimate objective to cure glomerulonephropathy. 
NephCure recommends that the subcommittee encourage NIDDK to continue 
to support CureGN as well as other primary glomerular disease program 
announcements.
    It is estimated that annually there are 20 new cases of ESRD per 
million African Americans due to FSGS, and 5 new cases per million 
Caucasians. This disparity is largely due to variants of the APOL1 
gene. Unfortunately, the incidence of FSGS is rising and there are no 
known strategies to prevent or treat kidney disease in individuals with 
the APOL1 genotype. NIMHD began supporting research on the APOL1 gene 
in fiscal year 2013. Due to the disproportionate burden of FSGS on 
minority populations, it remains appropriate for NIMHD to continue to 
advance this research. NephCure asks the subcommittee to encourage 
NIMHD to continue to study FSGS/NS, including the APOL1 gene.
                          patient perspective
    Mac was originally diagnosed with Childhood Nephrotic Syndrome 
after his 5-year-old well-child checkup. Our pediatrician noticed that 
Mac had elevated blood pressure and checked his urine, which was 
positive for protein (3+). Because he seemed so healthy, it was hard to 
believe that our spunky little boy was really sick. We were completely 
shocked and devastated by the news. Being a physician, Mac's dad knew 
enough about this disease to know that it would be life changing for 
all of us. How could Mac look so normal and healthy and be so sick? 
This is a question we continue to ask.
    After a referral to a pediatric nephrologist, we were relieved to 
hear that Mac most likely had Minimal Change Disease and should respond 
to steroid treatment. He was started on steroids and other medications 
to control the symptoms of the disease. In Mac's words, his kidneys 
were ``silly'' and he was a trooper through all of the tests and 
appointments. To our dismay, the steroids did not induce a remission, 
but he was greatly affected by the side-effects of the prednisone. This 
was the first time that he had ever appeared to be unhealthy. He was 
extremely swollen and his blood pressure was even further elevated, 
despite significantly restricting his salt intake and taking an anti-
hypertensive (not to mention the personality changes, hyperactivity, 
mood swings, etc). It was around this time that we realized that Mac's 
cholesterol was alarmingly high, so a statin was added to his daily 
meds.
    After failing to respond to several months of steroid treatment, 
our nephrologist recommended a kidney biopsy to get more information. 
Again, we were encouraged because his kidney tissue appeared normal (no 
evidence of FSGS) and the Minimal Change Disease diagnosis still seemed 
most likely, although our nephrologist always reminded us that FSGS was 
still a possibility. With this news, we were still holding out hope for 
a remission and moved to another course of treatment: cyclosporine.
    Again, while experiencing multiple unpleasant side effects (mood 
swings, fatigue, significant facial/body hair growth), Mac's kidneys 
did not stop spilling protein and his albumin (level of protein in his 
blood) remained significantly low. It was at this time that we decided 
to have some genetic testing and move to a different medication. The 
testing would tell us if Mac has one of the known genetic mutations 
that is linked with Nephrotic Syndrome (and will be highly unlikely to 
respond to treatment. While waiting on the results from the University 
of Michigan, Mac started taking Prograf (tacrilomus). Six months later, 
Mac still failed to show any response to treatment, but seemed to be 
tolerating the Prograf relatively well (other than some problems with 
sleep).
    The results from the genetic testing came back and we were thrilled 
to hear that Mac did not have any of the known genetic mutations. This 
restored hope for a response to treatment and relieved some of the fear 
that our other child could also be predisposed to Nephrotic Syndrome. 
Before deciding on our next step, our nephrologist recommended a second 
biopsy because he was suspicious that our original biopsy may have 
missed FSGS. As we feared, this biopsy did find the scarred tissue that 
confirmed a diagnosis of FSGS. Additional scarring caused by medication 
was also found. With this new information, we investigated the 
available studies that were examining the efficacy of Galactose, which 
is actually a naturally occurring sugar. We were hopeful that Galactose 
would be a great match for Mac, as he was found to be positive for the 
FSGS permeability factor, which Galactose is suspected of binding to, 
preventing the factor from doing its dirty work. Additionally, 
Galactose was a good next step for us because it is naturally occurring 
and should not cause additional scarring to the kidneys. Unfortunately, 
after several months of treatment, Galactose did not work for Mac.
    Discouraged, but not defeated, we made the decision, upon 
recommendation from our nephrologist, to give Mac's little body a break 
from the medications that are attempting to put the disease in 
remission. We decided to simply treat the side-effects of the disease 
(blood pressure, cholesterol, frequent vitamin imbalances, etc). It has 
been over a year now that we have been proceeding this way, and Mac has 
appeared to be healthier than ever. His body has been more effective at 
fighting sicknesses (common cold, flu, stomach viruses, etc) and he 
finally got his energy and appetite back! Although we are always 
looking for a new and promising treatment option for Mac, we are 
enjoying this period of time in which Mac feels well and can focus on 
just being a boy. We realize that things could change at any time.
    Now, more than 6 years into our fight against NS and FSGS, we 
continue to be amazed by Mac's physical and emotional strength through 
this process; however we are frustrated that he has neither been in 
remission nor responded positively to medication.
    Thank you for the opportunity to present the views of the FSGS/NS 
community. Please contact NephCure Kidney International if additional 
information is required.

    [This statement was submitted by Irving Smokler, Ph.D., President 
and Founder, Nephcure Kidney International.]
                                 ______
                                 
          Prepared Statement of the Neurofibromatosis Network
    Thank you for the opportunity to submit testimony to the 
Subcommittee on the importance of continued funding at the National 
Institutes of Health (NIH) for research on Neurofibromatosis (NF), a 
genetic disorder closely linked to many common diseases widespread 
among the American population. We respectfully request that you include 
the following report language on NF research at the National Institutes 
of Health within your fiscal year 2017 Labor, Health and Human 
Services, Education Appropriations bill.
    Neurofibromatosis [NF].--The Committee supports efforts to increase 
funding and resources for NF research and treatment at multiple NIH 
Institutes, including NCI, NINDS, NIDCD, NHLBI, NICHD, NIMH, NCATS, and 
NEI. Children and adults with NF are at significant risk for the 
development of many forms of cancer; the Committee encourages NCI to 
increase its NF research portfolio in fundamental basic science, 
translational research and clinical trials focused on NF. The Committee 
also encourages the NCI to support NF centers, NF clinical trials 
consortia, NF preclinical mouse models consortia and NF-associated 
tumor sequencing efforts. Because NF causes brain and nerve tumors and 
is associated with cognitive and behavioral problems, the Committee 
urges NINDS to continue to aggressively fund fundamental basic science 
research on NF relevant to nerve damage and repair. Based on emerging 
findings from numerous researchers worldwide demonstrating that 
children with NF are at significant risk for autism, learning 
disabilities, motor delays, and attention deficits, the Committee 
encourages NINDS, NIMH and NICHD to expand their investments in 
laboratory-based and clinical investigations in these areas. Since NF2 
accounts for approximately 5 percent of genetic forms of deafness, the 
Committee encourages NIDCD to expand its investment in NF2 basic and 
clinical research. NF1 can cause vision loss due to optic gliomas, the 
Committee encourages NEI to expand its investment in NF1 basic and 
clinical research.
    On behalf of the Neurofibromatosis (NF) Network, a national 
organization of NF advocacy groups, I speak on behalf of the 100,000 
Americans who suffer from NF as well as approximately 175 million 
Americans who suffer from diseases and conditions linked to NF such as 
cancer, brain tumors, heart disease, memory loss, and learning 
disabilities. Thanks in large part to this Subcommittee's strong 
support, scientists have made enormous progress since the discovery of 
the NF1 gene in 1990 resulting in clinical trials now being undertaken 
at NIH with broad implications for the general population.
    NF is a genetic disorder involving the uncontrolled growth of 
tumors along the nervous system which can result in terrible 
disfigurement, deformity, deafness, pain, blindness, brain tumors, 
cancer, and even death. In addition, approximately one-half of children 
with NF suffer from learning disabilities. NF is the most common 
neurological disorder caused by a single gene and is more common than 
Cystic Fibrosis, hereditary Muscular Dystrophy, Huntington's disease 
and Tay Sachs combined. There are three types of NF: NF1, which is more 
common, NF2, which initially involves tumors causing deafness and 
balance problems, and Schwannomatosis, the hallmark of which is severe 
pain. While not all NF patients suffer from the most severe symptoms, 
all NF patients and their families live with the uncertainty of not 
knowing whether they will be seriously affected because NF is a highly 
variable and progressive disease.
    Researchers have determined that NF is closely linked to heart 
disease, learning disabilities, memory loss, cancer, brain tumors, and 
other disorders including deafness, blindness and orthopedic disorders, 
primarily because NF regulates important pathways common to these 
disorders such as the RAS, cAMP and PAK pathways. Research on NF 
therefore stands to benefit millions of Americans.
Learning Disabilities/Behavioral and Brain Function
    Learning disabilities affect one-half of people with NF1. They 
range from mild to severe, and can impact the quality of life for those 
with NF1. In recent years, research has revealed common threads between 
NF1 learning disabilities, autism and other related disabilities. New 
drug interventions for learning disabilities are being developed and 
will be beneficial to the general population. Research being done in 
this area includes a clinical trial of the statin drug Lovastatin, as 
well as other categories of drugs.
Bone Repair
    At least a quarter of children with NF1 have abnormal bone growth 
in any part of the skeleton. In the legs, the long bones are weak, 
prone to fracture and unable to heal properly; this can require 
amputation at a young age. Adults with NF1 also have low bone mineral 
density, placing them at risk of skeletal weakness and injury. Research 
currently being done to understand bone biology and repair will pave 
the way for new strategies to enhancing bone health and facilitating 
repair.
Pain Management
    Severe pain is a central feature of Schwannomatosis, and 
significantly impacts quality of life. Understanding what causes pain, 
and how it could be treated, has been a fast-moving area of NF research 
over the past few years. Pain management is a challenging area of 
research and new approaches are highly sought after.
Nerve Regeneration
    NF often requires surgical removal of nerve tumors, which can lead 
to nerve paralysis and loss of function. Understanding the changes that 
occur in a nerve after surgery, and how it might be regenerated and 
functionally restored, will have significant quality of life value for 
affected individuals. Light-based therapy is being tested to dissect 
nerves in surgery of tumor removal. If successful it could have 
applications for treating nerve damage and scarring after injury, 
thereby aiding repair and functional restoration.
Wound Healing, Inflammation and Blood Vessel Growth
    Wound healing requires new blood vessel growth and tissue 
inflammation. Mast cells, important players in NF1 tumor growth, are 
critical mediators of inflammation, and they must be quelled and 
regulated in order to facilitate healing. Researchers have gained deep 
knowledge on how mast cells promote tumor growth, and this research has 
led to ongoing clinical trials to block this signaling, resulting in 
slower tumor growth. As researchers learn more about blocking mast cell 
signals in NF, this research can be translated to the management of 
mast cells in wound healing.
Cancer
    NF can cause a variety of tumors to grow, which includes tumors in 
the brain, spinal cord and nerves. NF affects the RAS pathway which is 
implicated in 70 percent of all human cancers. Some of these tumor 
types are benign and some are malignant, hard to treat and often fatal. 
Previous studies have found a high incidence of intracranial 
glioblastomas and malignant peripheral nerve sheath tumors (MPNSTs), as 
well as a six fold incidents of breast cancer compared to the general 
population. One of these tumor types, malignant peripheral nerve sheath 
tumor (MPNST), is a very aggressive, hard to treat and often fatal 
cancer. MPNSTs are fast growing, and because the cells change as the 
tumor grows, they often become resistant to individual drugs. Clinical 
trials are underway to identify a drug treatment that can be widely 
used in MPNSTs and other hard-to-treat tumors.
    The enormous promise of NF research, and its potential to benefit 
over 175 million Americans who suffer from diseases and conditions 
linked to NF, has gained increased recognition from Congress and the 
NIH. This is evidenced by the fact that numerous institutes are 
currently supporting NF research, and NIH's total NF research portfolio 
has increased from $3 million in fiscal year 1990 to an estimated $22 
million in fiscal year 2016. Given the potential offered by NF research 
for progress against a range of diseases, we are hopeful that the NIH 
will continue to build on the successes of this program by funding this 
promising research and thereby continuing the enormous return on the 
taxpayers' investment.
    We appreciate the Subcommittee's strong support for NF research and 
will continue to work with you to ensure that opportunities for major 
advances in NF research are aggressively pursued. Thank you.
                                 ______
                                 
                   Prepared Statement of New Leaders
    Thank you for the opportunity to provide testimony regarding the 
fiscal year 2017 Labor, Health and Human Services, Education, and 
Related Agencies Appropriations bill. New Leaders is a national 
nonprofit organization dedicated to providing all children with a high-
quality education that prepares and inspires them be successful in 
college, career, and citizenship. To achieve this critical goal, we 
develop transformational school leaders to serve the Nation's highest-
need communities and we advance the policies and practices that allow 
great leaders across the country to be successful. Since 2001, we have 
developed 2,500 leaders who are currently supporting 450,000 students, 
most of whom are students of color and come from low-income 
backgrounds.
    New Leaders is committed to making every school a place where great 
teachers love to teach and all students love to learn. We can reach 
this goal by paying more attention to how our schools--not just 
individual classrooms, but all classrooms within a school--are 
organized and led. We were pleased that the Every Student Succeeds Act 
(ESSA), passed by Congress in December 2015 to reauthorize the 
Elementary and Secondary Education Act (ESEA), maintains and 
strengthens several programs that provide critical support for school 
leadership. In addition, the authorizing language repeatedly emphasizes 
the important role of principals and school leaders, clearly 
demonstrating that Congress understands the relationship between strong 
school leadership and student success.
    The current appropriations process is an opportunity for Congress 
to solidify its support for school leaders and show its commitment to 
improving student outcomes by making meaningful investments in the 
programs that will enable and empower great principals to create 
schools where teachers can thrive and students can excel.
    As you consider fiscal year 2017 appropriations legislation, we 
urge you to provide robust funding for two programs specifically 
dedicated to fostering highly-effective school leaders: the School 
Leadership Retention and Support Program (SLRSP) and an updated Teacher 
Quality Partnerships (TQP) program.
  --The School Leadership Recruitment and Support Program (SLRSP) was 
        authorized under ESSA with bipartisan support. SLRSP updates 
        the School Leadership program (SLP, the program included in the 
        previous version of ESEA) and will give high-poverty districts 
        resources to develop and support dynamic leaders who have a 
        measurable, positive impact on student achievement. The program 
        empowers eligible entities--including State or local 
        educational agencies--to pursue a range of activities in 
        support of school leadership, including the development and 
        implementation of leadership training programs, the provision 
        of ongoing professional development for school leaders, and the 
        dissemination of best practices regarding the recruitment and 
        retention of highly effective school leaders. In addition, 
        eligible entities may carry out projects in partnership with 
        nonprofit organizations and institutions of higher education 
        (IHEs). Finally, under priorities set forth in the reauthorized 
        statute, SLRSP incentivizes eligible entities to focus on 
        principal preparation and professional development practices 
        for which there is evidence of effectiveness as demonstrated 
        through rigorous research.

    As implementation of ESSA moves to the State, local, and school 
        levels, it is more important than ever that we ensure every 
        school is led by an outstanding principal--a focus that can 
        lead to incredible results for kids. For example, Oakland 
        Unified School District started partnering with New Leaders 
        shortly after the passage of No Child Left Behind to strengthen 
        leadership in its lowest-performing schools. New Leaders' 
        growth in the district was made possible by an SLP grant. With 
        leadership as a key district initiative, Oakland achieved the 
        status of most-improved urban district for 8 years in a row, 
        outpacing the State's Academic Performance Index (API) growth 
        by as much as 25 percent annually. While there's more work to 
        be done, today Oakland schools are vastly different from what 
        they were before the district decided to prioritize school 
        leadership and rethink its approach to principal preparation 
        and support--a reality truly made possible by strategic, timely 
        Federal SLP support. We strongly recommend that Congress 
        allocate at least $30 million for SLRSP in fiscal year 2017, in 
        line with the Administration's budget request and sufficient to 
        carry out a new school leadership competition during the 
        critical planning year before full ESSA implementation takes 
        place in SY2017-18.
  --The Teacher Quality Partnerships Grant Program (TQP) funds 
        partnerships among IHEs and high-need LEAs to create model 
        teacher and principal preparation programs. We support the 
        goals of the TQP program--increasing student achievement by 
        improving the quality of new prospective teachers--and 
        encourage continued funding for this program at $125 million. 
        However, we also believe Federal lawmakers should take steps to 
        strengthen the program and, in particular, ensure that it 
        reflects the importance of school leaders. First, TQP should 
        fund partnerships among high-performing educator preparation 
        programs (including those run by both IHEs and nonprofit 
        organizations) and high-need LEAs. Current law needlessly 
        restricts eligibility and prevents proven, non-university-based 
        programs from applying--doing a significant disservice to high-
        need LEAs that wish to partner with an alternative program that 
        best meets its talent needs. In addition, TQP should allow 
        grantees to use funds to support programs that prepare teacher 
        leaders and principals, regardless of whether the partnership 
        also intends to prepare teachers. Finally, to strengthen our 
        collective understanding of the types of programs that prepare 
        highly effective educators, TQP should require grantees to 
        report on key outcomes measures, including those related to 
        graduates' placement and retention in relevant positions and 
        their influence on student achievement, among other potential 
        measures. Ideally, the recommendations listed above would be 
        incorporated into the reauthorization of the Higher Education 
        Act. Given the limited time left to legislate this year, we 
        believe that the President's proposed Teacher and Principals 
        Pathway program could serve as an opportunity to update and 
        replace TQP. We support $125 million in funding for the Teacher 
        and Principal Pathways program proposed in the Administration's 
        fiscal year 2017 budget request, including $35 million 
        dedicated specifically to principals.
    In addition to SLRSP and TQP, there are a number of other programs 
that have the potential to positively impact school leadership.
    The Education Innovation and Research (EIR) program provides 
support and creates a framework for developing, validating, and scaling 
up effective, innovative interventions for addressing persistent 
education challenges. Therefore, EIR can play a key role in identifying 
and expanding school leadership development programs that truly have a 
positive effect on student achievement and school performance, 
especially in predominantly low-income districts. New Leaders 
recommends funding EIR at a level of $180 million, the amount requested 
by the Administration.
    In addition, the Teacher and School Leader Incentive Program 
(TSLIP) provides for the development and implementation of sustainable, 
performance-based compensation systems for teachers, principals, and 
other personnel in high-need schools in order to increase educator 
effectiveness and student achievement. This program has been 
instrumental in helping schools and districts move from a pay system 
based primarily on seniority to one that focuses on student outcomes. 
New Leaders recommends at least $250 million in funding for TSLIP in 
fiscal year 2017--the amount requested by the Administration--and a 
continued focus on improving broader human capital systems in schools.
    Finally, the Supporting Effective Educator Development program 
(SEED) makes grants to national nonprofit organizations for projects 
that recruit, select, prepare, or provide professional development 
activities for teachers or principals. The importance of recruiting, 
training, and retaining effective principals and other school leaders 
cannot be overstated. School leaders account for 25 percent of a 
school's effect on a student achievement,\1\ and 97 percent of teachers 
say that the principal is responsible for determining whether a school 
can attract and retain great teachers.\2\ It is imperative that we make 
the necessary investments in evidence-based programs that help develop 
and retain outstanding leaders. New Leaders recommends that SEED be 
funded at $100 million in fiscal year 2017, as recommended in the 
Administration's budget request.
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    \1\ Leithwood, K., Louis, K. S., Anderson, S., & Wahlstrom, K. 
(2004). How Leadership Influences Student Learning. New York, NY: 
Wallace Foundation.
    \2\ Scholastic Inc. (2012). Primary Sources: America's Teachers on 
the Teaching Profession. New York, NY: Scholastic and the Bill and 
Melinda Gates Foundation.
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    Thank you for the opportunity to provide the views of New Leaders 
on the fiscal year 2017 appropriations. If you would like to discuss 
our recommendations, please do not hesitate to contact our Chief Policy 
Officer, Jackie Gran, at policyteam@newleaders.org.

    [This statement was submitted by Jean Desravines, CEO, New 
Leaders.]
                                 ______
                                 
    Prepared Statement of the North American Society for Pediatric 
               Gastroenterology, Hepatology and Nutrition
    We are pleased to offer testimony on the need for a public/private 
safety registry for pediatric patients with inflammatory bowel disease 
(IBD). Specifically, we request on behalf of the North American Society 
for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and 
the Pediatric IBD Foundation Subcommittee consideration of the 
following report language to the fiscal year 2017 Labor, Health and 
Human Services, Education and Related Agencies Appropriations bill:
    Pediatric IBD Safety Registry: The vast majority (an estimated 80 
percent) of medications prescribed by physicians to treat children with 
inflammatory bowel disease (IBD) are prescribed ``off-label'' without 
any mechanism to monitor safety. The Committee recognizes the need for 
a national pediatric IBD population-based database to capture 
information on evidence-based health outcomes related to specific 
therapies and interventions, including concomitant medications and 
adverse events, and to make data accessible to physicians, patients, 
industry, researchers, and Federal agencies. The Secretary, acting 
through the National Institutes of Health, in consultation with the 
Food and Drug Administration, is encouraged to enter into cooperative 
agreements with public or private entities for the collection, analysis 
and reporting of data on pediatric IBD.
Prevalence of Inflammatory Bowel Disease
    An estimated 1.6 million Americans are living with IBD (Crohn's 
disease and ulcerative colitis), with nearly one in four patients 
diagnosed under 20 years of age. IBD is a chronic inflammatory disorder 
of the intestines that does not have an identifiable cause (such as 
infection). Pediatric IBD causes the immune system to become 
inappropriately active, causing injury to the intestines. IBD does not 
have a medical cure but can be managed effectively through medication 
or other treatments. When IBD is not effectively managed, children do 
not grow normally because of a lack of absorption of nutrients. Many 
suffer constant intestinal pain causing them to miss school, have 
chronic diarrhea, multiple surgeries and, in some instances, wear 
colostomy bags.
Treating Inflammatory Bowel Disease
    Treatment of a child with active Crohn's disease typically involves 
an induction regimen that includes a potent therapy with a rapid onset 
of action. If a remission is achieved, the patient can be transitioned 
to a maintenance regimen, typically involving medications with a slower 
onset of action and fewer side effects. The selection of drugs for 
induction and maintenance depend on age, disease severity, location, 
and clinical course. In general, very young children with IBD are more 
likely to have severe or refractory disease, and to have an 
identifiable genetic cause of the disease (monogenic IBD).
    The ideal goal of treatment is clinical and laboratory remission 
with mucosal healing, not just symptomatic improvement. However, 
achieving this goal must be balanced against the risks of IBD 
therapies. Patients who achieve clinical, laboratory, and endoscopic 
remission may have better long-term outcomes. Optimal care therefore 
typically includes one of the following approaches:
  --Accelerated ``step-up'' therapy for most patients--Initiate 
        treatment with the least potent drug predicted to be effective, 
        promptly step-up therapy to more potent drug if response is 
        incomplete.
  --``Top-down'' therapy for selected high-risk patients and often 
        minority children--Early treatment with a highly potent 
        immunosuppressant (e.g., anti-tumor necrosis factor antibody) 
        for patients with high risks of complicated disease.
    With either approach, close monitoring of patients is important to 
assess for remission (including upper endoscopy and colonoscopy) and to 
monitor for drug toxicities.
Why a Pediatric IBD Registry is Needed
    There are many pediatric diseases and conditions for which great 
benefit could be derived through coordinated data collection. However, 
the creation of a pediatric IBD registry, which could serve as a model 
for other condition-based registries, should be more immediately 
supported by Congress for the following reasons:
    Monitoring the Safety of Off-Label Prescribing.--When medications 
are prescribed for the treatment of IBD in children, the vast majority 
of these medications (an estimated 80 percent) are not approved by the 
Food and Drug Administration (FDA) for the indication at the time they 
are given--meaning, they are not approved by the FDA for use in 
children and are therefore used ``off-label.'' Medications used to 
treat IBD are first approved in adults and approval for children may 
come many years later, if at all, for a variety of reasons which we 
believe must also be addressed by Congress and the FDA. When 
medications, often found to be highly effective, are prescribed off-
label to children, there is no mechanism to monitor safety, including 
potential side-effects and contra-indications. For example, a 
medication approved for treatment of Crohn's disease in adults was 
recently found to cause a rare but fatal lymphoma in boys who received 
the medication in combination with another Crohn's treatment. A 
national registry might have identified this problem much earlier.
    Expediting the Approval of Drugs for Pediatric Indications.--When 
medications are prescribed off-label, such is the case with medications 
to treat pediatric IBD, families frequently incur significant out-of-
pocket costs. This is because insurers will not cover medications for 
indications that are not FDA-approved, even though they are prescribed 
by physicians and are essential to properly and effectively treat these 
children, for whom there are few FDA-approved options. A pediatric IBD 
registry would help expedite drug approvals and encourage drug 
companies to pursue pediatric indications for FDA-approved drugs by 
allowing them to access a central data repository rather than 
establishing cost-prohibitive, proprietary, drug-specific registries 
for safety monitoring. Moreover, a registry would greatly enhance 
global pediatric drug development so medications that carry serious 
side-effects to treat IBD disease can be avoided and prescribed in more 
thoughtful evidence-based ways or replaced with better therapies.
    Informing Physician Decision-Making.--A public-private pediatric 
IBD registry would be accessible to physicians and patients to aid in 
treatment decisionmaking. The need for better data to inform treatment 
decisionmaking is of particular importance when caring for minority 
populations. Recent epidemiologic studies describe incidence rates of 
IBD among African American children have approached and even surpassed 
those in Caucasians. Furthermore, studies have shown that African 
American children are diagnosed later, when compared to Caucasian 
children. This could be for a variety of reasons, although it is 
speculated that the older age of IBD diagnosis among African American 
children may be due in part to a low index of suspicion for IBD in 
minority children among medical providers because IBD has traditionally 
been viewed as a disease of Caucasians and adults. Furthermore, under-
represented minorities often have decreased access to medical care or 
different patterns of healthcare seeking behavior thereby leading to 
much longer delays in diagnosis of IBD in African American children 
than in Caucasian children and, more importantly, the initiation of 
critically needed IBD therapy.
    Studies continue to show that the disease natural history in 
African American children is more aggressive, prone to more 
complications, and requires more interventions, including more powerful 
medications (i.e., biologics) at earlier stages of the disease after 
initial diagnosis (i.e., top-down therapy). Top down therapy (starting 
with an immune system suppressing biologic) has also been shown to be 
more commonly employed in African American pediatric populations with 
IBD, thus putting these children even more at risk for long-term use of 
these medications. Additionally, reporting adverse effects and safety 
monitoring is presently voluntary in the United States--a factor which 
further contributes to the difficulties facing underserved populations.
    IBD in minority populations--African American, Hispanic, African 
Caribbean--is clearly and substantially increasing in its frequency, 
and, represents a more aggressive type of IBD. Therefore, it is 
paramount that a mechanism be in place to monitor safety of the 
medications used to treat children with IBD, including minority 
populations.
    Maintaining a Central IBD Data Repository.--The goal of the 
aforementioned report language is the creation of a central data 
repository, which would supplement proprietary, drug-specific 
registries. Children being treated with IBD medications benefit from 
FDA-mandated registries, but these registries are often single product 
and proprietary. Since children are often on multiple products, these 
registries do not monitor the safety of drug interactions. In addition, 
most pediatric IBD therapies (approximately 80 percent) are off-label 
and manufacturers are not required to collect data on off-label use. 
Furthermore, significant safety data captured on a competitor's 
medication may not be made public, and these registries lack uniformity 
of data collection.
    Building on Previous Federal Investments.--We envision that 
existing IBD registries would share data points with the public IBD 
registry which would connect to an existing registry for pediatric 
rheumatology (CARRA--Childhood Arthritis and Rheumatoid Research 
Alliance). Connection to the CARRA registry would benefit both 
pediatric IBD and rheumatology patients because these auto-immune 
diseases are often treated with the same medications. CARRA was started 
with a $7.5 million grant to the National Institutes of Health (NIH) in 
2009 as a result of funding through the American Recovery and 
Reinvestment Act. Building on this federally-funded registry would 
encourage data sharing, extend the government's return on investment, 
and allow Federal regulators and researchers to access data without 
having to rely on proprietary registries. Presently CARRA is the only 
registry that meets Federal data sharing requirements per 21CFR-11. We 
appreciate the interest by many in Congress of a post-marketing data 
sharing system that could facilitate drug approval for treating rare 
diseases like pediatric IBD, particularly in diseases where many 
products are used off-label, thus relieving manufacturers from the 
obligation of collecting data. Fulfilling the vision of such a post-
marketing data sharing system would require each component (i.e., each 
registry) to meet compliance with 21CFR-11. Therefore the development 
of a pediatric IBD registry that meets 21CFR-11 requirements and its 
interconnectivity with the CARRA registry, which already meets these 
requirements, would offer an excellent demonstration of registry 
interconnectivity.
Conclusion
    A number of organizations have previously joined NASPGHAN and the 
Pediatric IBD Foundation in calling for a pediatric IBD registry, 
including the American Medical Association, the American Academy of 
Pediatrics and the American Gastroenterological Association.\1\ We 
believe report language specifying the need for a pediatric IBD 
registry is necessary for the initiation of a public-private 
partnership. Indeed, this language provides flexibility to the NIH and 
the FDA to initiate collaborative arrangements with other public and 
private entities as they did with the CARRA registry, which is an 
independent 501(c)(3). In this way, the registry is supported with a 
minimal outlay of Federal resources.
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    \1\ Letter to Sen. Llamar Alexander and Sen. Patty Murray, 
September 9, 2015.
---------------------------------------------------------------------------
    On behalf of the thousands of children with IBD, their families, 
and pediatric gastroenterologists, we thank you for your consideration 
of our request.

    [This statement was submitted by Carlo Di Lorenzo, MD, Nationwide 
Children's Hospital, Columbus, OH, President, North American Society 
for Pediatric Gastroenterology, Hepatology and Nutrition; Benjamin 
Gold, MD, Children's Center for Digestive Healthcare, Atlanta, GA, 
Member, North American Society for Pediatric Gastroenterology, 
Hepatology and Nutrition, Public Affairs and Advocacy Committee; Eric 
Zuckerman, DO, Bloomfield Hill, MI, Board Chairman, Pediatric IBD 
Foundation.]
                                 ______
                                 
              Prepared Statement of the Nursing Community
    The Nursing Community is a coalition comprised of 62 national 
professional nursing associations that builds consensus and advocates 
on a wide spectrum of healthcare issues surrounding education, 
research, and practice. These organizations are committed to promoting 
America's health through the advancement of the nursing profession. 
Collectively, the Nursing Community represents over one million 
Registered Nurses (RNs), Advanced Practice Registered Nurses (including 
certified nurse-midwives (CNMs), nurse practitioners (NPs), clinical 
nurse specialists (CNSs), and certified registered nurse anesthetists 
(CRNAs)), nurse executives, nursing students, faculty, researchers, and 
other nurses with advanced degrees. For fiscal year 2017, our 
organizations respectfully request $244 million for the Health 
Resources and Services Administration's (HRSA) Nursing Workforce 
Development programs (authorized under Title VIII of the Public Health 
Service Act [42 U.S.C. 296 et seq.]) and $157 million for the National 
Institute of Nursing Research (NINR), one of the Institutes and Centers 
within the National Institutes of Health (NIH).
  title viii programs: responding to the needs of america's patients 
                          through nursing care
    As integral members of the healthcare team, nurses collaborate with 
other professions and disciplines to improve the quality of America's 
healthcare system. The reach of their care is vast: they offer 
essential patient care in a variety of settings, including hospitals, 
long-term care facilities, community centers, State and local health 
departments, schools, workplaces, and patient homes. RNs comprise the 
largest group of health professionals with over three million licensed 
providers in the country.\1\ A constant focus must be placed on 
education, recruitment, and retention to ensure a stable workforce, 
particularly in geographic regions that will continue to experience 
health provider shortages in the coming years. A significant investment 
must be made in the education of new nurses to provide the Nation with 
the services it demands. For over 50 years, the Nursing Workforce 
Development programs, authorized under Title VIII of the Public Health 
Service Act, have helped to build the supply and distribution of 
qualified nurses to meet our Nation's healthcare needs. Title VIII 
programs bolster nursing education at all levels, from entry-level 
preparation through graduate study, and provide support for 
institutions that educate nurses for practice in rural and medically 
underserved communities. Today, the Title VIII programs are essential 
to ensuring the demand for nursing care is met. Title VIII programs 
target specific aspects of America's nursing workforce and patient 
populations that require Federal support in order to ensure efficient 
and effective delivery of healthcare services.
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    \1\ National Council of State Boards of Nursing. (2016). Active RN 
Licenses: A profile of nursing licensure in the U.S. as of January 23, 
2016. Retrieved from: https://www.ncsbn.org/6161.htm.
---------------------------------------------------------------------------
    For example, according to HRSA, there were over 61.2 million 
individuals living in primary care Health Professional Shortage Areas 
as of December 2015.\2\ Title VIII programs provide graduate students 
and practicing nurses exposure to caring for underserved communities 
such as these, thus helping to bolster recruitment and retention in 
these areas. In academic year 2014-2015, the Title VIII Advanced 
Education Nursing Traineeships supported 3,008 students, of which 72 
percent were trained in primary care,\3\ and the Title VIII Nurse 
Anesthetist Traineeships supported 3,229 students, of which 64 percent 
were trained in Medically Underserved Areas.4 Moreover, the U.S. Bureau 
of Labor Statistics' projection that employment of CRNAs, CNMs, and NPs 
is expected to grow 31 percent between 2012 and 2022.\4\ These programs 
strengthen the supply of these clinicians.
---------------------------------------------------------------------------
    \2\ U.S. Health Resources and Services Administration. (2016). 
Designated Health Professional Shortage Areas Statistics. Retrieved 
from: https://ersrs.hrsa.gov/ReportServer?/HGDW_Reports/BCD_HPSA/
BCD_HPSA_SCR50_Qtr_Smry_HTML&rc:Toolbar=false.
    \3\ U.S. Department of Health and Human Services. (2016). Health 
Resources and Services Administration Fiscal year 2017 Justification of 
Estimates for Appropriations Committees. Retrieved from: http://
www.hrsa.gov/about/budget/budgetjustification2017.pdf.
    \4\ U.S. Bureau of Labor Statistics. (2014). Occupational Outlook 
Handbook. Registered Nurses. Retrieved from: http://www.bls.gov/ooh/
healthcare/registered-nurses.htm.
---------------------------------------------------------------------------
    Additionally, the Title VIII NURSE Corps Loan Repayment and 
Scholarship Programs assist students who agree to serve at least 3 
years in facilities experiencing a critical shortage of providers.\4\ 
Last year, 55 percent of the Loan Repayment Program recipients extended 
their service contracts to work in these facilities beyond the required 
3 years.\4\ Clearly, these programs are instrumental to connecting 
current and future providers to patient populations most in need.
    America's aging population is another sector that will require 
additional providers. According to the U.S. Census Bureau, it is 
estimated that by year 2050, the number of people in the U.S. age 65 
and older will reach 83.7 million (nearly one-quarter of the projected 
population).\5\ Rising rates of chronic illness, coupled with an 
expanding population, will necessitate a cadre of nurses to care for 
these individuals. The Title VIII Comprehensive Geriatric Education 
program is designed to meet this call. In academic year 2014-2015 
alone, there were 22,743 students and trainees supported through these 
grants. These individuals are the future caregivers to elderly 
Americans. Funding through this program was utilized to prepare faculty 
members, develop and disseminate geriatric curriculum, and provide 
traineeships for students pursuing advanced education nursing degrees 
in gero-psychiatric nursing, long-term care, and other nursing 
specialties centered on caring for elderly populations.
---------------------------------------------------------------------------
    \5\ U.S. Census Bureau. (2014). An Aging Nation: The Older 
Population in the United States. Retrieved from: https://
www.census.gov/prod/2014pubs/p25-1140.pdf.
---------------------------------------------------------------------------
  --The Nursing Community respectfully requests $244 million for the 
        Nursing Workforce Development programs in fiscal year 2017.
 national institute of nursing research: foundation for evidence-based 
                                  care
    The care that nurses provide must be rooted in evidence. As one of 
the 27 Institutes and Centers at the NIH, NINR funds research that lays 
the groundwork for evidence-based nursing practice. NINR examines ways 
to improve care models to deliver safe, high-quality, and cost-
effective health services to the Nation. Our country must look toward 
the prevention aspect of healthcare as the vehicle for saving our 
system from further financial burden, and the work of NINR embraces 
this endeavor through research related to care management of patients 
during illness and recovery, reduction of risks for disease and 
disability, promotion of healthy lifestyles, enhancement of quality of 
life for those with chronic illness, and care for individuals at the 
end of life. NINR addresses these challenges through its Strategic 
Plan, which includes the themes of: symptom science for patients with 
chronic illness and pain; wellness to prevent illness across 
conditions, settings, and the lifespan; patient self-management to 
improve qualify of life; and end-of-life and palliative care 
science.\6\
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    \6\ National Institutes of Health. National Institute of Nursing 
Research. Implementing NINR's Strategic Plan: Key Themes. Retrieved 
from: http://www.ninr.nih.gov/aboutninr/keythemes#.VRVhGWZ_SSU.
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    In addition, NINR recognizes the need for improving global health 
and promotes research to reduce communicable diseases and improve 
public health and wellness such as maternal-newborn care. Moreover, 
NINR allots a generous portion of its budget towards training new 
nursing scientists, thus helping to sustain the longevity and success 
of nursing research. Training programs at NINR develop future nurse 
researchers, many of whom also serve as faculty in our Nation's nursing 
schools.
  --The Nursing Community respectfully requests $157 million for the 
        NINR in fiscal year 2017.
    The Ad Hoc Group for Medical Research requests at least $34.5 
billion for NIH in 2017, and the request level of $157 million for NINR 
denotes the same percentage increase for NIH applied to NINR.
       members of the nursing community submitting this testimony
Academy of Medical-Surgical Nurses
American Academy of Ambulatory Care Nursing
American Academy of Nursing
American Assembly for Men in Nursing
American Association of Colleges of Nursing
American Association of Critical-Care Nurses
American Association of Heart Failure Nurses
American Association of Neuroscience Nurses
American Association of Nurse Anesthetists
American Association of Nurse Assessment Coordination
American Association of Nurse Practitioners
American Association of Occupational Health Nurses
American College of Nurse-Midwives
American Nephrology Nurses' Association
American Nurses Association
American Organization of Nurse Executives
American Pediatric Surgical Nurses Association
American Psychiatric Nurses Association
American Society for Pain Management Nursing
American Society of PeriAnesthesia Nurses
Association for Radiologic and Imaging Nursing
Association of Community Health Nursing Educators
Association of Nurses in AIDS Care
Association of Pediatric Hematology/Oncology Nurses
Association of Public Health Nurses
Association of Rehabilitation Nurses
Association of Women's Health, Obstetric and Neonatal Nurses
Commissioned Officers Association of the U.S. Public Health Service
Dermatology Nurses' Association
Emergency Nurses Association
Gerontological Advanced Practice Nurses Association
Hospice and Palliative Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Society of Psychiatric-Mental Health Nurses
National Association of Clinical Nurse Specialists
National Association of Neonatal Nurse Practitioners
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women's Health
National Association of Pediatric Nurse Practitioners
National Black Nurses Association
National Council of State Boards of Nursing
National Gerontological Nursing Association
National League for Nursing
National Nursing Centers Consortium
National Organization of Nurse Practitioner Faculties
Nurses Organization of Veterans Affairs
Oncology Nursing Society
Organization for Associate Degree Nursing
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
Public Health Nursing Section, American Public Health Association
Society of Urologic Nurses and Associates
The Quad Council of Public Health Nursing Organizations
Wound, Ostomy and Continence Nurses Society
                      
                                 ______
                                 
                Prepared Statement of Open Hand Atlanta
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Open Hand Atlanta is part of a nationwide coalition, the Food is 
Medicine Coalition, of over 80 food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide 1.5 million 
medically tailored, home delivered meals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are walk-in food pantries and voucher programs. For those whose disease 
has progressed, home-delivered meals, home-delivered grocery bags, and 
supplements complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
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Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
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            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
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    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Matthew Pieper, Executive 
Director, Open Hand Atlanta, Inc.]
                                 ______
                                 
               Prepared Statement of Oral Health America
    Mr. Chairman, Ranking Member, and distinguished Members of the 
Subcommittee, Oral Health America (OHA), a leading organization 
dedicated to changing lives by connecting communities with resources to 
drive access to care, increase health literacy and advocate for 
policies that improve overall health through better oral health for all 
Americans, especially those most vulnerable; is requesting fiscal year 
2017 funding for all programs administered under the Older Americans 
Act (OAA) (U.S. Department of Health and Human Services, Administration 
on Aging) be restored to at least fiscal year 2010 levels. Of 
particular interest to OHA is to ensure Title III-D, Disease Prevention 
and Health Promotion, is restored to at least $21,000,000 because of 
the cost-effectiveness that health education, health promotion, and 
disease prevention programs provide to the system. Since fiscal year 
2012, Title III-D funding has remained stagnant at $19,848,000.
    The OAA provides Federal programs that serve to meet the needs of 
millions of older Americans. We understand the United States continues 
to operate amid a challenging budgetary environment. However, OHA 
believes that proper Federal investment in the OAA is critical to keep 
pace with the rate of inflation and to meet the needs of this ever-
growing segment of the population through the multitude of services the 
OAA provides. Simply stated, proper investment in OAA saves taxpayer 
dollars. This is especially evident when it comes to health services. 
Health services that emphasize prevention and promotion will help to 
reduce disease, leading to the improvement of the overall health and 
well-being of America's older adults and resulting in the reduction of 
premature and costly medical interventions. OHA strongly contends that 
one's health and overall well-being begins with proper oral health. 
This core belief applies throughout the lifespan and especially with 
older adults.
                               background
    The population of the United States is aging at an unprecedented 
rate. Older adults make up one of the fastest growing segments of the 
American population. In 2009, 39.6 million seniors were U.S. residents. 
This aging cohort is expected to reach 72.1 million by 2030--an 
increase of 82 percent.\1\
---------------------------------------------------------------------------
    \1\ Administration on Aging. (2013). Aging Statistics. Retrieved 
from http://www.aoa.gov/Aging_Statistics/.
---------------------------------------------------------------------------
    The oral health of older Americans is in a state of decay. The 
reasons for this are complex. Limited access to dental insurance, 
affordable dental services, community water fluoridation, and programs 
that support oral health prevention and education for older Americans 
are significant factors that contribute to the unmet dental needs and 
edentulism among older adults, particularly those most vulnerable. 
While improvements in oral health across the lifespan have been 
observed in the last half century, long term concern may be warranted 
for the 10,000 Americans retiring daily, as it is estimated that only 
9.8 percent of this ``silver tsunami''--baby boomers turning age 65--
will have access to dental insurance benefits.\2\
---------------------------------------------------------------------------
    \2\ Consumer Survey, National Association of Dental Plans. 2012.
---------------------------------------------------------------------------
    Dental Health and Disparities.--Oral health data reveals that many 
older adults experience adverse oral health associated with chronic and 
systemic health conditions. For example, associations between heart 
disease, periodontitis and diabetes have emerged in recent years, as 
well as oral conditions such as xerostomia associated with the use of 
prescription drugs.\3,4\ Xerostomia, commonly known as dry mouth, 
contributes to the inception and progression of dental caries 
(cavities). For older Americans, the occurrence or recurrence of dental 
caries coupled with an inability to access treatment may lead to 
significant pain and suffering along with other detrimental health 
effects.
---------------------------------------------------------------------------
    \3\ Ira B. Lamster, DDS, MMSc, Evanthia Lalla, DDS, MS, Wenche S. 
Borgnakke, DDS, PhD and George W. Taylor, DMD, DrPH. (2008). Journal of 
the American Dental Assocation.
    \4\ Fox, Philip C. (2008). Xerostomia: Recognition and Management. 
Retrieved from: http://www.colgateprofessional.com.hk/LeadershipHK/
ProfessionalEducation/Articles/Resources/profed_art_access-supplement-
2008-xerostimia.pdf.
---------------------------------------------------------------------------
    These oral conditions disproportionately affect persons with low 
income, racial and ethnic minorities, and those who have limited or no 
access to dental insurance. Older adults with physical and intellectual 
disabilities and those persons who are homebound or institutionalized 
are also at greater risk for poor oral health.\5\
---------------------------------------------------------------------------
    \5\ U.S. Department of Health and Human Services. (2000). Oral 
Health in America:
A Report of the Surgeon General. Retrieved from http://silk.nih.gov/
public/hck1ocv.@
www.surgeon.fullrpt.pdf.
---------------------------------------------------------------------------
    As examples of these disparities, older African American adults are 
1.88 times more likely than their white counterparts to have 
periodontitis; \6\ low-income older adults suffer more than twice the 
rate of gum disease than their more affluent peers (17.49 verses 8.62 
respectively); and Americans who live in poverty are 61 percent more 
likely to have lost all of their teeth when compared to those in higher 
socioeconomic groups.
---------------------------------------------------------------------------
    \6\ Borrel, L.N., Burt, B.A., & Taylor, G.W. (2005, October). 
Prevalence and Trends in Periodontitis in the USA: from the NHANES III 
to the NHANES, 1988 to 2000. Journal of Dental Research,84(10). 
Retrieved from http://jdr.sagepub.com/content/84/10/924.abstract.
---------------------------------------------------------------------------
    Aging in Place.--Despite these existing conditions, recent dental 
public health trends demonstrate that as the population at large ages, 
older Americans are increasingly retaining their natural teeth.\7\ 
Today, many older adults benefit from healthy aging associated with the 
retention of their natural teeth, improvements in their ability to 
chew, and the ability to enjoy a variety of food choices not previously 
experienced by earlier generations of their peers.
---------------------------------------------------------------------------
    \7\ Dolan, T. A., Atchison, K., & Huynh, T. N. (2005). Access to 
Dental Care Among Older Adults in the United States. Journal of Dental 
Education, 69(9), 961-974. Retrieved from http://www.jdentaled.org/
content/69/9/961.long.
---------------------------------------------------------------------------
    Nearly 90 percent of older adults want to stay in their own homes 
as they age, often referred to as ``Aging in Place.'' Today's older 
adults are living more independently than previous generations. In 
fact, only 9 percent of older adults live in a long term care setting. 
Maintaining a healthy mouth is one of the keys to independence as we 
age, however resources for oral health remain conspicuously absent from 
home and community-based services and are largely disconnected and 
difficult to access.
    Oral Care Provider Issues.--Although a growing number of older 
Americans need oral healthcare, the current workforce is challenged to 
meet the needs of older adults. The current dental workforce is aging, 
and many dental professionals will retire within the next decade. A 
lack of geriatric specialty programs complicates this problem, and few 
practitioners are choosing geriatrics as their field of choice.
    While these trends are favorable, adverse oral health consequences 
are emerging. Due to reasons stated in this report, together with 
increased demand for services, lack of access to dental benefits 
through Medicare, increased morbidity and mobility among older adults, 
and reduced income associated with aging and retirement, many older 
Americans are unable to access oral healthcare services. As a result, 
many older adults who have retained their natural teeth are now 
experiencing dental problems.
              older adults' oral health in state of decay
    OHA's 2016 A State of Decay, Vol. III report is a State-by-State 
analysis of oral healthcare delivery and public health factors 
impacting the oral health of older adults. The report revealed more 
than half of the country received a ``fair'' or ``poor'' assessment 
when it comes to minimal standards affecting dental care access for 
older adults. The top findings of the report were:
  --Tooth loss continues to be a signal of suboptimal oral health. 
        There are eight States with a 20 percent or more rate of 
        edentulism, with West Virginia still notably having an older 
        adult population that is 33.6 percent edentate.
  --Communities without fluoridated water ignore opportunities for 
        prevention. While States have increased the rates of 
        communities with fluoridated water since 2010, five States (10 
        percent) still have 60 percent or more of their residents 
        living in communities unprotected by fluoridated water. Hawaii 
        (89.2 percent) and New Jersey (85.4 percent) have the highest 
        rates of unprotected citizens, representing an unnecessary 
        public peril 70 years after Community Water Fluoridation (CWF) 
        was introduced and since named a public health best practice.
  --Persistent shortage of oral health coverage. Sixteen percent (8 
        States) cover no dental services through Medicaid and only four 
        States (8 percent) cover the maximum possible dental services 
        in Medicaid.
  --Critical lack of a strategic plan to address the oral health of 
        older adults. Eighty-four percent (42 States) lack a State Oral 
        Health Plan that both mentions older adults and includes SMART 
        objectives. Of the 42 States, 14 lack any type of State Oral 
        Health Plan.
  --Inadequate surveillance of the oral health condition of older 
        adults persists. Forty-six percent (23 States) have never 
        completed a Basic Screening Survey of older adults and have no 
        plan to do so.
    Moreover, poor oral health has substantial financial implications. 
For example, in 2010 alone, between $867 million and $2.1 billion was 
spent on emergency dental procedures.\8\ When compared to care 
delivered in a dentist's office, hospital treatments are nearly ten 
times more expensive than the routine care that could have prevented 
the emergency. This places a costly yet avoidable burden on both the 
individual and the health institutions that must then bear the expense.
---------------------------------------------------------------------------
    \8\ Wall, Thomas and Nasseh, Dr. Kamyar, ``Dental-Related Emergency 
Department Visits on the Increase in the United States,'' Health Policy 
Institute, ADA, May 2013, http://www.ada.org//media/ADA/
Science%20and%20Research/HPI/Files/HPIBrief_0513_1.ashx.
---------------------------------------------------------------------------
    In sum, oral health and access to preventive care significantly 
impact overall health and expenditure, yet are difficult to maintain--
particularly for older adults--in the Nation's present context of 
support systems and healthcare.
     how oha empowers older adults to meet their oral health needs

    Oral Health America's Wisdom Tooth Project aims to change the 
lives of older adults especially vulnerable to oral disease. Its goal 
is to educate Americans about the oral health needs of older adults, 
connect older adults to local resources, and to advocate for policies 
that will improve the oral health of older adults. The Wisdom Tooth 
Project achieves these goals through five strategies: our web portal, 
regional symposia, communications, advocacy and demonstration projects.
    In addition to the A State of Decay report referenced above, a 
vital component of the Wisdom Tooth Project is Toothwisdom.org, which 
is a first-of-its-kind website created to connect older adults and 
their caregivers to local care and education around the oral health 
issues they face, the importance of continuing prevention as we age, 
and the overall impact of oral health on overall health.
    importance of oaa reauthorization to oral health of older adults
    Recognizing this current state of oral health among older adults, 
Oral Health America vigorously applauds Congress for passing the 
bipartisan-supported Older Americans Act reauthorization, S.192. The 
bill includes--for the first time--a small provision that allows the 
Aging Network to use funds they receive for disease prevention and 
health promotion activities to conduct oral health screenings. 
Preventive dental care that can be provided through oral health 
screenings can head off more expensive dental work and help prevent 
severe diseases. Unfortunately, dentists see older adults everyday 
living with infection and pain that could be easily avoided with proper 
care that these screenings could provide. Although the oral health 
screenings provision would not require new or additional funding under 
Title III-D, Disease Prevention and Health Promotion Services, 
restoring funding to at least fiscal year 2010 levels would greatly 
assist the Aging Network to conduct the screenings. More succinctly, 
the reauthorization bill recognizes the importance of oral health and 
its role in disease prevention. We view this as a step toward improving 
the oral--and overall--health of older adults and call for the bill's 
passage.
                             recommendation
    It is evident the United States' healthcare system is woefully 
unprepared to meet the oral health challenges of a burgeoning 
population of older adults with special needs, chronic disease 
complications, and a growing inability to access and pay for dental 
services. However, the benefits of proper oral hygiene and routine care 
for older adults to our Nation's healthcare system and economy are also 
quite clear. Through OHA's Wisdom Tooth Project, OHA aspires to change 
the lives of older adults especially vulnerable to oral disease. OHA 
views proper funding of the Older Americans Act as a crucial Federal 
investment vehicle to advance health promotion and disease prevention. 
Therefore, OHA recommends the Subcommittee to restore fiscal year 2017 
funding for all OAA programs to at least fiscal year 2010 levels, and 
moreover, to ensure Title III-D, Disease Prevention and Health 
Promotion, is restored to at least $21,000,000 because of the cost-
effectiveness that health education, health promotion, and disease 
prevention programs provide to the system.
    Thank you for the opportunity to present and submit our written 
testimony before the Subcommittee.

    [This statement was submitted by Beth Truett, CEO/President, Oral 
Health America.]
                                 ______
                                 
                       Prepared Statement of PATH
    PATH is appreciative of the opportunity afforded by Chairman Blunt, 
Ranking Member Murray, and members of the Subcommittee on Labor, Health 
and Human Services, Education and Related Agencies to submit written 
testimony regarding fiscal year 2017 funding for global health programs 
within the U.S. Department of Health and Human Services (HHS). PATH 
acknowledges the strong leadership the Committee has shown in 
supporting HHS' work in this area, and recommends that this support 
continue. This testimony is submitted on behalf of PATH, a leader in 
global health innovation. As an international nonprofit organization, 
PATH saves lives and improves health, especially among women and 
children. Accelerating innovation across five platforms--vaccines, 
drugs, diagnostics, devices, and system and service innovations--PATH 
harnesses its entrepreneurial insight, scientific and public health 
expertise, and passion for health equity. By mobilizing partners around 
the world, PATH takes innovation to scale, working alongside countries 
primarily in Africa and Asia to tackle their greatest health needs. 
With these key partners, PATH delivers measurable results that disrupt 
the cycle of poor health. Therefore, we respectfully request that this 
Subcommittee ensure robust funding for global health programs within 
HHS in fiscal year 2017--including $224 million for the Center for 
Disease Control and Prevention's (CDC's) global immunization programs, 
$25.5 million for CDC's malaria programs, $65.2 million for CDC's 
Division of Global Public Health Protection and Security, and $33.1 
billion for the National Institutes of Health (NIH)--which capitalize 
on the agency's technical expertise to improve health and increase 
security, while bolstering the ability of partner countries to lead in 
the future.
          the vital role of hhs in global health and security
    Recent outbreaks of Zika, Ebola, and measles have demonstrated that 
the health of U.S. citizens is inherently connected to the health of 
people living around the globe. Global pandemics and increasing 
international travel only intensify Americans' vulnerability to 
diseases that have historically impacted communities outside our 
borders. For these and other reasons, HHS has been active in global 
health programs for decades. For example, within HHS, agencies such as 
CDC collaborate with partner governments to build public health 
infrastructure and expertise to track and combat diseases worldwide, 
while conducting research to support the development of new and 
improved technologies to better help us fight disease threats in the 
future.
    HHS's Global Health Strategy (2011), currently being revised for 
2016 and beyond, articulates the department's international role in 
guiding efforts to safeguard health globally. This role was further 
strengthened in HHS' central role in the Global Health Security Agenda, 
launched in 2014. These efforts--such as addressing antimicrobial 
resistance, and improving laboratory safety and workforce development 
in more than 34 countries--help to better protect Americans' health and 
security, while increasing partner countries' ability to contain 
outbreaks and provide for the health of their citizens.
    With continued funding for these activities, the department will be 
able to continue to strengthen health systems around the world, improve 
access to proven health interventions in communities where they are 
needed most, and invest in solutions to tomorrow's health and security 
challenges.
             using cost-effective strategies to save lives
    One key strategy for achieving HHS' global health and security 
goals is immunization, with the majority of activities to ensure 
vaccine delivery overseen by CDC's Global Immunization Division, NIH 
and BARDA. Vaccines are one of the most impactful and cost-effective 
public health interventions available today. They have played an 
outsized role in the reduction--by half--of the number of child deaths 
since 1990. Worldwide, polio cases have dropped by more than 99 percent 
since 1988; measles deaths declined by 79 percent from 2000 through 
2014; and 2 to 3 million deaths are averted each year through 
immunization. HHS has contributed significantly to this achievement. 
For example, thanks in part to HHS' role in global polio immunization 
efforts, including as a leading partner in the Global Polio Eradication 
Initiative, Southeast Asia, including India, was certified polio-free 
in March 2014. Nigeria has not had a case of polio in a year and half, 
and is expected to be certified polio-free next year if no further 
cases are reported. Only two countries (Afghanistan and Pakistan) 
remain endemic, down from more than 125 in 1988.
    Globally, programs to immunize populations against a range of 
vaccine preventable diseases have been built on the foundation of polio 
vaccination efforts. In fact, polio and routine immunization programs 
have been a driving force behind strengthening public health systems in 
many of the world's least developed countries. As polio nears 
eradication, it is critical to maintain investment--in some cases 
transitioning funds that have previously been allocated under the 
heading of polio--to support activities that maintain and expand 
routine immunization and strengthen public health infrastructure.
    Infrastructure and expertise created to address polio have not only 
reduced cases of that disease and expanded immunization to prevent 
other diseases, but have also been leveraged to address epidemics. For 
example, Nigeria was able to rapidly adapt its polio infrastructure and 
emergency operating center, built with CDC input and support, to 
respond to and contain an importation of Ebola in October 2014 in 
Lagos. Continued funding will enable HHS to further extend the delivery 
of lifesaving vaccines to where they are needed most, which will save 
lives and reduce the burden of disease globally.
    Additionally, 2015 marks the halfway point of the Decade of 
Vaccines, an initiative which established a global framework (2010-
2020) endorsed by the United States and 192 other nations with the aim 
of expanding access to immunization. While some progress has been made 
toward the goals outlined in the framework, and individual achievements 
in countries have demonstrated what is possible with focused efforts, 
we are off track to meet many of the milestones outlined in the plan, 
and the delay means more lives lost. The U.S. Government is positioned 
to lead the way in accelerating progress toward the framework's goals, 
if coordination of efforts continues across various agencies. We are 
pleased to see HHS making strides toward strengthening the collective 
impact of its agencies engaged on global immunization, including the 
CDC and the NIH, among others, as well as across other departments of 
the U.S. Government. We urge the committee to continue to fully fund 
these efforts and encourage stronger coordination.
                     fighting to eliminate malaria
    In addition to its critical work in immunization, HHS has a long 
history in controlling and eliminating malaria. CDC, in particular, 
played a critical role in eliminating malaria from the United States. 
As a joint implementer of the President's Malaria Initiative (PMI), CDC 
continues to play a leading role in global control and elimination 
efforts alongside the U.S. Agency for International Development. These 
efforts have made a significant impact. Between 2001 and 2015, an 
estimated 6.2 million lives were saved as a result of scaled-up malaria 
interventions. While incredible progress has been made, progress is 
fragile, and investments must be sustained to prevent reemergence of 
malaria in communities that have succeeded in controlling it. Last 
year, PMI set forth a 5-year strategy, which includes an ambitious 
agenda to reduce malaria mortality by one-third from 2015 levels in 
PMI-supported countries, thereby achieving a greater than 80 percent 
reduction from PMI's 2000 baseline. The strategy also looks toward 
elimination of the disease regionally, in order to shrink malaria's 
footprint across the globe. Robust funding is required to execute on 
this goal.
    With evidence of growing insecticide and drug resistance, CDC's 
Parasitic Diseases and Malaria program also plays a key role in malaria 
monitoring and surveillance, evaluation, and its work to ensure we have 
the new tools necessary to fight this ever-changing disease. Examples 
of CDC's contributions include evaluations of the impact of improved 
nets, insecticides, and strategic use of antimalarial drugs, as well as 
field trials of promising malaria vaccines, such as RTS,S, the malaria 
vaccine candidate furthest along in development globally, and recently 
recommended by the World Health Organization for pilot implementations 
in Africa.
    While CDC's mandate has grown, their budget for malaria has been 
flat. Increased funding would better equip the agency to track the 
spread of drug and insecticide resistance, develop and deploy new 
tools, and ensure the more timely surveillance that is necessary for 
ultimate malaria elimination.
            protecting u.s. leadership in global health r&d
    While access to existing, proven health interventions--whether 
vaccines, bed nets, or drugs--must be extended, it is also critical to 
support research and development (R&D) into future technologies that 
can prevent existing and emerging global health threats. Investments 
made by the U.S. Government, including through the NIH, FDA, and CDC 
over the past three decades, have enabled many partners, including 
PATH, to advance innovations that have improved health and saved lives 
around the world. These innovations include new and improved vaccines, 
such as an effective, low-cost vaccine against meningitis A, which 
historically caused devastating outbreaks each year in Africa's 
Meningitis Belt. Zero cases of meningitis A have occurred among the 
more than 235 million Africans vaccinated since 2010. We also leveraged 
U.S. support to pioneer safe injection technologies that have helped to 
prevent millions of blood-borne infections. Thanks to a discovery made 
by scientists at NIH, PATH was able to develop a simple, rapid test for 
exposure to river blindness, a disease that affects 25 million people. 
This test was launched commercially last year and is an important tool 
in the fight to eliminate river blindness in Africa.
    The promise of new global health technologies can only be realized 
when products are developed, tested, licensed, and scaled up for use 
globally. Investment in these activities at NIH, CDC, and FDA should 
continue. Furthermore, strengthened collaboration and coordination 
between HHS operating divisions and other U.S. agencies funding new and 
improved drugs, diagnostics, vaccines, and devices will be critically 
important to better align R&D investments and global health program 
priorities across the U.S. Government to maximize the impact of U.S. 
taxpayer dollars.
         an investment in health, at home and around the world
    With strong funding for global health programs within HHS, the 
department will be able to improve access to proven health 
interventions in the communities where they are needed most, while at 
the same time investing in solutions to tomorrow's challenges. By fully 
funding the global health and immunization-related accounts, the U.S. 
can protect the health of Americans while ensuring that people 
everywhere have the opportunity to lead healthy lives and reach their 
full potential.

    [This statement was submitted by Brandon Ball, Policy & Advocacy 
Officer, PATH.]
                                 
                                 ______
                                 
                Prepared Statement of Peel Ann D.  deg.
                   Prepared Statement of Ann D. Peel
                              amyloidosis
    Mr. Chairman, amyloidosis is a rare and often fatal disease. I ask 
that you include language in the subcommittee's report for fiscal year 
2017 recommending that the National Institutes of Health (NIH) expand 
its research efforts into amyloidosis, a rare disease characterized by 
abnormally folded protein deposits in tissues. I also request that the 
report language for fiscal 2017 directs NIH to keep the subcommittee 
informed on the steps taken to increase the understanding of the causes 
of amyloidosis and the measures taken to improve the diagnosis and 
treatment of this devastating group of diseases.
    There is no known cure for amyloidosis. Current methods of 
treatment are risky and unsuitable for many patients. I have endured 
two stem cell transplants in order to fight the deadly disease 
amyloidosis and have survived the disease for 13 years due to the 
intensive, life-saving treatment that I have received. I want to use my 
experience with this rare disease to help save the lives of others.
    Amyloidosis can cause heart, kidney, or liver dysfunction and 
failure and severe neurologic problems. Left untreated, the average 
survival is about 15 months from the time of diagnosis. Amyloidosis can 
literally kill people before they even know that they have the disease.
    More research needs to be funded for various types of amyloidosis. 
Researchers have not been able to determine the root cause of the 
disease or an effective low-risk treatment. The patients with 
amyloidosis who are able to obtain treatment face challenges that can 
include high dose chemotherapy and stem cell transplantation or organ 
transplantation.
    Amyloidosis is vastly under-diagnosed. Thousands of people die 
because they were diagnosed too late to obtain effective treatment. 
Thousands of others die never knowing they had amyloidosis.
                              amyloidosis
    Amyloidosis occurs when unfolded or misfolded proteins form amyloid 
fibrils and are deposited in organs, such as the heart, kidney and 
liver. These misfolded proteins clog the organs until they no longer 
are able to function--sometimes at a very rapid pace. I have been 
treated for primary (AL) amyloidosis, a blood or bone marrow disorder.
    In addition to AL amyloidosis, there are also thousands of cases of 
inherited (familial) and age-related amyloidosis. The most common 
familial type of amyloidosis was found to be caused by mutations in a 
protein made in the liver. This is the form of amyloidosis that may be 
present in a significant number of African-Americans.
    Older Americans are susceptible to heart disease due to amyloidosis 
formed from the non-mutated form of the same protein. Another type of 
amyloidosis, secondary or reactive amyloidosis, occurs in patients with 
chronic infections or inflammatory diseases.
    It was not until the 1980s that research identified the most common 
amyloid proteins and rationales for treatment began being discussed. 
The first clinical trial using oral chemotherapy for primary 
amyloidosis was begun 27 years ago, and high dose chemotherapy with 
stem cell transplantation was developed in 1994. The first liver 
transplant in the United States for familial amyloidosis was performed 
in 1992.
    All of these types of amyloidosis, left undiagnosed or untreated, 
are fatal. There is no explanation for how or why amyloidosis develops. 
Although progress has been made in developing alternate forms of 
treatment for amyloidosis, there is still no known reliable cure.
                         amyloidosis treatment
    The Amyloidosis Center at Boston University School of Medicine and 
Boston Medical Center, and other centers for amyloidosis treatment, 
have found that high dose intravenous chemotherapy followed by stem 
cell transplantation is an effective treatment in selected patients 
with primary amyloidosis. Abnormal bone marrow cells are killed through 
high dose chemotherapy, and the patient's own extracted blood stem 
cells are replaced in order to improve the recovery process.
    The high dose chemotherapy and stem cell rescue and other new drugs 
have increased the remission rate and long-term survival dramatically. 
However, this treatment can also be life threatening and more research 
needs to be done to provide less risky forms of treatment.
                                research
    Although it has been 13 years since my initial stem cell transplant 
for amyloidosis, I, like most patients, am faced with recurring 
amyloidosis. Fortunately, due to research, there are new forms of 
treatment that are options for me and patients with recurring 
amyloidosis. These were not available 13 years ago. This is evidence 
that funding through Health and Human Services can make a difference.
    The limited research and equipment funding through HHS and NIH has 
been helpful in developing new treatment alternatives for some patients 
with amyloidosis. Although funding is severely limited, researchers are 
moving forward to develop targeted treatments that will specifically 
attack the amyloid proteins.
    The current funding for amyloidosis research shows what might be 
possible with increased funding and emphasis on the disease--but it 
does not go far enough.
    Additional funding for research and equipment is needed to 
accomplish this task. Only through more research is there hope of 
further increasing the survival rate and finding additional treatments 
to help more patients.
                               diagnosis
    Timely diagnosis is also of great concern. Although I was diagnosed 
at a very early stage of the disease, many people are diagnosed after 
the point that they are physically able to undertake treatment.
    Early diagnosis and treatment are the keys to success. More needs 
to be done in these areas to alert health professionals to identify 
this disease.
                          current initiatives
    Through the leadership of this Committee and the further 
involvement of the U.S. Government, a number of positive developments 
have occurred.
  --The National Institutes of Health has substantially increased its 
        interest in amyloidosis. The NIH, particularly the Office of 
        Rare Diseases, participates in meetings and symposia and works 
        closely with organizations doing research and outreach on 
        amyloidosis. The Amyloidosis Research Consortium (ARC), a 
        network of clinical centers caring for amyloidosis patients, 
        has developed and is working with the Food and Drug 
        Administration and pharmaceutical companies to more rapidly 
        test new therapies for amyloidosis.
  --Research supported by the National Institute of Neurologic 
        Disorders and Stroke at NIH and the Office of Orphan Products 
        Development at the Food and Drug Administration led to 
        successful repurposing of a generic drug that markedly slows 
        progression of familial amyloidosis. This was the first drug 
        treatment for this disease and worked by stabilizing the 
        precursor protein. In partnership with pharmaceutical 
        companies, new types of treatment, RNA interference, that work 
        by decreasing production of the precursor protein are now in 
        clinical trials. There is also hope, with increased funding for 
        research, to expand the range of treatment to other categories 
        of amyloidosis.
  --There has been increased basic and clinical research at the Boston 
        University Amyloidosis Center: models of light chain (AL) 
        amyloid disease have been developed; serum chaperone proteins 
        that cause amyloid precursor protein misfolding are being 
        identified; imaging techniques for the diagnosis of amyloid 
        disease are being investigated, and new clinical trials for AL 
        and familial amyloidosis are underway. A study of the age-
        related form of amyloid heart disease has provided natural 
        history data indicating a shorter survival than had been 
        previously appreciated for this under recognized form of 
        amyloidosis. The National Institute of Aging has been 
        supporting this work.
  --Federal funding for research, equipment and treatment has been an 
        important element in progress to date. Further funding is 
        essential to speed the pace of discovery for basic and clinical 
        research.
                      request for fiscal year 2017
    Mr. Chairman, I ask that the subcommittee take the following 
actions to help address this deadly disease:
  --First, include in the fiscal year 2017 subcommittee report language 
        recommending that NIH expand its research efforts into 
        amyloidosis, a group of rare diseases characterized by 
        abnormally folded protein deposits in tissues.
  --Second, direct the NIH to keep the subcommittee informed on the 
        steps taken to increase the understanding of the causes of 
        amyloidosis and the measures taken to improve the diagnosis and 
        treatment of this devastating group of diseases.
    Help me turn what has been my own life-threatening experience into 
hope for others.
    Thank you for your consideration.
                                 ______
                                 
  Prepared Statement of the Physician Assistant Education Association
    On behalf of the 199 accredited physician assistant (PA) education 
programs in the United States, the Physician Assistant Education 
Association (PAEA) is pleased to submit this statement on the fiscal 
year 2017 appropriations. PAEA supports funding of at least $280 
million in fiscal year 2017 for the health professions education 
programs authorized under Title VII of the Public Health Service Act 
and administered through the Health Resources and Services 
Administration (HRSA). We also request that $12 million of that funding 
support PA programs operating across the country. This relatively small 
investment will reinforce the capacity of physician assistant 
education, and will greatly enhance PA educational programs. Title VII 
funding is the only designated source of Federal funding for PA 
education. This funding is crucial to the U.S. PA education system's 
ability to meet the demand for PAs and produce highly skilled PAs ready 
to enter the healthcare workforce in an average of 27 months.
Need for Increased Federal Funding
    The unmet need for primary care services in the United States is 
well documented. In fact, the need for primary care services is 
expected to grow as the population ages and requires more healthcare 
services especially as formerly uninsured patients gain access. 
Healthcare systems are rapidly evolving; amidst this change; the need 
for qualified healthcare providers in numbers sufficient enough to meet 
the demand remains a constant concern. Primary care has been clearly 
identified as the critical entry point into the healthcare system where 
access must be guaranteed. The PA profession was created specifically 
to address a shortage of primary care physicians almost 50 years ago. 
Today's PAs continue this tradition and stand ready to help address the 
challenges our Nation faces in primary care and other specialties. The 
effectiveness of physician assistants is seen in better patient access, 
especially for Medicaid patients; high patient satisfaction; and 
healthcare outcomes similar to physicians. Importantly, PAs could play 
an even larger role in high-quality, cost-effective care with stronger 
Federal support and through innovations in the PA education system.
    Like physicians, the PA profession faces a shortage of graduates 
that will hinder its ability to help fully address the primary care 
issue in the United States. Without new solutions, at the current 
output of approximately 8,000 PA graduates annually, these shortages 
will persist, particularly in the rural and underserved communities 
where care is most needed.
Background on the Profession
    Since the 1960s, PAs have consistently demonstrated they are 
effective partners in healthcare, readily adaptable to the needs of an 
ever-changing delivery system. Physician assistants are licensed health 
professionals with advanced education in general medicine that practice 
medicine as members of the healthcare team. They provide a broad range 
of medical and therapeutic services to diverse populations in rural and 
urban settings, including prescriptive authority in all 50 States, the 
District of Columbia, and Guam. PAs practice medicine to the extent 
allowed by law and within the physician's scope of practice. Their 
combination of medical training, advanced education, and hands-on 
experience allows PAs to practice with significant autonomy, and in 
rural and other medically underserved areas where they are often the 
only full-time medical provider. The profession is well established, 
yet nimble enough to embrace new models of care, adopt innovative 
approaches to training and education, and adapt to health system 
challenges.
PA Education: The Pipeline for Physician Assistants
    There are currently 199 accredited PA education programs in the 
United States. Together these programs graduate close to 8,000 PA 
students each year. PAs are educated as generalists in medicine, which 
gives them the flexibility to practice in more than 60 medical and 
surgical specialties. Approximately one third of PAs are working in 
primary care. The average PA education program is 27 months in length 
and includes one didactic year in the classroom, and another year 
devoted to clinical rotations. Most curricula include 340 hours of 
basic sciences and nearly 2,000 hours of clinical training, second only 
to physicians in time spent in clinical study.
    As of today, approximately 55 new PA programs are in the pipeline 
at various stages of development and moving toward accredited status. 
The growth rate in the applicant pool is even more pronounced. Since 
its inception, the Centralized Application Service (CASPA) used by most 
programs grew from 4,669 applicants to over 20,000. As of March 2015, 
there were 22,997 applicants to PA education programs, which represents 
more than a 40 percent increase in CASPA applicants over the past 5 
years alone.
    The PA profession is expected to continue to grow as a result of 
the projected shortages of physicians and other healthcare 
professionals, the growing demand for care driven by an aging 
population, and the continuing strong PA applicant pool. Accordingly, 
The Bureau of Labor Statistics projects a 39 percent increase in the 
number of PA jobs between 2008 and 2018. With its relatively short 
training time and the flexibility of generalist-trained PAs, the PA 
profession is well positioned to help fill projected shortages in the 
numbers of healthcare professionals--if appropriate resources are 
available to support the education system behind them.
                          areas of acute need
Faculty Shortages
    Faculty development is one of the PA professions critical needs, 
especially as we continue to foster the growing demand for an increased 
primary care workforce. The PA teaching profession faces large numbers 
of retirements in the next 10-15 years as nearly half of PA program 
faculty are 50 years or older. An interest in education must be 
developed early in the educational process to ensure a continuous 
stream of educators. Furthermore, the significant loan burdens that 
prevent many physician assistants from entering academia must be 
alleviated. In order to attract the most highly qualified faculty, PA 
education programs must have the resources to help clinicians 
transition into education, including curriculum development, teaching 
methods, and laboratory instruction. Without Federal support, we will 
face an impending shortage of educators who are prepared for and 
committed to the critical teaching role that will ensure the next 
generation of skilled practitioners.
Clinical Site Shortages
    Outside of the classroom, PA education faces additional challenges 
in meeting the demand for qualified and highly trained practitioners. A 
lack of clinical sites for PA education is hampering PA programs' 
ability to produce PAs at the pace needed to meet the demand for 
primary care in the U.S. This shortage is caused by two main factors: a 
shortage of medical professionals (preceptors) willing to teach 
students as they are cycling through their clinical rotations, and a 
lack of sites with the physical space to teach. Cutbacks in Federal and 
State funding of Area Health Education Centers (AHECs) has also 
contributed to reduced access to clinical training for PA students, 
particularly in rural and underserved communities. Federal funding can 
help incentivize practicing clinicians to both offer their time as 
preceptors, and volunteer their clinical operations as training grounds 
for interprofessional training opportunities with PAs and other members 
of the health professional.
Enhancing Diversity
    The Physician Assistant Education Association is committed to 
enhancing the diversity of the PA education community, workforce 
diversity, and practice in underserved areas. It is increasingly 
important for patient care that the health workforce better represents 
America's changing demographics, as well as addresses the issues of 
disparities in healthcare. PA programs have been committed to 
attracting students from underrepresented minority groups and 
disadvantaged backgrounds into the profession, including veterans who 
have served our country and desire to transition to civilian health 
professions. Studies have found that health professionals from 
underserved areas are three to five times more likely to return to 
underserved areas to provide care. PA programs are looking for unique 
ways to recruit diverse individuals into the profession, and sustain 
them as leaders in the education field and within their communities. 
PAEA recognizes the need to recruit diverse faculty, as a diverse 
faculty pool with a broad perspective of experiences, enhances the 
educational setting and is beneficial to students. If we can provide 
resources to schools that are particularly poised to improve their 
diversity recruitment efforts and replicate or create best practices 
including transition programs for our veterans, we can begin to address 
this systemic need.
    In order to leverage the efforts of PA programs through Title VII 
funding to increase workforce diversity in the PA profession, PAEA also 
supports funding for the Health Careers Opportunity Program (HCOP), and 
increased funding for the Scholarships for Disadvantaged Students and 
National Health Service Corps. These programs help to provide a clear 
path for students who might not otherwise consider a physician 
assistant career.
Title VII Funding
    Title VII funding can serve as a solution and a remedy to many of 
the PA profession's areas of need, including faculty development, 
clinical site expansion and diversification of the primary care 
workforce. These funds enhance clinical training and education, assist 
PA programs with recruiting applicants from minority and disadvantaged 
backgrounds, and enable innovative programs that focus on educating a 
culturally competent workforce. Title VII funding increases the 
likelihood that PA students will practice in medically underserved 
communities with health professional shortages. The absence of this 
funding would result in the loss of care to patients with the most 
urgent needs.
    Title VII support for PA programs was strengthened in 2010 when 
Congress enacted a 15 percent allocation in the appropriations process 
specifically for PA programs working to address the health provider 
shortage. This funding has enhanced capabilities to train future PAs, 
creatively expand care to the underserved, and develop a more diverse 
PA workforce:
  --One Texas program has used its PA training grant to support the 
        program at a site in an underserved area. This grant provides 
        assistance to the program for recruiting, educating, and 
        training PA students in the largely Hispanic South Texas and 
        mid-Texas/Mexico border areas and supports new faculty 
        development.
  --A New York program is using its PA training grant to operate a 
        mobile health vehicle to provide health education and initial 
        health screenings to local underserved communities. The direct 
        exposure achieved by utilizing a mobile health vehicle provides 
        the communities with medical and preventive education and 
        health screenings while also addressing the students' awareness 
        of cultural competency and health literacy. Equally as 
        important, the experience has motivated students to specialize 
        in primary care.
  --A Virginia program uses its PA training grant to support 
        transitioning veterans, while increasing the placement of 
        graduates in primary care and medically underserved 
        communities. The grant allows the PA program to provide 
        scholarship to incoming physician assistant students who are 
        veterans, and who dedicate the beginning of their careers to a 
        primary care setting.
Recommendations on Fiscal Year 2017 Funding
    The Physician Assistant Education Association requests the 
Appropriations Committee's support in funding for Title VII health 
professions programs at a minimum of $280 million for fiscal year 2017. 
This level of funding is crucial to support the Nation's ability to 
produce and maintain highly skilled primary care practitioners, 
particularly those from diverse backgrounds and the military who will 
practice in medically underserved areas and serve vulnerable 
populations. We also ask for the continuation of the 15 percent 
allocation for PA education programs in the Primary Care cluster.
    We thank the members of the subcommittee for their support of the 
health professions and look forward to your continued commitment to 
finding solutions to the Nation's health workforce shortage.

    [This statement was submitted by Anthony Miller, M.Ed., PA-C, Chief 
Policy and Research Officer, Physician Assistant Education 
Association.]
                                 ______
                                 
Prepared Statement of the Population Association of America/Association 
                         of Population Centers
                              introduction
    Thank you, Chairman Blunt, Ranking Member Murray, and other 
distinguished members of the Subcommittee, for this opportunity to 
express support for the National Institutes of Health (NIH), National 
Center for Health Statistics (NCHS), and Bureau of Labor Statistics 
(BLS). These agencies are important to the members of the Population 
Association of America (PAA) and Association of Population Centers 
(APC) because they provide direct and indirect support to population 
scientists and the field of population, or demographic, research 
overall. In fiscal year 2017, we urge the Subcommittee to adopt the 
following funding recommendations: $34.5 billion for the NIH, 
consistent with the level recommended by the Ad Hoc Group for Medical 
Research; $170 million for the NCHS, consistent with the Friends of 
NCHS recommendation; and $640.9 million, for the BLS, consistent with 
the Administration's request.
    The PAA and APC are two affiliated organizations that together 
represent over 3,000 social and behavioral scientists and approximately 
40 population research centers nationwide that conduct research on the 
implications of population change. Our members, which include 
demographers, economists, sociologists, and statisticians, who conduct 
scientific research, analyze changing demographic and socio-economic 
trends, develop policy recommendations, and train undergraduate and 
graduate students. Their research expertise covers a wide range of 
issues, including adolescent health and development, aging, health 
disparities, retirement, and labor. Population scientists compete for 
discretionary grant funding from the NIH and rely on data from the 
Nation's statistical agencies to conduct research and research training 
activities.
                     national institutes of health
    Demography is the study of populations and how or why they change. 
A key component of the NIH mission is to support biomedical, social, 
and behavioral research that will improve the health of our population. 
The health of our population is fundamentally intertwined with the 
demography of our population. Recognizing the connection between health 
and demography, NIH supports extramural population research programs 
primarily through the National Institute on Aging (NIA) and the 
National Institute of Child Health and Human Development (NICHD).
    PAA and APC thank the subcommittee for supporting a $2 billion 
increase for the NIH in fiscal year 2016 and look forward to working 
with the Congress to ensure NIH can continue to receive sustainable, 
steady increases in fiscal year 2017 and beyond.
                      national institute on aging
    By 2030, there will be 72 million Americans aged 65 and older. To 
inform the implications of our rapidly aging population, policymakers 
need objective, reliable data about the antecedents and impact of 
changing social, demographic, economic, health and well being 
characteristics of the older population. The NIA Division of Behavioral 
and Social Research (BSR) is the primary source of Federal support for 
basic population aging research.
    In addition to supporting an impressive research portfolio, that 
includes the prestigious Centers on the Demography and Economics of 
Aging, the NIA BSR Division also supports several large, accessible 
surveys. For example, the Health and Retirement Study (HRS), provides 
unique information about economics transitions in work, income, and 
wealth, allowing scientists to study how the domains of family, 
economic resources, and health interact. Since 1992, the HRS has 
collected data, including, most recently, biomarkers, from a 
representative sample of more than 27,000 Americans over the age of 50 
every 2 years. These data are accessible to researchers worldwide and 
have informed numerous scientific findings.
    In 2015, NIA grantee using vital statistics data as well as data 
from the HRS, published findings confirming rising mortality rates 
among middle aged, white, non-Hispanic Americans. This change reversed 
decades of progress in mortality and was unique to the United States. 
The study found increasing death rates resulted largely from ``diseases 
of despair''--drug and alcohol poisonings, suicide, and chronic liver 
diseases and cirrhosis. The most dramatic increases in mortality 
occurred among the poorly educated. The findings point to alarming 
trends in populations previously thought to be healthy and underscore 
the need for broad public health strategies to combat their causes.
    With additional support in fiscal year 2017, the Institute can 
sustain and expand its investment in population aging research, 
including contributing to the Institute's efforts to address the 
scourge of dementia and Alzheimer's disease. The BSR division is also 
eager to support research and data collection on the causes of widening 
disparities in health and longevity at older ages, and the role of 
social factors, such as education and income, in the health and well-
being of older people. As members of the Friends of NIA, we urge the 
Committee to provide the NIH with an additional $500 million in fiscal 
year 2017 to support aging research activities not only at the NIA, but 
also across the agency.
  eunice kennedy shriver national institute on child health and human 
                              development
    Since 1968, NICHD has supported research on population processes 
and change. This research is housed in the Institute's Population 
Dynamics Branch, which supports research and research training in 
demography, reproductive health, and population health and funds major 
national studies that track the health and well-being of children and 
their families from childhood through adulthood. These studies include 
Fragile Families and Child Well Being, the first scientific study to 
track the health and development of children born to unmarried parents, 
and the National Longitudinal Study of Adolescent Health (Add Health), 
tracing the effects of childhood and adolescent exposures on later 
health. The Add Health study received a 2016 Golden Goose Award, 
recognizing its significant and unique scientific contributions and 
innovations.
    In 2015, scientists, using data from these large-scale data sets 
published numerous findings. For example, scientists, used data from 
the Fragile Families and Child Wellbeing Survey, found a negative 
association between father engagement and children's behavioral 
problems, independent of the mother's characteristics and her level of 
engagement. Using data from the Add Health study, scientists determined 
that social relationships affect individual's physical health, 
including chronic disease and longevity. (http://
www.populationassociation.org/wp-content/uploads/PAAAPC-Advances-in-
Population-Research.pdf).
    In additional to supporting individual research grants and surveys, 
NICHD supports the Population Dynamics Centers Research Infrastructure 
Program. These highly productive centers, based at U.S. universities 
and private research institutions nationwide, have advanced U.S. 
science by fostering groundbreaking interdisciplinary research on human 
health and development, and increased the scientific pipeline by 
nurturing the careers of junior researchers. With additional funding in 
fiscal year 2017, the Institute will be able to maintain its strong 
commitment to these centers of research excellence. As members of the 
Friends of NICHD, PAA and APC request that the Institute receive a 
funding level of $1.441 billion in fiscal year 2017.
                 national center for health statistics
    The National Center for Health Statistics (NCHS) is the Nation's 
principal health statistics agency, providing data on the health of the 
U.S. population and backing essential data collection activities. Most 
notably, NCHS funds and manages the National Vital Statistics System 
(NVSS), which contracts with the States to collect birth and death 
certificate information. NCHS also funds a number of complex large 
surveys to help policy makers, public health officials, and researchers 
understand the population's health, influences on health, and health 
outcomes. These surveys include the National Health and Nutrition 
Examination Survey and National Survey of Family Growth. The wealth of 
data NCHS collects makes the agency an invaluable resource for 
population scientists.
    In recent years, NCHS has made significant progress toward 
modernizing the NVSS, moving many States from paper-based to electronic 
filing of birth and death statistics and expediting the release of 
these data to the user community. However, persistent flat funding 
levels in recent years, and the loss of funds from the Prevention and 
Public Health Fund, are hampering the agency's ability to enact 
additional innovations and make necessary survey redesigns and system 
improvements. That is why as members of the Friends of NCHS, PAA and 
APC request that NCHS receive $170 million in budget authority in 
fiscal year 2016, an amount $10 million above the Administration's 
request. Among other things, NCHS could use this additional money to 
support ongoing implementation of electronic death records nationwide 
to provide faster, better vital statistics and to pursue a thoughtful, 
well-conducted redesign of the National Health Interview Survey.
                       bureau of labor statistics
    BLS produces essential economic information for public and private 
decisionmaking. Population scientists who study and evaluate labor and 
related economic policies and programs use its data extensively. The 
agency also supports the National Longitudinal Studies program and the 
American Time Use Survey, which are invaluable datasets that the 
population sciences use to understand how complex factors, such as 
changes in work status, income, and education, interact to affect 
health and achievement outcomes in children and adults.
    PAA and APC joins other organizations comprising the Friends of 
Labor Statistics in thanking the subcommittee for providing BLS with a 
$17 million increase in fiscal year 2016. However, the agency is still 
struggling to overcome years of insufficient support. Between fiscal 
year 2009 and fiscal year 2015, the absolute value and/or the 
purchasing power of BLS appropriations decreased every year. As a 
result, the agency eliminated several programs in fiscal year 2013 and 
fiscal year 2014 and in fiscal year 2015 had to rely on a one-time 
transfer from the Department of Commerce to maintain BLS' Export Price 
Program. The agency also cut back its rate of replacement of staff and 
staff training and development to unsustainable levels in 2015.
    Given the importance and unique nature of BLS data, we urge the 
Subcommittee to support the Administration's request, $640.9 million, 
an increase of $31.9 million above the fiscal year 2016 funding level. 
This funding would allow BLS to support its core programs and surveys 
and to conduct other postponed activities, including a supplement to 
the Current Population Survey and changes to the Consumer Expenditure 
Survey to support development of a supplemental statistical poverty 
measure.
    Thank you for considering our organization's positions on these 
agencies under your subcommittee's jurisdiction.

    [This statement was submitted by Mary Jo Hoeksema, Director, 
Government and Public Affairs, Population Association of America/
Association of Population Centers.]
                                 ______
                                 
                Prepared Statement of Prevent Blindness
                        funding request overview
    Prevent Blindness appreciates the opportunity to submit testimony 
to the Subcommittee and respectfully requests the following allocation 
and support in fiscal year 2017 to help promote eye health and prevent 
eye disease and vision loss:
  --Provide $1,500,000 to strengthen the Vision Health at the Centers 
        for Disease Control and Prevention (CDC).
  --Support the Maternal and Child Health Bureau's (MCHB) National 
        Center for Children's Vision and Eye Health.
                       introduction and overview
    Prevent Blindness--the Nation's leading non-profit, voluntary 
organization committed to preventing blindness and preserving sight--
maintains a long-standing commitment to working with policymakers at 
all levels of government, organizations and individuals in the eye care 
and vision loss community, and other interested stakeholders to 
develop, advance, and implement policies and programs that prevent 
blindness and preserve sight.\1\
---------------------------------------------------------------------------
    \1\ For more information about Prevent Blindness and our Federal 
Government relations and public policy efforts, please visit 
www.preventblindness.org.
---------------------------------------------------------------------------
    Vision-related conditions affect people across the lifespan. Good 
vision is an integral component to health and well-being. It affects 
virtually all activities of daily living and impacts individuals 
physically, emotionally, socially, and financially. Loss of vision can 
have a devastating impact on individuals and their families. An 
estimated 80 million Americans have a potentially blinding eye disease, 
three million have low vision, more than one million are legally blind, 
and 200,000 are more severely visually blind. Vision impairment in 
children is a common condition that affects five to 10 percent of 
preschool age children, and is a leading cause of impaired health in 
childhood. Recent research showed that the economic burden of vision 
loss and eye disorders is $139 billion each year, $47.4 billion of 
which is Federal spending. Alarmingly, while half of all blindness can 
be prevented through education, early detection, and treatment, the 
National Eye Institute (NEI) reports that ``the number of Americans 
with age-related eye disease and the vision impairment that results is 
expected to double within the next three decades.'' \2\
---------------------------------------------------------------------------
    \2\ ``Vision Problems in the U.S.: Prevalence of Adult Vision 
Impairment and Age-Related Eye Disease in America,'' Prevent Blindness 
America and the National Eye Institute, 2008.
---------------------------------------------------------------------------
    To curtail the increasing incidence of vision loss in America, and 
its accompanying economic burden, Prevent Blindness advocates sustained 
and meaningful Federal funding for programs that promote eye health and 
prevent eye disease, vision loss, and blindness; needed services and 
increased access to vision screening; and vision and eye disease 
research. In a time of significant fiscal constraints, we recognize the 
challenges facing the Subcommittee and urge you to consider the 
ramifications of decreased investment in vision and eye health. Vision 
loss is often preventable, but without continued efforts to better 
understand eye conditions, and their treatment, through research to 
develop the public health systems and infrastructure to disseminate and 
implement good science and prevention strategies, millions of Americans 
face the loss of independence, loss of health, and the loss of their 
livelihoods, all because of the loss of their vision.
 vision and eye health at the cdc: helping to save sight and save money
    The CDC serves a critical role in promoting vision and eye health. 
Since 2003, the CDC and Prevent Blindness have collaborated with other 
partners to create a more effective public health approach to vision 
loss prevention and eye health promotion. The CDC works to promote eye 
health and prevent vision loss; improve the health and lives of people 
living with vision loss by preventing complications, disabilities, and 
burden; reduce vision and eye health related disparities; and integrate 
vision health with other public health strategies. However, severely 
constrained financial resources have limited the CDC's ability to take 
the work of the Vision Health Initiative (VHI) to the next level.
    Prevent Blindness requests at least $1,500,000 in fiscal year 2017 
to strengthen vision and eye health efforts of the CDC. This funding 
level would allow the VHI to increase vision impairment and eye disease 
surveillance efforts, apply previous CDC vision and eye health research 
findings to develop effective prevention and early detection 
interventions, and begin to incorporate vision and eye health promotion 
activities into State and national public health chronic disease 
initiatives, with an initial focus on early detection of diabetic 
retinopathy.
    In addition, the CDC engaged the Institute of Medicine (IOM) at the 
National Academies of Sciences, Engineering, and Medicine to study 
public health approaches to reduce vision impairment and improve eye 
health. The IOM will release a report in fiscal year 2016 that captures 
findings from the study, and funding within this request would be 
allocated to support the implementation of the Academy's 
recommendations for CDC.
    investing in the vision of our nation's most valuable resource--
                                children
    While the risk of eye disease increases after the age of 40, eye 
and vision problems in children are of equal concern. If left 
untreated, they can lead to permanent and irreversible visual loss and/
or cause problems socially, academically, and developmentally. Although 
more than 12.1 million school-age children have some form of a vision 
problem, only one-third of all children receive eye care services 
before the age of six.\3\ Vision disorders are among the leading cause 
of impaired health in childhood as 1 in 4 school-aged children has a 
vision problem significant enough to affect learning. But early 
detection can help prevent vision loss and blindness and understands 
many serious ocular conditions in children are treatable if diagnosed 
at an early stage.
---------------------------------------------------------------------------
    \3\ ``Our Vision for Children's Vision: A National Call to Action 
for the Advancement of Children's Vision and Eye Health, Prevent 
Blindness America,'' Prevent Blindness America, 2008.
---------------------------------------------------------------------------
    In 2009, the MCHB established the National Center for Children's 
Vision and Eye Health (the Center), a national vision health 
collaborative effort aimed at developing the public health 
infrastructure necessary to address issues surrounding children's 
vision screening.
    The Center has established a National Advisory Committee to provide 
recommendations toward national guidelines for quality improvement 
strategies, vision screening and developing a continuum of children's 
vision and eye health. With this support the Center, will continue to: 
(1) provide national leadership in dissemination of best practices, 
infrastructure development, professional education, and national vision 
screening guidelines that ensure a continuum of vision and eye 
healthcare for children; (2) advance State-based performance 
improvement systems, screening guidelines, and a mechanism for uniform 
data collection and reporting; and (3) provide technical assistance to 
States in the implementation of strategies for vision screening, 
establishing quality improvement measures, and improving mechanisms for 
surveillance.
    Therefore, Prevent Blindness encourages the Subcommittee to support 
the work of the Center which, through partnerships, sound science, and 
targeted policy initiatives, promotes vision and eye health for the 
Nation's children.
                               conclusion
    On behalf of Prevent Blindness, our Board of Directors, and the 
millions of people at risk for vision loss and eye disease, we thank 
you for the opportunity to submit written testimony regarding fiscal 
year 2017 funding for the CDC Vision Health Initiative, and the MCHB 
National Center for Children's Vision and Eye Health. Please know that 
Prevent Blindness stands ready to work with the Subcommittee and other 
Members of Congress to advance policies that will prevent blindness and 
preserve sight. Please feel free to contact us at any time; we are 
happy to be a resource to Subcommittee members and your staff. We very 
much appreciate the Subcommittee's attention to--and consideration of--
our requests.

    [This statement was submitted by Hugh Parry, President & CEO, 
Prevent Blindness.]
                                 ______
                                 
                Prepared Statement of Project Angel Food
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Project Angel Food is part of a nationwide coalition, the Food is 
Medicine Coalition, of over 80 food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In Los Angeles County, we provide over 500,000 
medically tailored, home delivered meals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses .
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications , and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals , suppo1i services help stabilize individuals living with 
or at risk of HIV. When needs are met, and life's emergencies are held 
at bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure,.they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible . Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process . 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.

    [This statement was submitted by Richard Ayoub, Executive Director, 
Project Angel Food.]
                                 ______
                                 
               Prepared Statement of Project Angel Heart
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Project Angel Heart is part of a nationwide coalition, the Food is 
Medicine Coalition, of food and nutrition services providers, 
affiliates and their supporters across the country that provide food 
and nutrition services to people living with HIV/AIDS (PWH) and other 
chronic illnesses. In our service area, we provide 318, 665 medically 
tailored, home delivered meals annually. Collectively, the Food is 
Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy.\6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by Erin Pulling, President & CEO, 
Project Angel Heart.]
                                 ______
                                 
      Prepared Statement of the Pulmonary Hypertension Association
       the associations's fiscal year 2017 l-hhs appropriations 
                            recommendations
_______________________________________________________________________

  --$7.48 billion in discretionary budget authority for the Health 
        Resources and Services Administration (HRSA).
  --$7.8 billion in program level funding for the Centers for Disease 
        Control and Prevention (CDC), which includes budget authority, 
        the Prevention and Public Health Fund, Public Health and Social 
        Services Emergency Fund, and PHS Evaluation transfers.
    --A proportional fiscal year 2016 funding increase for CDC's 
            National Center for Chronic Disease Prevention and Health 
            Promotion (NCCDPHP).
  --At least $34.5 billion in program level funding for the National 
        Institutes of Health (NIH).
    --Proportional funding increases for NIH's National Heart, Lung, 
            and Blood Institute (NHLBI); the National Institute of 
            Child Health and Human Development (NICHD), and the 
            National Center for Advancing Translational Sciences 
            (NCATS).
_______________________________________________________________________

    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the priorities of the 
pulmonary hypertension community as you work to craft the fiscal year 
2017 L-HHS Appropriations Bill.
                      about pulmonary hypertension
    Pulmonary hypertension (PH) is a disabling and often fatal 
condition simply described as high blood pressure in the lungs. It 
affects people of all ages, races and ethnic backgrounds. Although 
anyone can get PH, there are risk factors that make some people more 
susceptible.
    Treatment and prognosis vary depending on the type of PH. In one 
type, pulmonary arterial hypertension (PAH), the arteries in the lungs 
become too narrow to handle the amount of blood that must be pumped 
through the lungs. This causes several things to happen: a backup of 
blood in the veins returning blood to the heart; an increase in the 
pressure that the right side of the heart has to pump against to push 
blood through the lungs; and a strain on the right side of the heart 
due to the increased work that it has to do. If this increased pressure 
is not treated, the right side of the heart can become overworked, 
become very weak and may possibly fail. Because blood has difficulty 
getting through the lungs to pick up oxygen, blood oxygen level may be 
lower than normal. This can put a strain not only on the heart, but 
also decrease the amount of oxygen getting to the brain.
    There is currently no cure for PAH. Twelve treatment options are 
available to help patients manage their disease and feel better day to 
day but even with treatment, life expectancy with PAH is limited.
                        the patient perspective
The Hicks Family
    Carl Hicks is a former Army Ranger and a retired Colonel who led 
the first battalion into Iraq during the first Iraq war. Every member 
of his family was touched by pulmonary hypertension after the diagnosis 
of his daughter Meghan in 1994. I share their story here, in Carl's own 
words:
    We're sorry Colonel Hicks, your daughter Meaghan has contracted 
primary pulmonary hypertension. She likely has less than a year to live 
and there is nothing we can do for her.
    ``Those words were spoken in the spring of 1994 at Walter Reed Army 
Medical Center. They marked the start down the trail of tears for a 
young military family that, only hours before, had been in Germany. My 
family's journey down this trail hasn't ended yet, even though 
Meaghan's fight came to an end with her death on January 30th, 2009. 
She was 27.
    Pulmonary hypertension (PH) struck our family, as it so often does, 
without warning. One day, we had a beautiful, healthy, energetic 12-
year old gymnast, the next, a child with a death sentence being robbed 
of every breath by this heinous disease. The toll of this fight was 
far-reaching. Over the years, every decision of any consequence in the 
family was considered first with regards to its impact on Meaghan and 
her struggle for breath.
    The investment made by our country in my career was lost, as I left 
the service to stay nearer my family. The costs for Meaghan's medical 
care, spread over the nearly 14 years of our fight, ran well into the 
seven figures. Meghan even underwent a heart and dual-lung transplant. 
These challenges, though, were nothing compared to the psychological 
toll of losing Meaghan who had fought so hard for something we all take 
for granted, a breath of air.''
Jessica Armstrong
    In 2011, at the age of 29, GS12 Human Terrain Analyst Jessica 
(Puglisi) Armstrong who was serving in Afghanistan as Department of the 
Army Civilian began experiencing progressive shortness of breath 
dizziness, and exercise intolerance.. Jessica reported her symptoms 
multiple times. The first time she was told that she needed to eat 
more, then she was diagnosed with dehydration. As her symptoms 
continued to progress, as is the case with many PH patients, she was 
told she had asthma and given a series of inhalers . Two months later, 
she fainted for no apparent reason. A CT scan revealed blood clots in 
her lungs and Jessica was medically evacuated to Germany and then to 
the U.S. Six months after her fist symptoms, she was given a clean bill 
of health and orders to return to Afghanistan. Not feeling better she 
sought a second opinion at a civilian hospital where she was finally 
given a complete work up and diagnosed with chronic thromboembolic 
pulmonary hypertension.
    Jessica had a unique form of PH due to blood clots that can be 
mitigated with a pulmonary thromboendarterectomy (PTE)--a complex 
surgery that involves opening the chest cavity and stopping circulation 
for up to twenty minutes. She describes the surgery, which she 
underwent at the University of California San Diego, as ``more painful 
than I could ever imagine.'' She notes that UCSD's PTE program did not 
begin until 1990 and even now, despite being recognized as the global 
leaders on this procedure, UCSD has only completed about 3,000 
surgeries. The procedure that saved Jessica's life was developed in her 
lifetime.
    Jessica was terminated from Army employment and spent more than 
$60,000 out of pocket on medical expenses which she has not been able 
to recoup. She was forced to begin a civilian job just two weeks after 
her PTE in order to obtain health insurance. Despite this, Jessica is, 
in many ways, one of the lucky ones. I am glad to report that she is 
now doing well and serving an integral role at PHA as the Senior 
Manager of our Early Diagnosis Campaign.
    Over the past decade, treatment options, and the survival rate, for 
pulmonary hypertension patients have improved significantly. However, 
courageous patients of every age lose their battle with PH each day. 
There is still a long way to go on the road to a cure and biomedical 
research holds the promise of a better tomorrow.
              health resources and services administration
    Due to the serious and life-threatening nature of PH, it is common 
for patients to face drastic health interventions, including heart-lung 
transplantation. Federal organ transplantation activities are 
coordinated through HRSA. To ensure HRSA can expand its important 
mission and continue to make improvements in donor lists and donor-
matching please provide HRSA with a meaningful funding increase in 
fiscal year 2017.
               centers for disease control and prevention
    As a result of Federal investment in medical research, there are 
now twelve FDA-approved treatments for PH. The effectiveness of these 
therapies, however, is dependent on how early a patient can receive an 
accurate diagnosis and begin treatment. Unfortunately, two-thirds of 
patients are not diagnosed until PH has reached a late stage. In 
addition to mitigating the impact of many treatments, late diagnosis 
puts PH patients in a position to face interventions like heart-lung 
transplantation and even death. CDC and NCCDPHP have the resources to 
compliment PHA's own Sometimes its PH Early Diagnosis Campaign. 
Improving public awareness and recognition of PH will not only save 
lives, it can save the Federal healthcare system money. Please provide 
CDC with meaningful funding increases so the agency can expand its 
focus into increasingly important and cost-effective areas.
                     national institutes of health
    NIH hosts a sizable PH research portfolio. Further, NIH and PHA 
have a strong track record of working together to advance our 
scientific understanding of PH. The twelve FDA-approved treatments, 
more than nearly every other rare disease, are evidence of the return-
on-investment from these activities. Please provide NIH with meaningful 
increases to facilitate expansion of the PH research portfolio so we 
can continue to improve diagnosis and treatment.
NCATS
    The Office of Rare Diseases Research (ORDR), located within NCATS, 
supports and coordinates rare disease research and provides information 
on rare diseases to patients, their families, healthcare providers, 
researchers and the public. In collaboration with other NIH institutes, 
ORDR funds rare diseases research primarily through the Rare Diseases 
Clinical Research Network (RDCRN), which supports clinical studies, 
investigator training, pilot projects, and access to information on 
rare diseases.
NHLBI
    PHA's Research Program has committed more than $15 million for PH 
research by leveraging partnerships with the National Heart, Lung, and 
Blood Institute (NHLBI) and the American Thoracic Society (ATS). We 
have supported 70 promising researchers through four independently 
reviewed, cutting-edge research programs.
    Through a career development award partnership with the National 
Heart, Lung, and Blood Institute (NHLBI), the Pulmonary Hypertension 
Association is pleased to provide supplemental funding to individuals 
who receive an NHLBI Mentored Clinical Scientist Research Career 
Development Award (K08) or a Mentored Patient-Oriented Research Career 
Development Award (K23) for research on pulmonary hypertension. The K23 
award is focused on patient oriented research where clinicians interact 
directly with patients in their studies. The K08 award provides support 
to researchers through supervised research career development in the 
fields of biomedical and behavioral research, including translational 
research but whose studies do not include direct interaction with 
patients.
    This program's award recipients are active in the PH community and 
PHA is proud to have provided support to 11 researchers to date.
    The NHLBI-funded Centers for Advanced Diagnostics and Experimental 
Therapeutics in Lung Diseases Stage II program, which began in fiscal 
year 2014, provides a mechanism to accelerate the development of 
therapies for lung diseases, including pulmonary fibrosis and pulmonary 
arterial hypertension.

    [This statement was submitted by Mr. Rino Aldrighetti, President 
and CEO, Pulmonary Hypertension Association.]
                                 
                                 ______
                                 
               Prepared Statement of Reamer Andrew  deg.
                  Prepared Statement of Andrew Reamer
    Chairman Blunt, Ranking Member Murray, and members of the 
Subcommittee, I am writing in support of the President's budget request 
for $641 million for the Bureau of Labor Statistics (BLS) in fiscal 
year 2017.
    As a research professor at the George Washington Institute of 
Public Policy, I focus on policies that promote U.S. economic 
competitiveness. From this perspective, I believe that a fully-funded 
BLS is essential to the health of the Nation's economy. I offer three 
reasons:
  --Congress has given the BLS a number of specific mandates that 
        require adequate resources to fulfill. I summarize these 
        mandates in an appendix to this testimony.
  --BLS data--particularly data on employment, unemployment, prices, 
        and productivity--are essential for sound Federal macroeconomic 
        policies.
  --BLS data enable efficient U.S. labor markets by enabling 
        participants--workers, students, educators, and employers--to 
        make more informed decisions. Better decisions in labor markets 
        will result in employers finding workers with desired skills, 
        workers with high value credentials, and reduced Federal 
        expenditures for education and workforce development grants.
    Since 2010, however, real appropriations for the BLS have fallen by 
9 percent and staff capacity by eight percent. As a result, the agency 
has not been able to fully carry out its mandated responsibilities, to 
the detriment of the U.S. economy. I encourage the Subcommittee to 
understand that a relatively small amount of taxpayer funds invested in 
current, reliable statistics will lead to substantial increases in 
economic activity as measure by jobs and income.
    The value of cutting-edge BLS efforts can be seen in its release 
today of a new data series on the attainment of industry-recognized 
certifications and occupational licenses among adults. Subcommittee 
members may see these data at http://www.bls.gov/cps/certifications-
and-licenses.htm.
    I encourage the Subcommittee to approve the two BLS budget 
initiatives to greatly enlarge our understanding of two important 
dimensions of economic activity--contingent work and employer-provided 
training. To the extent that workers receive training through 
employers, Federal expenditures for workforce development can decline.
    I very much appreciate the opportunity to provide this testimony, 
hope the Subcommittee finds it of value, and look forward to the 
Subcommittee's decision with regard to the BLS.
                       bls mandates from congress
    Nationwide Workforce and Labor Market Information System.--The 
Secretary of Labor is directed to develop, maintain, and continuously 
improve, in cooperation with the States, a nationwide workforce and 
labor market information system that facilitates Federal, State, and 
local policy and program design, implementation, and evaluation; labor 
market research; and informed decisionmaking by employers, workers, 
students, educational agencies, and workforce investment boards.\1\ The 
U.S. Code gives BLS five more focused mandates that fit inside this 
broader one:
---------------------------------------------------------------------------
    \1\ 29 USC 49l-2 and 29 USC 2864(d)(2)(E)).
---------------------------------------------------------------------------
  --Collect, collate and report at least once each year full and 
        complete statistics on the conditions of labor; \2\
---------------------------------------------------------------------------
    \2\ 29 USC 2.
---------------------------------------------------------------------------
  --Collect, collate, report, and publish monthly and annual employment 
        and wage statistics by detailed industry and geography; \3\
---------------------------------------------------------------------------
    \3\ 29 USC 2.
---------------------------------------------------------------------------
  --Operate statistical programs essential for development of . . . 
        national statistical series, including those related to 
        employment and unemployment; \4\
---------------------------------------------------------------------------
    \4\ 29 USC 49l-1.
---------------------------------------------------------------------------
  --Develop methods for estimating Hispanic unemployment; \5\ and
---------------------------------------------------------------------------
    \5\ 29 USC 8.
---------------------------------------------------------------------------
  --Conduct an annual study of veterans' unemployment.\6\
---------------------------------------------------------------------------
    \6\ 38 USC 4110A.
---------------------------------------------------------------------------
    Determination of Federal Pay by Locality.--Congress declares a 
policy that: Federal pay for employees under the General Schedule be 
based on equal pay for equal work; Federal pay distinctions be 
maintained in line with work and performance distinctions; within any 
local pay area, Federal pay rates be compatible with non-Federal pay 
rates for the same levels of work; and pay disparities between Federal 
and non-Federal employees should be eliminated.\7\ In line with these 
principles, Federal pay rates are to be determined on the basis of a 
number of specified data sources, including these BLS products:
---------------------------------------------------------------------------
    \7\ 5 USC 5301.
---------------------------------------------------------------------------
  --Employment Compensation Index (national)
  --National Compensation Survey (pay to non-Federal workers by 
        occupation and work level, by pay locality)
  --Unemployment rate (national)
  --Consumer Price Index (national)
  --Producer Price Index (national)
    Reports on Industrial Production and Productivity.--BLS is directed 
to:
  --Collect, collate and report at least once each year full and 
        complete statistics on the products of the Nation's labor force 
        and the distribution of these products; \8\
---------------------------------------------------------------------------
    \8\ 29 USC 2.
---------------------------------------------------------------------------
  --At intervals of not less than 2 years, . . .  report the general 
        conditions of production of the Nation's leading industries; 
        \9\ and
---------------------------------------------------------------------------
    \9\ 29 USC 4.
---------------------------------------------------------------------------
  --Make continuing studies of productivity and labor costs in the 
        manufacturing, mining, transportation, distribution, and other 
        industries.\10\
---------------------------------------------------------------------------
    \10\ 29 USC 2b.
---------------------------------------------------------------------------
    Imports Monitoring.--The Secretary of Labor and the Secretary of 
Commerce are directed to monitor imports of goods and services to 
identify changes in volume of imports and the impacts on production and 
employment, by geography.\11\
---------------------------------------------------------------------------
    \11\ 19 USC 2393(a).
---------------------------------------------------------------------------
    Occupational Health and Safety Statistics.--The Secretary of Labor 
is directed to develop and maintain an effective program of collection, 
compilation, and analysis of occupational safety and health statistics. 
The program should provide accurate statistics on work injuries and 
illnesses that include all disabling, serious, or significant injuries 
and illnesses, whether or not involving loss of time from work, and 
which involve medical treatment, loss of consciousness, restriction of 
work or motion, or transfer to another job.\12\
---------------------------------------------------------------------------
    \12\ 29 USC 673(a).
---------------------------------------------------------------------------
    Price Statistics.--While the U.S. Code does not require BLS to 
produce the Consumer Price Index (CPI), it mandates the use of the CPI 
over 200 times.
    In addition to its congressional mandates, the BLS is charged by 
the Office of Management and Budget with calculating and publishing 
seven Principal Federal Economic Indicators (PFEIs): \13\
---------------------------------------------------------------------------
    \13\ OMB, Statistical Policy Directive No. 3: Compilation, Release, 
and Evaluation of Principal Federal Economic Indicators, September 25, 
1985.
---------------------------------------------------------------------------
    1.  Employment Situation (unemployment rate and nonfarm payroll 
        employment)
    2. Producer Price Indexes (PPI)
    3. Consumer Price Index (CPI)
    4. Real Earnings
    5. Labor Productivity and Costs
    6. Employment Cost Index
    7. Import and Export Price Indexes \14\
---------------------------------------------------------------------------
    \14\ OMB, ``Schedule of Release Dates for Principal Federal 
Economic Indicators for 2016,'' September 2015, p. 3.

    [This statement was submitted by Andrew Reamer, Research Professor, 
George Washington Institute of Public Policy, George Washington 
University.]
                                 ______
                                 
                 Prepared Statement of Research!America
    On behalf of Research!America, the Nation's largest not for profit 
education and advocacy alliance working to accelerate medical progress 
and strengthen our Nation's public health system, thank you for this 
opportunity to share our views on fiscal year 2017 appropriations under 
the jurisdiction of the Subcommittee on Labor, Health and Human 
Services, Education, and Related Agencies.
The National Institutes of Health (NIH) Drives the Discovery of New 
        Treatments and Cures
    NIH is the world's leading funder of basic biomedical research, and 
Americans appreciate the value this research delivers. Since 1992, 
Research!America has commissioned national and State-level surveys to 
gauge public sentiment on issues related to health research and 
innovation. One of the most consistent findings over time has been 
Americans' support for basic research. In a survey commissioned in 
January 2015, 70 percent of respondents agreed that ``even if it brings 
no immediate benefits, basic scientific research that advances the 
frontiers of knowledge is necessary and should be supported by the 
Federal Government.''
    More than 80 percent of NIH funding is awarded through almost 
50,000 competitive grants to 300,000 researchers at more than 2,500 
universities, medical schools, and other research institutions in every 
State and around the world. Research supported by NIH is typically at 
the early, non-commercial stages of the research pipeline; therefore, 
NIH funding complements critical private sector investment and 
development. The NIH also plays an essential role in educating and 
training America's future scientists and medical innovators. In 2015, 
NIH sponsored over 5,000 training grants and fellowships for 
biomedical- and health-focused graduate and medical students, 
postdoctoral researchers and young investigators-- a pivotal investment 
in America's future research workforce.
    We believe it is in the strategic interests of the United States to 
increase funding for NIH by at least 10 percent in fiscal year 2017. To 
achieve this increase, it is crucial to continue your successful 
efforts to rebuild annual appropriations for NIH, growing the 
Institutes' base budget in fiscal year 2017 by at least $2.4 billion or 
5 percent after inflation is taken into account. Research!America 
believes this increase is merited by the magnitude of our health 
challenges, the cost of inaction and the extraordinary return on 
medical progress.
    The Centers for Disease Control and Prevention (CDC) Safeguards the 
Nation's Health
    CDC is tasked with safeguarding the Nation's health, and over the 
past 70 years it has worked diligently to thwart deadly outbreaks, 
costly pandemics and debilitating disease. Moreover, CDC plays a key 
role in research that leads to life-saving vaccines, bolsters defenses 
against bioterrorism and improves health tracking and data analytics. 
CDC's work has hastened many health and safety improvements, such as 
lowering teen pregnancy rates, reducing deaths from motor vehicle 
accidents, lowering tobacco use and preventing millions of 
hospitalizations.
    Ebola, Zika, Dengue fever and other emerging health threats have 
shown just how critical CDC is to our Nation, and have also revealed 
the enormity of the challenge the agency faces as it works to safeguard 
American lives. To protect Americans, CDC needs to have a global reach; 
CDC scientists must be on the ground fighting public health challenges 
wherever and whenever they occur. But there is an imbalance between the 
funding provided to CDC and its increasingly growing mission demands. 
We request that CDC receive at least $7.8 billion in fiscal year 2017 
to carry out its crucially important responsibilities.
AHRQ Maximizes the Return on Medical Progress
    AHRQ is the lead Federal agency responsible for ensuring medical 
progress translates into better patient care. Medical discovery, 
development and delivery are intertwined: the value of discovery and 
development hinge on smart healthcare delivery. That's where AHRQ comes 
in. AHRQ-funded research is used to ensure patients receive the right 
care at the right time in the right settings. This research serves many 
critical purposes, from ensuring information about new medical 
discoveries reaches doctors and patients as quickly as possible, to 
deploying health IT to address challenges in healthcare access and 
delivery, to cutting the number of deadly--and preventable--medical 
errors.
    If we underinvest in AHRQ, we are inviting unnecessary healthcare 
spending and squandering the opportunity to ensure patients receive the 
quality care they need. We ask that you commit to investing in life and 
cost-saving health services research by funding AHRQ at $364 million in 
fiscal year 2017.
Conclusion
    There are few Federal investments that convey benefits as important 
and far-reaching as funding for NIH, CDC and AHRQ: new cures, new 
businesses, new jobs; innovative solutions that improve healthcare 
delivery and optimize the use of limited health dollars; and a public 
health system nimble and sophisticated enough to meet daunting 
challenges to the health and safety of the American people. We 
appreciate your consideration of our funding requests and thank you for 
your stewardship over such critically important Federal spending 
priorities.
                                 ______
                                 
               Prepared Statement of Results for America
    Chairman Blunt and Ranking Member Murray: Results for America (RFA) 
is pleased to present our recommendations for fiscal year 2017 to the 
Senate Appropriations Subcommittee on the Departments of Labor, Health 
and Human Services and Education. RFA and our partners are requesting 
support for evidence-based programs that will improve outcomes for 
young people, their families and communities by helping to drive 
Federal resources towards results-oriented solutions. The attached 
letter and table outlines our requests for fiscal year 2017.
    Results for America is improving outcomes for young people, their 
families and communities by shifting public resources toward practices, 
policies, and programs that use evidence and data to improve quality 
and get better results. In a climate of constrained resources and 
mounting demands, we know that public funds must increasingly be 
invested in ``what works.''
    Over the past few years, all levels of government have taken an 
interest in improving the way taxpayer dollars are invested to ensure 
that limited resources are spent in the most efficient manner possible, 
but with that efficiency comes the responsibility of getting the most 
for each dollar. This can be achieved by investing these dollars in 
evidence-based solutions. This approach has a strong history of 
bipartisan support. President George W. Bush's Administration put a 
priority on improving the performance of Federal programs and 
encouraged more rigorous evaluations to assess their effectiveness. The 
Obama Administration has built on this effort by supporting an 
increasing number of evidence and evaluation-based policies and 
programs. Mayors and governors from both parties across the country are 
also increasingly using data and evidence to steer public dollars to 
more effectively address needs in their communities and States.
    By identifying how to ``invest in what works'' this approach 
becomes the new norm for allocating public dollars and can be used as a 
catalyst for, and funder of, effective and innovative solutions that 
produce greater social impact, that will help drive public resources 
toward programs that are evidence-based, performance-driven and 
competitively selected and away from programs that consistently fail to 
achieve results.
    On February 29, 2016, the following 133 organizations sent a letter 
to Chairmen Rogers and Cochran, and Vice Chairwoman Mikulski and 
Ranking Democratic Member Lowey, requesting bill and report language to 
achieve the goal of investing in what works. To provide you with a 
complete picture of our evidence and evaluation agenda, we have also 
included bill and report language requests for other departments and 
agencies and mandatory programs outside of the Appropriations 
Committees jurisdiction.
                          invest in what works
    Dear Chairmen Cochran and Rogers, Vice Chairwoman Mikulski and 
Ranking Democratic Member Lowey: We are writing to urge you to include 
the attached Invest in What Works provisions in the Appropriations 
Committees' fiscal year 2017 bills and reports for the Departments of 
Labor, Health and Human Services, Education, and, Related Agencies; the 
Departments of Commerce, Justice, Science, and Related Agencies; the 
Departments of Transportation, Housing and Urban Development, and 
Related Agencies; and the Department of State, Foreign Operations, and 
Related Agencies. We have also included some information regarding our 
mandatory funding requests in order to provide you with a complete 
picture of the data and evidence provisions we support.
    America continues to face severe budget constraints at all levels 
of government as well as enormous social and economic shifts. These 
factors, combined with an increasingly globally competitive workforce, 
require us to invest taxpayer dollars in the most effective and 
efficient manner possible. The recently enacted Consolidated 
Appropriations Act, 2016 includes an unprecedented commitment to 
evidence-based, results-driven solutions, but more needs to be done. 
While we applaud the Administration's fiscal year 2017 budget, which 
proposes an increased focus on data and evidence, we must continue to 
ensure that scarce Federal resources are invested in what works.
    We thank you for the positive steps you have taken toward building 
a strong evidence-based, results-driven policy agenda, and we ask you 
to incorporate the attached Invest in What Works recommendations in the 
fiscal year 2017 appropriations bills and committee reports.
    Thank you for your consideration of our requests.

Achieve! Minneapolis
Achievement Network (ANet)
AdvancED
America Forward
America's Promise Alliance
American School Health Association
AppleTree Institute for Education Innovation
Atlanta Neighborhood Charter School
Be The Change
Blue Engine
Boston Plan for Excellence
Building Educated Leaders for Life (BELL)
California League of Middle Schools
CASA de Maryland
Cascade Philanthropy Advisors
Center for Employment Opportunities
Center for Research and Reform in Education, Johns Hopkins University
Challenger Center for Space Science Education
Charitable Assistance to Community's Homeless (CATCH)
Children's Literacy Initiative
Citizen Schools
City of Boise
City of Las Vegas
City Year
College Possible National
College Summit
Communities In Schools
Community Supervision Alternatives
Community Training and Assistance Center (CTAC)
Congreso de Latinos Unidos
ConnCAN
CSH
Democrats for Education Reform
The Dibble Institute
EDGE Consulting Partners
Education Analytics
Education Development Center
Education Reform Now
Education Northwest
The eMINTS National Center
Forum for Youth Investment
Greater Twin Cities United Way
GreenLight Fund
Green and Healthy Homes Initiative
Green Dot Public Schools
Healthy Teens Coalition of Manatee County
IDEA Public Schools
Infusing INnovative STEM Practices Into Education (INSPIRE)
Institute for Child Success
Internationals Network for Public Schools
Jobs for the Future
Kentucky Valley Educational Cooperative
KIPP
Knowledge Alliance
Leading Educators
Leaps and Bounds Family Services
LIFT
Literacy Design Collaborative
Local Initiatives Support Corporation (LISC)
March of Dimes
McREL International
Mental Health Partners
MENTOR: The National Mentoring Partnership
Methodist Healthcare Ministries of South Texas
Mile High United Way
Montgomery County Schools (NC)
Morino Institute
The National Campaign to Prevent Teen and Unplanned Pregnancy
National Center for Learning Disabilities
National Center for Teacher Residencies
National Council on Crime and Delinquency
National Forum to Accelerate Middle Grades Reform
National Prevention Science Coalition (NPSC)
Nebraska Children and Families Foundation
New Classrooms
New Leaders
New Profit
New Schools for New Orleans
New Teacher Center
Nonprofit Finance Fund
Nurse Family Partnership
Opportunity Nation
PACE Center for Girls, Inc.
Parents as Teachers
Peace Alliance
Public Counsel
REDF
Research Institute for Key Indicators (RIKI)
Results for America
RMC Research Corporation
Saint Paul Promise Neighborhood
Seneca Family of Agencies
ServeMinnesota
Silicon Valley Community Foundation
Social Finance
Society for Adolescent Health and Medicine
Sorensen Impact Center, University of Utah
South Carolina Campaign to Prevent Teen Pregnancy
Spurwink Services
StriveTogether
Student Peace Alliance
Success for All Foundation
Teach For America
Teach Plus
The Policy & Research Group
Third Sector Capital Partners
TNTP
Turnaround for Children
United Way for Southeastern Michigan
United Way of Greenville County
United Way of Lane County
The University of Missouri College of Education
University of North Carolina at Greensboro
Uplift Education
Urban Alliance
U.S. Soccer Foundation
Venture Philanthropy Partners
Voices for National Service
Way to Grow
WestEd
Workforce Data Quality Campaign
Wyman Center
Year Up
YES Prep Public Schools
Youth Villages
Paul Carttar, former Director, Social Innovation Fund and Senior 
Advisor, The Bridgespan Group
Lynn Cominsky, Director, Education and Public Outreach Group, Sonoma 
State University
Sandra Domingcil, Teen Parent Program, Salinas Union High School 
District (CA)
Michael Greenstone, Milton Friedman Professor in Economics, University 
of Chicago and Director, Energy Policy Institute at Chicago
Rebecca Maynard, Professor of Education & Social Policy, University of 
Pennsylvania
Diane Schanzenbach, Associate Professor, School of Education and Social 
Policy, Northwestern University and Director, The Hamilton Project, The 
Brookings Institution
Matt Segneri, Director, Social Enterprise Initiative, Harvard Business 
School
Martin West, Associate Professor of Education, Harvard Graduate School 
of Education
                      
                          invest in what works
          summary of fiscal year 2017 appropriations requests

                          department of labor
    Language--WIOA Pay for Performance: provide technical assistance 
for Pay for Performance
    Language--Evaluation Set-Aside: set aside 1 percent of 
discretionary appropriations for evaluations
    $40,000,000--Workforce Data Quality Initiative: build State and 
local data capacity for tracking employment and educational outcomes of 
WIOA program participants
                department of health and human services
    $25,000,000--Head Start Designation Renewal System (DRS): use 
evidence to determine if Head Start and Early Head Start agencies 
deliver high-quality and comprehensive services
    $104,790,000--Teen Pregnancy Prevention: continue a tiered-evidence 
approach to scaling-up proven programs and developing, testing, and 
evaluating innovative programs
    Language--Maternal, Infant, and Early Childhood Home Visiting 
Program: encourage HRSA and ACF to continue collaboration to improve 
outcomes for at-risk pregnant women and families through evidence-based 
home visiting programs
    Language--Community Mental Health Services Block Grant: set aside 
10 percent of funds to support evidence-based mental health prevention 
and treatment practices
    Language --Modernizing Senior Nutrition Programs: set aside up to 1 
percent of nutrition funds to expand evidence-based models, and set 
aside 1 percent for evaluations
    $15,000,000--Children's Research and Technical Assistance: develop 
and evaluate approaches to reducing welfare dependency and increasing 
well-being of minor children
    Language--Statistical Access to National Directory for New Hires 
(NDNH): allow select access to the NDNH dataset, consistent with 
privacy and confidentiality protections
                        department of education
    $180,000,000--Education Innovation and Research: support a tiered-
evidence approach to creating, replicating, scaling-up, and evaluating 
evidence-based innovations
    $100,000,000--Replication and Expansion of High-Quality Charter 
Schools: support competitive grants to charter management organizations 
with proven track records of success
    $100,000,000--First in the World: support the implementation and 
evaluation of evidence-based strategies to improve college completion, 
particularly for high need students
    Language--Evaluation Set Aside: set aside 1 percent of all 
discretionary appropriations, except for Pell Grants, for program 
evaluations
    $100,000,000--Supporting Effective Educator Development Grants 
(SEED): support evidence-based educator support by applicants with a 
track record of success
    Language--TRIO: support the Secretary's use of evidence in awarding 
competitive grants
    $15,000,000--InformEd: collect, analyze, and release data and 
evaluation studies, for internal users and the public, to answer 
pressing education questions
    $75,000,000--American Technical Training Fund: support a tiered-
evidence approach to developing, implementing, scaling-up, and 
evaluating job-training models
             corporation for national and community service
    $70,000,000--Social Innovation Fund: support evidence-based 
approaches that demonstrate measurable outcomes, including a 20 percent 
set aside for Pay for Success
    $386,010,000--AmeriCorps State and National: support community-
based organizations and programs that implement evidence-informed and 
evidence-based solutions
      general provisions--departments of labor, hhs and education
    Language--Performance Partnership Pilots: support establishing up 
to 10 Performance Partnership Pilots
                         department of justice
    Second Chance Act Offender Re-entry Programs: set aside $20,000,000 
for Pay for Success, of which $10,000,000 shall be for implementing the 
Permanent Supportive Housing Model
    Language--Performance Partnership Pilots (P3): allow participation 
with other agencies in carrying out P3
                         department of commerce
    Ryan-Murray Evidence-Based Policy Commission: create a commission 
to make administrative data widely available, while ensuring data 
security, privacy, and confidentiality
              department of housing and urban development
    Language--Performance Partnership Pilots: permit HUD to partner 
with other Federal agencies in carrying out Performance Partnership 
Pilots
    Language--Office of Policy Development and Research--Transfer 
Authority: authorize the transfer of up to $120 million to integrate 
evidence throughout program policy and management
                          department of state
    $22,400,000--USAID--Development Innovation Ventures: support a 
tiered-evidence approach to testing, developing, implementing, scaling-
up, and evaluating global development solutions
                     support for mandatory programs
    $400,000,000--Maternal, Infant, and Early Childhood Home Visiting 
Program: encourage HRSA and ACF to continue collaboration to improve 
outcomes for at-risk pregnant women and families through evidence-based 
home visiting programs
    $300,000,000--Pay for Success (PFS): authorize a new PFS program 
within the Department of Treasury for State and local governments to 
establish PFS projects
    Language--Social Services Block Grant Program (SSBG): set aside-up 
to 1.5 percent of SSBG funds for research and program evaluation.

    [This statement was submitted by Michele Jolin, CEO, Results for 
America.]
                                 ______
                                 
               Prepared Statement of Rotary International
    Chairman Blunt, members of the Subcommittee, Rotary International 
appreciates this opportunity to submit testimony in support of the 
polio eradication activities of the U. S. Centers for Disease Control 
and Prevention (CDC). The Global Polio Eradication Initiative (GPEI) is 
an unprecedented model of cooperation among national governments, civil 
society and UN agencies working together to reach the most vulnerable 
children through the safe, cost-effective public health intervention of 
polio immunization. We appeal to this Subcommittee for continued 
leadership to ensure we seize the opportunity to conquer polio once and 
for all. Rotary International strongly supports the President's 2017 
request of $174 million for the polio eradication activities of the CDC 
to enable full implementation of the polio eradication strategies and 
innovations outlined in the Polio Eradication and Endgame Strategic 
Plan (2013-2018).
           progress in the global program to eradicate polio
    Thanks to this committee's funding for the fiscal year 2016 polio 
eradication activities of the CDC:
  --There were fewer cases of polio in fewer places than in any point 
        in history. Only 74 cases were confirmed for the entire year of 
        2015--a decrease of more than 80 percent over 2014 levels. Only 
        two countries--Pakistan and Afghanistan--confirmed cases of 
        wild polio in 2015.
  --There have been no cases of polio on the African continent since 
        August of 2014.
  --Nigeria was removed from the list of endemic countries in September 
        2015 following more than a year without a case of wild polio.
  --Polio immunization campaigns reaching more than 400 million 
        children were conducted in more than 30 countries, primarily in 
        Africa, South Asia and the Middle East.
  --Polio outbreaks in the Middle East, Horn of Africa, and Central 
        Africa, which accounted for roughly 60 percent of all cases in 
        2013, have been brought under control. All polio free countries 
        remain at risk for outbreaks until the wild poliovirus has been 
        eradicated in the remaining places where it persists.
  --The Global Polio Eradication Initiative is cautiously optimistic 
        that type 3 polio may have been eradicated. There have been no 
        cases of type 3 polio since November 2012.
  --While the program works to ensure no child is ever paralyzed again 
        by wild polio, it is also taking steps to stop rare instances 
        of vaccine-derived polio cases by beginning the withdrawal of 
        the oral polio vaccine and the global introduction of the 
        inactivated polio vaccine, which carries no risk of paralysis.
    The United States has been the leading public sector donor to the 
Global Polio Eradication Initiative. Rotary International appreciates 
the United States' generous support and recognizes increased funding 
provided by Congress in fiscal year 2016 to ensure the GPEI can fully 
implement the plan. Rotarians are committed to continuing their own 
fundraising for the program until the world is certified polio free. 
Rotarians will also continue to advocate support from the public and 
other governments, both polio free and polio affected, to support the 
successful execution of the Strategic Plan. The ongoing support of 
donor countries, like the United States, is essential to ensure the 
necessary human and financial resources are made available to polio-
endemic and at risk countries to certify the world polio free.
    Global polio eradication is Rotary International's top priority. 
Rotary's global membership of over 1.2 million business and 
professional leaders (more than 336,000 of which are in the U.S.) has 
contributed more than U.S.$1.5 billion toward a polio free world. 
Rotary also leads the United States Coalition for the Eradication of 
Polio, a group of committed child health advocates that includes the 
March of Dimes Foundation, the American Academy of Pediatrics, the Task 
Force for Global Health, the United Nations Foundation, and the U.S. 
Fund for UNICEF.
         cdc's vital role in global polio eradication progress
    Rotary commends CDC for its leadership in the global polio 
eradication effort, and greatly appreciates the Subcommittee's 
increased support of CDC's polio eradication activities to support full 
implementation of the Strategic Plan. The United States is the leader 
among donor nations in the drive to eradicate this crippling disease. 
CDC has used the Congressional support to make the following 
significant programmatic contributions:
Globally:
    With funding from fiscal year 2015, CDC provided:
    --$33.9 million to UNICEF for approximately 100 million doses of 
            oral polio vaccine, 6.9 million doses of inactivated polio 
            vaccine, and $6.3 million for operational costs for NIDs in 
            all polio-endemic countries and other high-risk countries 
            in Asia, the Middle East and Africa. Most of these NIDs 
            would not take place without the assurance of CDC's 
            support.
    --$52.2 million to WHO for surveillance, technical staff and 
            immunization activities' operational costs, primarily in 
            Africa.
    --CDC Atlanta-based staff spent 2,360 person-days during 295 
            deployments providing technical assistance to global 
            headquarters of partners, countries and regional offices on 
            polio. Through April 2016, CDC Atlanta-based staff provided 
            1,352 person-days of technical assistance on 169 
            deployments to global headquarters of partners, countries 
            and regional offices on polio.
  --CDC's Stop Transmission of Polio (STOP) program trains and deploys 
        public health professionals to improve vaccine-preventable 
        disease surveillance and to help plan, implement, and evaluate 
        vaccination campaigns. STOP places staff resources in countries 
        of higher-risk for poliovirus transmission to support critical 
        national immunization functions. STOP has trained and deployed 
        more than 1,800 public health professionals to work on polio 
        surveillance, data management, campaign planning and 
        implementation, program management, and communications in high-
        risk countries. In 2015, the STOP program sent 247 
        professionals on 379 assignments to 42 countries.
  --The CDC Director serves as the Chari of the Polio Oversight Board 
        (POB), the top governance body for the Global Polio Eradication 
        Initiative. The CDC also houses the Secretariat for the POB in 
        support of the Director's role as POB Chair. This involves 
        coordination across the highest levels of the Global Polio 
        Eradication Initiative partnership.
  --The CDC led efforts to coordinate the switch from trivalent oral 
        polio vaccine to bivalent vaccine, scheduled to occur in April 
        2016. At the same time, CDC continues to work with partners to 
        help all countries introduce one dose of inactivated polio 
        vaccine to their routine schedules by the last quarter of 2017.
  --The CDC also supports global polio eradication by participating in 
        technical advisory groups, EPI manager and other key global 
        meetings. The CDC also published 27 articles on the progress 
        toward polio eradication in the Morbidity and Mortality Weekly 
        Report (MMWR) and in peer-reviewed journals.

  --Build Capacity in Nigeria.-- The National Stop Transmission of 
        Polio (N-STOP) program, adapted from the original STOP Program, 
        has provided Nigeria with an accessible, flexible, and 
        culturally competent workforce at the front lines of public 
        health. N-STOP includes participatory training for public 
        health workers composed of ten modules covering poliomyelitis, 
        vaccine management and monitoring, program management, and 
        problem-solving practices. CDC's National STOP program for 
        Nigeria trained 219 staff at the Local Governing Area level in 
        the highest risk States, playing a key role in interrupting 
        transmission of wild polio. Nigeria's polio legacy planning 
        will transition those workers to build lasting improvements in 
        Nigeria's immunization system.

  --Build capacity in Pakistan.--In collaboration with the Pakistan 
        Ministry of Health and in coordination with WHO and the USAID's 
        mission in Islamabad, 64 national epidemiologists from CDC's 
        Field Epidemiology Training Program (FETP) were trained and 
        deployed to the highest risk districts for circulation of wild 
        polio virus to help improve the quality of surveillance and 
        immunization activities.
Improve Program Management and Efficiency:
  --Based on best practices developed in India and Nigeria, CDC 
        established several important benchmarks to improve the 
        performance of polio programs and to achieve greater 
        efficiency. These benchmarks streamline decisionmaking for 
        program officials, by making clear who is accountable for 
        achieving results while empowering program officials to respond 
        rapidly to events on the ground.
  --CDC also guided the establishment of Emergency Operations Centers 
        (EOCs) and guided use of CDC-developed dashboards through the 
        country and State levels. These have directly contributed to 
        the dramatic turnaround in program quality in Nigeria and 
        Pakistan.
Ensure High Quality Global Surveillance:
    CDC provided (and continues to provide):
    --expertise in virology, diagnostics, and laboratory procedures, 
            including quality assurance, and genomic sequencing of 
            samples obtained worldwide.
    --training for virologists from around the world in advanced 
            poliovirus research and public health laboratory support. 
            CDC's Atlanta laboratories serve as a global reference 
            center and training facility.
    --the largest volume of operational (poliovirus isolation) and 
            technologically sophisticated (genetic sequencing of polio 
            viruses) lab support to the 145 laboratories of the global 
            polio laboratory network. CDC has the leading specialized 
            polio reference lab in the world.
    --scientific and technical expertise to WHO on research issues 
            regarding: (1) laboratory containment of wild poliovirus 
            stocks following polio eradication, and (2) when and how to 
            stop or modify polio vaccination worldwide following global 
            certification of polio eradication.
Foster the Effective Transition of Global Polio Eradication Assets
  --CDC is leading the efforts to raise awareness of the importance and 
        urgency of transition planning amongst donors, country 
        governments and other stakeholders to begin polio legacy 
        planning to ensure that key polio functions, including 
        immunization, surveillance, outbreak response and bio 
        containment, will be in place post-eradication. Presently, the 
        global polio eradication staff is the single largest source of 
        external technical assistance for immunization and surveillance 
        in low-income countries, and polio eradication efforts are 
        responsible for reaching the world's most vulnerable children 
        with vaccines and other health interventions.
                    fiscal year 2017 budget request
    For fiscal year 2017, we request this subcommittee to provide $174 
million for the CDC's polio eradication activities, the level that was 
requested in the President's budget. This will allow CDC to provide to 
continue to build capacity to support intense supplementary 
immunization activities in polio-affected and at-risk countries, to 
develop leadership on data management and evidence-based 
decisionmaking, and to implement for effective management and 
accountability. These funds will also help maintain essential 
certification standard surveillance. Finally, continued funding will 
enable CDC to capitalize on polio eradication efforts to strengthen 
immunization systems and protect the gains made in polio free and at-
risk countries. Every year delayed eradicating this disease will 
require $800 million to continue this fight.
    Since 1988, tens of thousands of public health workers have been 
trained to manage massive immunization programs and investigate cases 
of acute flaccid paralysis. Cold chain, transport and communications 
systems for immunization have been strengthened. The global network of 
145 laboratories and trained personnel established by the GPEI also 
tracks measles, rubella, yellow fever, meningitis, and other infectious 
diseases and will do so beyond polio eradication.
    A study published in the November 2010 issue of the journal Vaccine 
estimates that the GPEI could provide net benefits of at least $40-50 
billion over the next 20 years. As many as 200,000 children could be 
paralyzed annually in the next 10 years if we do eradicate polio now. 
Success will ensure that the significant investment made by the U.S., 
Rotary International, and many other countries and entities, is 
protected in perpetuity.
                                 
                                 ______
                                 
           Prepared Statement of Rowe Carole and David  deg.
              Prepared Statement of Carole and David Rowe
    Dear Chairman Cochran, Vice Chairwoman Mikulski, Chairman Blunt and 
Ranking Member Murray:

    We write to express our strong disapproval for Senator Gillibrand 
and her colleagues' request for increased OCR funding. We respectfully 
ask that this subcommittee deny this and any other request for 
increased funding that will enable OCR to continue to enforce 
directives issued in violation of the Administrative Procedure Act.
    In its effort to protect and propel the claims of those who file 
reports of sexual harassment, OCR has created a system whereby the 
accused of such allegations have been stripped of their right to due 
process. We are personally aware of scores of students (all male) who 
have been unjustly suspended or expelled from their college or 
university as a result of these unjust policies and procedures. We 
cannot express strongly enough the damage that such undeserved 
punishments cause to the accused. They suffer emotional distress, 
depression, rejection, isolation, and unwarranted shame. Their lives 
and futures are ripped out from beneath them.
    Instead of increasing OCR's funding, we need to step back and take 
a look at the injustices occurring as a result of the current policies 
in place; policies adopted by colleges and universities as a direct 
result of the Dear Colleague Letter of 2011. The lower preponderance 
standard of proof has eroded due process on campuses all over the 
country.
            Respectfully submitted,
                                   Carole and David Rowe
                                 ______
                                 
    Prepared Statement of the Ryan White Medical Providers Coalition
    My name is Dr. Alice C. Thornton, and I serve as Medical Director 
of the Bluegrass Care Clinic (BCC) at the University of Kentucky 
Medical Center in Lexington, Kentucky. I write to submit testimony on 
behalf of the Ryan White Medical Providers Coalition (RWMPC), which I 
Co-Chair. RWMPC is a national coalition of medical providers and 
administrators who work in clinics supported by the Ryan White HIV/AIDS 
Program funded by the HIV/AIDS Bureau (HAB) at the Health Resources and 
Services Administration (HRSA). I thank the Subcommittee for its $4 
million funding increase for Ryan White Part C Programs in fiscal year 
2016. And while I am very grateful for this support, and understand 
that times are hard, I request $225.1 million, or a $20 million 
increase, for Ryan White Part C programs in fiscal year 2017. While I 
know that this is a lot of funding, it is in fact well below the 
estimated need--in 2015, my clinic alone enrolled 179 new patients into 
care--a 14 percent increase in 1 year. These funds help Ryan White 
clinics identify, engage, and effectively treat persons living with 
HIV/AIDS in a way that saves both lives and money.
    My Ryan White-funded clinic, the BCC, has served as the source for 
HIV primary care in the 63 counties of central and eastern Kentucky for 
the past 25 years. Over half of the counties served are federally 
recognized as economically distressed, and BCC cares for 74 percent of 
the people living with HIV in the region. Since the BCC received its 
first Part C grant in 2001, the number of patients has increased by 
almost 300 percent. To help fund these enormous patient and cost 
increases, the University incurs an annual deficit of approximately 
$1.2 million.
    Most Part C clinics, including BCC, also receive support from other 
parts of the Ryan White Program (RWP) that help us provide medications; 
additional medical care, such as dental services; and support services, 
such as case management and transportation--all essential components of 
the effective Ryan White HIV care model that results in excellent 
outcomes.
Ryan White Part C Programs Support Comprehensive, Expert, and Effective 
        HIV Care
    Part C of the Ryan White Program directly funds comprehensive and 
effective HIV care and treatment--services that are responsible for the 
dramatic decrease in AIDS-related mortality and morbidity over the last 
decade. The Ryan White Program has supported the development of expert 
HIV care and treatment programs that achieve key outcomes that improve 
individual health and help prevent the transmission of HIV. In 2011, a 
ground-breaking clinical trial--named the ``scientific breakthrough of 
the year'' by Science magazine--found that HIV treatment not only saves 
the lives of people living with HIV, but also reduces HIV transmission 
risk to near zero--proving that HIV treatment is also HIV prevention.
    The comprehensive, HIV care model that is supported by the Ryan 
White Program has been highly successful at achieving positive clinical 
outcomes with a complex patient population.\1\ In a convenience sample 
of eight Ryan White-funded Part C programs ranging from the rural South 
to the Bronx, retention in care rates ranged from 87 to 97 percent. 
However, estimates from the Centers for Disease Control and Prevention 
(CDC) show that only 40 percent of all people with HIV are engaged in 
care nationally.\2\ Once in care, patients served at Ryan White clinics 
do very well--more than 81 percent of Ryan White patients achieved 
viral suppression in 2014. BCC is doing even better than this national 
average for Ryan White clinics--in 2015, 92 percent of BCC patients had 
an undetectable viral load. Additionally, many BCC patients continue to 
work and remain active community members.
---------------------------------------------------------------------------
    \1\ See Improvement in the Health of HIV-Infected Persons in Care: 
Reducing Disparities at http://cid.oxfordjournals.org/content/early/
2012/08/24/cid.cis654.full.pdf+html.
    \2\ See CDC's HIV in the United States: The Stages of Care, http://
www.cdc.gov/nchhstp/newsroom/docs/HIV-Stages-of-Care-Factsheet-508.pdf, 
November 2014.
---------------------------------------------------------------------------
Investing in Ryan White Part C Programs Saves Both Lives and Money
    Early and reliable access to HIV care and treatment both helps 
patients with HIV live relatively healthy and productive lives and is 
more cost effective. One study from the Part C Clinic at the University 
of Alabama at Birmingham found that patients treated at the later 
stages of HIV disease required 2.6 times more healthcare dollars than 
those receiving earlier treatment meeting Federal HIV treatment 
guidelines. On average it costs $3,501 per person per year to provide 
the comprehensive outpatient care and treatment available at Part C 
funded programs. The comprehensive services provided often include lab 
work, STD/TB/Hepatitis screening, ob/gyn care, dental care, mental 
health and substance abuse treatment, and case management. This is a 
bargain when compared to the high cost of hospital and emergency care.
Fully Funding and Maintaining Ryan White Part C Programs Is Essential
    Because of both the inadequacy of insurance coverage for people 
with complex conditions such as HIV and the fact that some individuals 
will remain uncovered, fully funding and maintaining the Ryan White 
Program is essential to providing comprehensive, expert and effective 
HIV care nationwide. However, RWMPC is concerned about the proposal to 
consolidate Ryan White Part D funding into Part C. RWMPC's specific 
concerns include:
  --Parts C and D programs both provide comprehensive, effective care 
        and treatment for women, infants, children and youth living 
        with HIV/AIDS. However, Part D programs have cultivated special 
        expertise for engaging and retaining women (including pregnant 
        women) and young people in care and Part D allows funding for 
        key services not covered by Part C. With adolescents accounting 
        for 26 percent of new HIV infections in the U.S., it is still 
        critical to target resources to support the effective, 
        comprehensive services that Part D programs provide to these 
        vulnerable populations and not enact this significant 
        structural change outside of a broader reauthorization of the 
        program.
  --In some communities, Part D-funded programs are the main providers 
        of HIV care and treatment. It is critical to ensure that 
        implementation of any budget proposal does not leave any 
        community without adequate access to effective and 
        comprehensive HIV care and treatment. Also, for Ryan White 
        medical clinics that currently receive only Part D funding, it 
        could prove difficult to successfully compete for Part C 
        funding if there already is a Part C program serving that 
        community; and loss of that Part D program could reduce the 
        community's overall access to HIV and treatment.
  --It is unclear exactly how the proposed consolidation would impact 
        grantees. More detail outlining how the consolidation process 
        would actually impact grantees and access to HIV care and 
        treatment in specific communities is needed before instituting 
        a program change that could reduce community access to HIV care 
        and treatment.
    At this critical time in the HIV/AIDS epidemic, when research has 
confirmed that early access to HIV care and treatment not only saves 
lives but prevents new infections by reducing the risk of transmission 
to near zero for patients who are virally suppressed and keeps patients 
engaged and working, it is essential to maintain overall funding levels 
for the Ryan White Program. Increasing access to and successful 
engagement in effective, comprehensive HIV care and treatment is the 
only way to lead the Nation to an AIDS-free generation and reduce the 
devastating costs of--including lives lost to--HIV infection.
Continue to Permit the Use of Federal Funds for Syringe Access Programs 
        that Help to Advance Public Health and Address Drug Use in 
        Kentucky and Nationwide
    RWMPC commends Congress for leading the Nation by modifying the ban 
on Federal funding for syringe access programs. RWMPC is committed to 
evidence-based public health interventions that both increase access to 
healthcare and decrease transmission of HIV, viral hepatitis, and other 
blood-borne pathogens. Injection drug use is a major transmission route 
for these infections, and increasing access to syringe access programs 
through Federal funding will help decrease the spread of hepatitis C 
and HIV, as well as help connect individuals to critical healthcare and 
support services, including overdose prevention, substance use 
treatment, and medical care for hepatitis C, HIV, and other life-
threatening infections.
    Kentucky has one of the highest rates of acute hepatitis C in the 
country. We have seen a dramatic increase in hepatitis C infections 
with a majority of infections occurring in young persons who live in 
non-urban areas with a history of injection drug use, and previously 
used opioid agonists such as oxycodone.\3\ In University of Kentucky's 
infectious diseases practice, hepatitis C and infections such as 
endocarditis, have compromised the lives of too many Kentuckians, and 
we have been frustrated by our inability to employ the full range of 
effective tools available to prevent infections and help patients 
address their addiction. These problems also have been seen in West 
Virginia, Ohio, and many other States and communities, including Scott 
County, Indiana, where new HIV infections reached 168 in just the first 
6 months of 2015 in a small, rural area that beforehand had under 10 
HIV infections each year.
---------------------------------------------------------------------------
    \3\ Centers for Disease Control and Prevention. Surveillance for 
Viral Hepatitis--United States, 2012. Online at: http://www.cdc.gov/
hepatitis/Statistics/2012Surveillance/Commentary.htm.
---------------------------------------------------------------------------
    Last year, Kentucky legislators acted decisively to improve public 
health and the lives of residents by passing into law a comprehensive 
set of medical interventions, including expanded access to opioid 
overdose medication and substance use treatment. The law also included 
a syringe exchange program provision that allows local jurisdictions to 
establish syringe access programs that provide clean syringes and other 
critical services, including referral to substance use treatment and 
other needed medical care. My clinic worked with the local public 
health department to establish the syringe access program in Lexington, 
and we are pleased that Federal funds now could help support the budget 
of this and other syringe access programs nationwide.
    Data from the Centers for Disease Control and Prevention (CDC) 
highlighting links between HIV infection and injection drug use 
illustrate the importance of syringe access programs. Data, published 
in CDC's Morbidity and Mortality Weekly Report, were gathered from 20 
U.S. cities in 2012 and showed that of more than 10,000 injecting drug 
users tested for HIV, 11 percent are infected with HIV. Of those who 
answered interview questions, 30 percent reported injecting themselves 
with a syringe that was shared with other people.
    We urge Congress to maintain the fiscal year 2016 omnibus 
appropriations language that allows access to syringe services in 
jurisdictions that are experiencing or are at risk for an increase in 
hepatitis infections or an HIV outbreak due to injection drug use as a 
key element of infectious disease prevention and as a way to identify 
and engage individuals in critical medical care, including substance 
use treatment. And again, we urge you to please fully fund the Ryan 
White Program this year. Thank you so much for your time and 
consideration of these requests.

    [This statement was submitted by Alice Thornton, MD, Medical 
Director, Bluegrass Care Clinic and Co-Chair, Ryan White Medical 
Providers Coalition.]
                                 ______
                                 
                Prepared Statement of Sac and Fox Nation
    Chairman Blunt and esteemed members of the Committee, on behalf of 
the Sac and Fox Nation I thank you for the opportunity to present our 
requests for the fiscal year 2017 Budgets and matters for consideration 
for Health and Human Services and Education. The Sac and Fox Nation is 
home of Jim Thorpe, one of the most versatile athletes of modern sports 
who earned Olympic gold medals for the1912 pentathlon and decathlon.
    Each of our suggestions and requests for your budgets this year is 
contained in more detail below. I am so pleased to be able to provide 
you this testimony and hope that it helps you in your many 
deliberations regarding the budgets for fiscal year 2017. The Sac and 
Fox Nation looks forward to building a positive relationship with your 
committee and enhancing the future of our people and our youth.
                      national requests--education
    Increase in Funding Directly to Education Departments to Leave More 
Money for Programs.--The fiscal year 2017 budget identifies funding 
directly for education departments and this is a priority for the Sac 
and Fox Nation. Having direct funding for the administration would 
leave more money for programs which are seriously underfunded. Right 
now, we receive only $84,000 per year in higher education and 
vocational education funds. With the increase in demand among Native 
Students entering College, we are able to accommodate only about half 
of the requests we receive every year. An increase in this area and 
funding to leave more money in the program would be a significant 
benefit to all our Tribal students. With the adoption of the every 
student succeeds act, we are looking for more funding and more 
flexibility in programs that would allow us to target the best areas to 
put our funding on these issues.
    Support the President's Budget Fiscal Year 2017 Funding Investing 
in Tribally Driven Education.--The Presidents Proposed Budget for 
fiscal year 2017 provides for a significant increase in funding, $450 
million dollars over the amount allocated last year, for the ED's Title 
I Program. This program is the largest K-12 grant program serving the 
Tribal Youth in Communities all across the United States. We at the Sac 
and Fox Nation feel that approval of this funding increase is critical 
to provide the support that low income schools need to bring their 
systems and the education of our youth into the future. It is 
especially important to us because Oklahoma has so many rural and small 
schools who struggle to provide their students with books and materials 
let alone high speed Internet or access to research systems which can 
be critical to a well-rounded education. There has long been a 
disparity between the educations these rural schools can provide 
students. There is no reason for that disparity to exist. Those funds 
will also provide for supplies, books and materials that are currently 
unavailable in these rural communities because of funding concerns. 
With such a large portion of the Tribal Youth of the United States 
attending rural schools it is imperative that the funding levels 
reflect the needs that exist today.
    Increase Funding to Early Development and Preschool Services.--The 
Budget presented by the President is bold in its provision for $350 
million dollars for preschool development grants, $100 Million over the 
levels from fiscal year 2016. This increase is both needed and forward 
thinking. As it has been said over and over, the youth are our future 
and if we cannot provide for them we will not be able to move forward. 
The Sac and Fox Nation is proud to offer early childhood development 
and head start programs to our Tribal Children throughout our 
jurisdiction. However, these programs are consistently underfunded and 
cannot provide for all of the demands that exist. Especially in 
Oklahoma communities which can be very rural there are not a lot of 
options for preschool or early education. We are proud of our programs, 
but they are located in major areas like Shawnee, Norman and Cushing 
Oklahoma. More funding and more opportunities in this area would allow 
programs like ours to grow and expand to make sure that all Tribal 
youth are being served when it comes to early education.
              national requests--health and human services
    Authorize Mandatory Funding and Fully Fund Contract Support Costs 
(CSC) for IHS.--The President's fiscal year 2017 Budget proposal fully 
funds the estimated need for CSC for Indian Health Services at $800 
million, a significant increase over the levels of funding from fiscal 
year 2016. The estimated increase includes funding for new and expanded 
contracts and compacts. The Budget also requests that CSC be 
reclassified to a mandatory appropriation beginning in fiscal year 
2018. We at the Sac and Fox Nation strongly urge you to consider 
allocating all the requested funds in this area and making these 
appropriations mandatory and separate in the future. Our health and the 
access of our Native People to healthcare is a serious and major 
concern all around Indian Country. It is always prominent for us 
because we have so many people in rural communities who need greater 
access to medical care. Fully funding contract support costs and making 
them mandatory serves to take pressure off Tribal Nations who have a 
lack of certainty in their medical services when they are not sure if 
the funding will be there or not. When there is certainty, it allows 
programs like ours to expand both services and locations to provide 
better care within reach of our people.
    Increase Funding to Social Services in Indian Country Through 
Health and Human Services.--The President's fiscal year 2017 Budget 
provides robust funding for the desperately needed social services in 
Indian Country. That budget is calling for a $204 million dollar 
increase of the funding level from 2016. These funds are being 
dedicated to the most critical issues currently facing Indian Country 
including $916 Million for HHS's Administration for Children and 
Families, $231 Million for Head Start Programs (which I previously 
addressed), $194 Million for Tribal TANF, $55 Million for Child 
Support, $212 Million for Child Care Programs, $106 Million for Child 
Welfare Programs, $53 Million for the Administration of Native 
Americans, and $55 million in SAMHSA to help reduce the ever worrisome 
increases in suicide among native youth. There is no shortage of things 
to say regarding each of these issues and why increasing their funding 
levels is critical. However, in order to be brief, I will simply say 
that these main issues are the ones we deal with every day on the 
ground in Tribal Governments. Tribal members are in desperate need of 
aid in these areas just to make their lives work. Our children are a 
critical resource that we must protect and the great work that is done 
by the Administration of Children and Families and all the Indian Child 
Welfare departments across the Nation should be properly funded. With 
the expansion of Indian Child Welfare, the BIA Guidelines and possible 
regulations these programs are in dire need of funding to ensure that 
they are running at the best capacity and efficiency possible. 
Protecting our Native youth from birth, through school and their trying 
years of finding themselves and their purpose is something that is 
paramount in our eyes. We strongly encourage you to consider this 
increase and to help us fight to make sure that critical services are 
reaching those who are most in need.
    Increase the Level of Funding for Programs Like the Title VI Elders 
Program Food Delivery.--At the Sac and Fox Nation we are seeing a great 
increase in the number of elders who need help getting meals. However, 
not all of those elders are medically homebound. Some don't have 
transportation or vehicles, some have issues with being able to drive 
properly and others are too far from the kitchens where we serve are 
meals. We would like an increase in funding to this program and 
implementation of more flexibility or another program to include 
increasing issues like those we are seeing. With an increase in funding 
to these programs, more kitchens or meals centers could be opened to 
provide for the care of our growing population of elders. While this 
may seem small compared to the other major issues we know you are 
dealing with, it is no small issue to us. For a lot of our elder 
population, who may live in rural areas or communities, a meal delivery 
may provide them the only opportunity with human interaction on any 
given day. Moreover, it allows them to have a good, nutritious meal 
which is not a possibility for a lot of them on their own. Our meal 
delivery staff is critical to the health of our elders to make sure 
they are eating, taking care of themselves and can get help when it is 
needed. In a rural community, a meal delivery could save a life.
    Thank you for allowing me to submit these requests on these fiscal 
year 2017 Budgets.

    [This statement was submitted by Hon. Kay Rhoads, Principal Chief, 
Sac and Fox Nation.]
                                 ______
                                 
               Prepared Statement of Safe Sates Alliance
    Safe States Alliance, the national membership association dedicated 
to strengthening the practice of injury and violence prevention, 
appreciates the opportunity to provide testimony in support of injury 
and violence prevention programs at the Centers for Disease Control and 
Prevention (CDC) and Health Resources and Services Administration 
(HRSA). Safe States Alliance requests that as you craft the fiscal year 
2017 Labor, Health and Human Services and Education Appropriations 
bill, you consider including the following priorities:
  --$20 million to expand the State Core Violence and Injury Prevention 
        Program;
  --$5 million to pursue a traumatic brain injury (TBI) surveillance 
        program;
  --$25 million for nationwide expansion of the National Violent Death 
        Reporting System;
  --Preserve the Prevention and Public Health Fund and allocate 
        resources to support injury and violence prevention efforts;
  --Maintain funding for the Preventive Health and Health Services 
        Block Grant at $180 million and provide $650 million to HRSA 
        for the Maternal and Child Health Block Grant;
  --$19 million to increase youth violence prevention-related 
        investments across all Federal agencies, including restoration 
        of funding for youth violence prevention activities;
  --$10 million to research the causes and prevention of firearm-
        related violence and injuries; and,
  --$18 million for the Injury Control Research Centers for 
        interdisciplinary research and train future injury and violence 
        prevention practitioners and researchers.
                               background
    Injuries and violence are serious public health problems. Areas 
include:

Assault & Homicide
Bullying
Child Maltreatment
Child Passenger Safety
Disaster Response
Domestic & Intimate Partner Violence
Drowning
Elder Abuse
Falls
Fire & Burns
Motor Vehicle Safety
Pedestrian & Bicycle Safety
Poisoning & Prescription Drug Overdose
Sexual Assault & Rape
Suicide
Traumatic Brain Injury
Youth Violence
                      
    In 1985, the Institute of Medicine (IOM) first called attention to 
the lack of recognition and funding for injury and violence prevention 
(IVP) as a public health issue in the United States.\1\ Although some 
progress has been made, injuries and violence continue to have a 
significant impact on the health of Americans and the healthcare 
system, as more people ages 1--44 die from injuries than from any other 
cause, including cancer, HIV, or the flu.\2\
---------------------------------------------------------------------------
    \1\ National Research Council. Injury in America: A Continuing 
Public Health Problem. Washington, DC: The National Academies Press, 
1985.
    \2\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars.
---------------------------------------------------------------------------
    In fact, in 2013 injury and violence resulted in more than 27 
million visits to emergency departments, three million 
hospitalizations, and roughly 193,000 deaths--one person every three 
minutes.\2\ Furthermore, in 2013 injuries and violence cost $671 
billion in medical costs and lost productivity.\3\ Yet, today there is 
no national program to support State public health IVP programs.
---------------------------------------------------------------------------
    \3\ Centers for Disease Control and Prevention, National Center for 
Injury Prevention and Control. Web-based Injury Statistics Query and 
Reporting System (WISQARS) [online] (2007) [accessed 2013 Feb 15]. 
Available from URL: http://www.cdc.gov/injury/wisqars.
---------------------------------------------------------------------------
    At the Federal level, the CDC Injury Center serves as the focal 
point for the public health approach to IVP. The CDC Injury Center only 
receives approximately 3 percent of the CDC/Agency for Toxic Substances 
and Disease Registry budget to address the significant burden of 
injuries and violence nationwide.
              core violence and injury prevention program
    Given its limited budget, the CDC Injury Center currently provides 
small capacity building grants of approximately $250,000 to only 20 
State health departments (SHDs) through the Core Violence and Injury 
Prevention Program (VIPP). The Core VIPP is comprised of multiple 
components including: Basic Prevention (20 States); Regional Network 
Leaders (five States); Surveillance Quality Improvement (four States); 
Older Adult Falls Prevention (three States); and Motor Vehicle/Child 
Injury Prevention (four States).
    Opioid pain relievers are now involved in more overdose deaths than 
cocaine and heroin combined. From 2000 to 2014 nearly half a million 
people died from drug overdoses. The CDC Injury Center provides 
leadership in enhancing drug overdose surveillance, identifying and 
evaluating effective program and policy interventions for preventing 
overdoses, improving clinical practice to reduce prescription drug 
diversion and abuse, and equipping and empowering States with the 
information and resources they need to reverse the epidemic. Due to 
limited funding, a small number of Core VIPP States support promising 
surveillance and prevention strategies. State health departments are 
well positioned to coordinate the necessary multi-sector responses to 
reverse the epidemic through the regulation of healthcare 
professionals, prescription drug monitoring programs, and other major 
levers for preventing prescription drug abuse.
    Ohio's Core Violence and Injury Prevention Program (VIPP) provides 
statewide leadership and funding for community-based efforts to address 
prescription drug abuse and overdose through the PHHS Block Grant from 
CDC. The OH VIPP coordinates the development and implementation of 
statewide prevention strategies, conducts surveillance, supports the 
Governor's Cabinet Opiate Action Team Prescriber Education Work Group 
including the development of opioid prescribing guidelines, and 
provides support and technical assistance to expand naloxone 
distribution programs. Examples of locally PHHS Block Grant funded 
strategies include: expanding access to naloxone distribution programs; 
facilitating healthcare system changes such as implementation of opioid 
prescribing guidelines and other pain management strategies; obtaining 
commitment of prescribers to use the Ohio prescription drug monitoring 
program; and expanding access to sustainable drug disposal options.
    Safe States Alliance recommends an allotment of $20 million for the 
Core VIPP to support injury and violence prevention programs in ALL 
States and territories and full funding for the Preventive Health and 
Health Services Block Grant at $180 million.
                national violent death reporting system
    NVDRS (National Violent Death Reporting System) is a State-based 
surveillance system that uses information from a variety of States and 
local agencies and sources--medical examiners, coroners, police, crime 
labs and death certificates--to form a more complete picture of the 
circumstances that surround violent deaths. State and local violence 
prevention practitioners use these data to guide their prevention 
programs, policies and practices including: identifying common 
circumstances associated with violent deaths of a specific type (e.g. 
gang violence) or a specific area (e.g. a cluster of suicides); 
assisting groups in selecting and targeting violence prevention 
efforts; supporting evaluations of violence prevention activities; and 
improving the public's access to in-depth information on violent 
deaths. CDC Injury Center currently funds 32 States to implement NVDRS 
and received an approximately $5 million increase in fiscal year 2016 
to expand number of participating States.
    In Oregon, the Oregon Older Adult Suicide Prevention Advisory Work 
Group and the Oregon Department of Human Services used NVDRS to develop 
and focus suicide prevention programs for older adults. NVDRS found 
that almost 50 percent of men ages 65 and older who died by suicide 
were reported to have a depressed mood before death, but only a small 
proportion were receiving treatment, suggesting screening and treatment 
for depression might have saved lives. As a result, Oregon developed 
primary care recommendations in 2006 to better integrate with mental 
health services so that suicidal behavior and ideation are diagnosed 
and older adults received appropriate treatment. As a result, the 
suicide rates among males ages 65 and older in Oregon decreased 
approximately 8 percent from 2007 to 2010.
    Safe States Alliance supports an increase of $7.5 million to 
complete nationwide expansion of NVDRS.
           preventive health and health services block grant
    For more than 30 years, the PHHS (Preventive Health And Health 
Services) Block Grant has remained an essential source of Federal 
agencies to support State solutions to State health problems. The PHHS 
Block Grant allows each State to respond to its own distinct health 
priorities and need and is the only source of funding for States 
without Core VIPP that supports local IVP prevention efforts. In fiscal 
year 2011, more than 20 percent of the Prevent Block Grant was used by 
States to support IVP and emergency medical services. According to a 
2011 survey conducted by Safe States Alliance, 29 States reported 
receiving an average of $329,000 from the Prevent Block Grant for IVP 
efforts.\4\ The Prevent Block Grant is a critical source of funding for 
SHD IVP programs representing 9.4 percent of total State funding in 
2011.
    Safe States Alliance supports continued funding of the PHHS Block 
Grant at the $180 million level.
    Preventable injuries exact a heavy burden on Americans through 
premature deaths and disabilities, pain and suffering, medical and 
rehabilitation costs, disruption of quality of life for families, and 
disruption of productivity for employers. Strengthening investments in 
public health IVP programs is a critical step to keep Americans safe 
and productive for the 21st century. Safe States Alliance would like to 
thank the Committee for consideration of this testimony.
---------------------------------------------------------------------------
    \4\ State of the States: 2011 Report. Atlanta, GA: Safe States 
Alliance; 2013.

    [This statement was submitted by Amber Williams, Executive 
Director, Safe Sates Alliance.]
                                 ______
                                 
         Prepared Statement of Save the Children Action Network
    Chairman Blunt, Ranking Member Murray, and honorable Members of the 
Subcommittee, thank you for the opportunity to provide testimony about 
the critical investments that must be made in early childhood 
education. My name is Mark Shriver and I am the President of Save the 
Children Action Network (SCAN). SCAN is a national, non-profit 
organization that aims to mobilize all Americans to support critical 
investments in early childhood education.
    For the fiscal year 2017 Labor, Health and Human Services, 
Education and Related Agencies Appropriations bill, SCAN supports:
  --$3.4 billion for Child Care and Development Block Grants (CCDBG)
  --$10.1 billion of Head Start and Early Head Start
  --$350 million for Preschool Development Grants
  --$1.3 billion for 21st Century Community Learning Centers
  --$27 million for Innovative Approaches to Literacy
                               background
    Early Childhood Education (ECE) programs are critical for children. 
During the first 5 years of life, a child develops many of the skills 
necessary to become successful. It is during these years that they 
build the foundation for reading, math, science and academics, as well 
as the skills necessary for character building, social-emotional 
growth, gross-motor development, and executive functioning--including 
everything from impulse control to problem solving.
    Unfortunately, two out of five American children are not enrolled 
in preschool. Without access to high quality early learning programs, 
children fall behind. Many never catch up. By age five, more than half 
of all American children are not prepared for school.\1\
---------------------------------------------------------------------------
    \1\ Julia B. Isaacs, ``Starting School at a Disadvantage: The 
School Readiness of Poor Children,'' Center on Children and Families at 
Brookings, (March 2012).
---------------------------------------------------------------------------
    Early education--starting at birth and continuing until a child's 
first day in kindergarten--is a critical window for ensuring future 
academic achievement. This window, however, closes quickly, and 
children who enter kindergarten unprepared are more likely to 
experience serious negative social impacts. Disadvantaged children who 
don't participate in high quality early education programs are:
  --70 percent more likely to be arrested for a violent crime; and
  --60 percent more likely to never attend college;
  --50 percent more likely to be placed in special education;
  --40 percent more likely to become a teen parent.\2\
---------------------------------------------------------------------------
    \2\ ``Early Childhood Education in the U.S.,'' Save the Children 
USA, (2015), Print.
---------------------------------------------------------------------------
  --25 percent more likely to drop out of school;
    Additionally, there are strong social and economic benefits to high 
quality ECE programs, including improved social skills and significant 
gains in literacy, language and math and a return on investment of $7 
for every $1 invested.\3,4\ It is critical to ensure that access to 
high-quality preschool and comprehensive early education and family 
engagement programs are available for all children regardless of their 
income.
---------------------------------------------------------------------------
    \3\ James Heckman, Seong Hyeok Moon, Rodrigo Pinto, Peter Savelyev, 
and Adam Yavitz, ``A New Cost-Benefit and Rate of Return Analysis for 
the Perry Preschool Program: A Summary,'' NBER Working Paper Series, 
(2010), http://jenni.uchicago.edu/papers/Heckman_Moon_etal_
2010_NBER_wp16180.pdf.
    \4\ Investing in Our Future: The Evidence Base on Preschool 
Education, Foundation for Child Development & Society for Research in 
Child Development, (Oct. 2013), http://fcd-us.org/sites/default/files/
Evidence%20Base%20on%20Preschool%20Education%20FINAL.pdf.
---------------------------------------------------------------------------
         save the children's work on early childhood education
    Save the Children has long been a part of the movement to improve 
early childhood education in the United States. To advance early 
learning, Save the Children supports education programs for children at 
home and in the classroom. Our child experts work to ensure that our 
Nation's most underserved children have the best chance for success. 
Every day, we help children get ready to learn and succeed in school 
and live healthy, active lives.
Save the Children's Early Steps to School Success (ESSS)
    ESSS has been serving children in the United States since 2006. In 
2014, more than 7,200 children and their families across 14 States and 
the District of Columbia participated in Save the Children's Early 
Steps to School Success program. The vast majority of these children 
are growing up in poverty and facing many hurdles to success. Despite 
their challenges, more than 80 percent of the children in the program 
score at or above the normal range for vocabulary acquisition and enter 
kindergarten on par with their middle-income peers, ready to succeed in 
school and in life.
Save the Children Early Head Start and Head Start Programs
    Children who participate in federally-funded Head Start and Early 
Head Start have a higher likelihood of graduating high school and a 
lower likelihood of being charged with a crime than similar children 
who do not participate in Head Start.\5\ Furthermore, participation in 
Head Start has been shown to close over one-third of the gap in test 
scores between children who participate in Head Start and their more 
advantaged peers.\6\ Three-year olds who participate in Early Head 
Start perform significantly better on cognitive, language and social-
emotional measures than their peers.\7\ In 2015, through these 
programs, Save the Children reached tens of thousands of American 
children with early education services.
---------------------------------------------------------------------------
    \5\ Eliana Garces, Duncan Thomas, and Janet Currie, ``Longer-Term 
Effects of Head Start,'' The American Economic Review, 92.4, (Sept. 
2002), http://www.jstor.org/stable/3083291?seq=
1#page_scan_tab_contents.
    \6\ Janet Currie and Duncan Thomas, ``Does Head Start Make a 
Difference?'' The America Economic Review, (1995): 359, http://
www.econ.ucla.edu/people/papers/Currie/Currie14.pdf.
    \7\ Early Head Start Benefits Children and Families, Early Head 
Start National Resource Center, An Office of the Administration for 
Children and Families, (June 2015), 
http%3A%2F%2Feclkc.ohs.acf.hhs.gov%2Fhslc%2Ftta-
system%2Fehsnrc%2Fabout-ehs%23
benefits.
---------------------------------------------------------------------------
    A recent review of programs operated under Maternal, Infant and 
Early Childhood Home Visiting Program (MIECHV) found various positive 
outcome measures.\8\ Research shows that high quality, rigorous home 
visiting programs result in improved child development and school 
readiness as well as improved family economic self-sufficiency.\9\ A 
leading model shows significant outcomes in reducing rates of State-
verified reports of child abuse and neglect.\10\
---------------------------------------------------------------------------
    \8\ Sarah Avellar, Diane Paulsell, Emily Sama-Miller, Patricia Del 
Grosso, Lauren Akers, and Rebecca Kleinman, ``Home Visiting Evidence of 
Effectiveness Review: Executive Summary,'' Office of Planning, Research 
and Evaluation, Administration for Children and Families, U.S. 
Department of Health and Human Services, (2014): 9, http://
homvee.acf.hhs.gov/HomVEE_
Executive_Summary_2014-59.pdf.
    \9\ Kimberly Boller, Deborah Daro, Patricia Del Grosso, Russell 
Cole, Diane Paulsell, Bonnie Hart, Brandon Coffee-Borden, Debra Strong, 
Heather Zaveri, and Margaret Hargreaves, Making Replication Work: 
Building Infrastructure to Implement, Scale-up, and Sustain Evidence-
Based Early Childhood Home Visiting Programs with Fidelity (Princeton, 
NJ: Mathematica Policy
Research, 15 June 2014), http://www.mathematica-mpr.com/our-
publications-and-findings/
publications/making-replication-work-building-infrastructure-to-
implement-scaleup-and-sustain-evidence.
    \10\ ``Evidentiary Foundations of Nurse-Family Partnership,'' Nurse 
Family Partnership, (2011), http://www.nursefamilypartnership.org/
assets/PDF/Policy/NFP_Evidentiary_Foundations.aspx.
---------------------------------------------------------------------------
                       appropriations priorities
Child Care and Development Block Grant (CCDBG)
    The bipartisan reauthorization of CCDBG was a crucial moment for 
children and their families. Unfortunately, without significant new 
funding, States may be forced to make difficult decisions such as 
cutting the number of children receiving child care assistance or 
reducing payments to already low-paid child care providers.
    Making matters worse, Federal and State child care spending has 
fallen to an 11-year low and the number of children receiving 
assistance is at a 16-year low. Between 2006 and 2014, more than 
364,000 children lost Federal child care assistance. Only Oregon 
reimburses child care providers who serve children receiving child care 
assistance at the federally recommended level. Without the requested, 
new funding for CCDBG, fewer families will be able to receive the help 
they need affording child care, providers will be further deprived of 
the resources they need to support high-quality care, and the goals of 
the CCDBG reauthorization will go unfulfilled.
Head Start and Early Head Start
    Head Start and Early Head Start are key to providing and expanding 
comprehensive early care and education to our poorest children. At the 
current level of funding, Head Start is only able to serve roughly two 
out of every five eligible preschoolers. Proposals for more Head Start 
programs to provide full-day, full-year services would help ensure our 
lowest-income children receive a strong early learning experience. This 
change, however, will require additional investments so that the 
additional hours and days of programming do not result in cuts in the 
number of children participating in Head Start, the number of staff 
employed by programs, or impact the quality of programming provided. 
Additionally, while the very early years of a child's life are critical 
to their development, Early Head Start serves less than 5 percent of 
eligible infants and toddlers. The increased funding request is 
required to expand access to this life changing program.
Preschool Development Grants
    Currently, fewer than three in ten four-year-olds participate in a 
high-quality preschool program. Funding to encourage States to 
establish or expand their own prekindergarten programs to serve more 
children and bolster the quality of these programs is critical. This 
program has already served over 70,000 children who otherwise would not 
have had access to pre-school. In the next 2 years, it is estimated 
that an additional 100,000 children will gain access to these vital 
programs. States' commitment to increasing access to high-quality 
preschool opportunities is extremely strong, as is their eagerness to 
partner with the Federal Government in this endeavor. Congress should 
match their enthusiasm and provide States with the resources they need.
21st Century Community Learning Centers (CCLC)
    The CCLC program supports the creation of community learning 
centers that provide academic enrichment opportunities during non-
school hours for children, particularly students who attend high-
poverty and low-performing schools. The program helps students meet 
State and local student standards in core academic subjects, such as 
reading and math, and offers students a broad array of enrichment 
activities that can complement their regular academic programs. 
Additionally, the program offers literacy and other educational 
services to the families of participating children. Under the Every 
Student Succeeds Act, funds can also be used to pay for additional 
time, support and enrichment activities during the school day.
    Every day 11.3 million children are alone after school and are 
unsupervised for an average of seven hours per week. Parents of more 
than 19.4 million youth say their children would participate in an 
afterschool program if one were available in their community. Programs 
like CCLC help working families, keep young people safe during the 
hours after school when juvenile crime peaks, and improve academic 
achievement. These programs also provide children with physical 
activity and engage them in their learning. Without funding for 
afterschool and summer learning programs, students will lose out on 
essential learning opportunities that help them prepare for school, 
college and careers.
Innovative Approaches to Literacy (IAL)
    The IAL program supports high-quality programs designed to develop 
and improve literacy skills for children and students from birth 
through 12th grade in high-need schools and underserved communities. 
These innovative programs promote early literacy for young children, 
motivate older children to read, and increase student achievement by 
using school libraries, pediatricians, and national nonprofit 
organizations as partners to improve childhood literacy.
    IAL is the primary source of Federal funding for school libraries 
and childhood literacy programs. Focusing on low income communities, 
these funds help many schools bring their school libraries up to 
standards and provide at-risk children with access to literacy 
programs. This money is not enough to help every child, but it does 
provide some support for disadvantaged schools to update materials and 
equipment, allowing children to have school library services and gain 
skills to become college and career ready.
                               conclusion
    On behalf of Save the Children Action Network, and our advocates 
across the country, I want to thank the subcommittee for its continued 
leadership on early childhood education programs and its demonstrated 
bipartisan support for these priority programs in the fiscal year 2016 
appropriations process, and ask that you make a robust investment in 
early childhood education in fiscal year 2017. We appreciate the 
subcommittee's support for programs that are essential to giving 
children opportunity for success. We ask for your continued partnership 
in investing in children, increasing access to opportunity, and 
ensuring a more prosperous America for generations to come.

    [This statement was submitted by Mark Shriver, President, Save the 
Children Action Network.]
                                 ______
                                 
            Prepared Statement of the Scleroderma Foundation
 the foundation's fiscal year 2017 l-hhs appropriations recommendations
_______________________________________________________________________

  --$7.8 billion in program level funding for the Centers for Disease 
        Control and Prevention (CDC), which includes budget authority, 
        the Prevention and Public Health Fund, Public Health and Social 
        Services Emergency Fund, and PHS Evaluation transfers.
    --A proportional fiscal year 2017 funding increase for CDC's 
            National Center for Chronic Disease Prevention and Health 
            Promotion (NCCDPHP).
  --At least $34.5 billion in program funding for the National 
        Institutes of Health (NIH).
    --Proportional funding increases for NIH's National Heart, Lung, 
            and Blood Institute (NHLBI); National Institute of 
            Arthritis and Musculoskeletal and Skin Diseases (NIAMS); 
            National Institute of Diabetes and Digestive and Kidney 
            Diseases (NIDDK); National Institute of Allergy and 
            Infectious Diseases (NIAID); National Center for Advancing 
            Translational Sciences (NCATS).
_______________________________________________________________________

    Chairman Blunt and distinguished members of the Subcommittee, thank 
you for your time and your consideration of the scleroderma community's 
priorities while working to craft the fiscal year 2017 L-HHS 
Appropriations Bill.
                           about scleroderma
    Scleroderma, or systemic sclerosis, is a chronic connective tissue 
disease generally classified as one of the autoimmune rheumatic 
diseases.
    The word ``scleroderma'' comes from two Greek words: ``sclero'' 
meaning hard, and ``derma'' meaning skin. Hardening of the skin is one 
of the most visible manifestations of the disease. The disease has been 
called ``progressive systemic sclerosis,'' but the use of that term has 
been discouraged since it has been found that scleroderma is not 
necessarily progressive. The disease varies from patient-to-patient.
    It is estimated that about 300,000 Americans have scleroderma. 
About one third of those people have the systemic form of scleroderma. 
Since scleroderma presents with symptoms similar to other autoimmune 
diseases, diagnosis is difficult. There may be many misdiagnosed or 
undiagnosed cases.
    Localized scleroderma is more common in children, whereas systemic 
scleroderma is more common in adults. Overall, female patients 
outnumber male patients at a ratio of 4-to-1. Factors other than 
gender, such as race and ethnic background, may influence the risk of 
getting scleroderma, the age of onset, and the pattern or severity of 
internal organ involvement. The reasons for this are still unknown. 
Although scleroderma is not directly inherited, some scientists feel 
there is a slight predisposition to it in families with a history of 
rheumatic or autoimmune diseases. While, scleroderma can develop in 
every age group from infants to the elderly, its onset is most frequent 
between the ages of 25 to 55.
    Currently, there is no cure for scleroderma. Treatments are based 
on a patient's particular symptoms. For instance, heartburn can be 
controlled by medications called proton pump inhibitors or medicine to 
improve the motion of the bowel. Some treatments are directed at 
decreasing the activity of the immune system. Due to the fact that 
there is so much variation from one person to another, there is great 
variation in the treatments prescribed.
    Any chronic disease can be serious. The symptoms of scleroderma 
vary greatly for each person, and the effects of scleroderma can range 
from mild to life threatening. The seriousness will depend on which 
organ systems of the body are affected, and the extent to which they 
are affected. A mild case can become more serious if not properly 
treated. Prompt and proper diagnosis and treatment by qualified 
physicians may minimize the symptoms of scleroderma and lessen the 
chance for irreversible damage.
                          about the foundation
    The non-profit Scleroderma Foundation is the national organization 
for people with scleroderma and their families and friends. It was 
formed January 1, 1998, by a merger between the West Coast-based United 
Scleroderma Foundation and the East Coast-based Scleroderma Federation. 
The national office is headquartered in Danvers, Massachusetts. The 
Foundation has a three-fold mission of support, education, and 
research.
Support
    The Scleroderma Foundation offers the following tools and resources 
in support of people living with scleroderma and their families:
  --A nationwide network of 24 chapters and more than 150 support 
        groups
  --A toll-free helpline providing information and referrals to callers
  --Educational materials, including a quarterly magazine called 
        ``Scleroderma Voice"
  --Offer a variety of brochures, booklets and newsletters, along with 
        our informative website
    Additionally, the Foundation hosts an annual National Patient 
Education Conference. The conference offers various educational and 
networking opportunities for people living with scleroderma, their 
caregivers, family members and friends. Workshops, panel discussions 
and other educational sessions are led by the leading scleroderma 
researchers and healthcare professionals.
Education
    As part of our education mission, we not only perform all the 
functions mentioned above, we also work with our Medical Advisory Board 
of internationally known scleroderma experts to provide patient 
education programs as well as education for physician/healthcare 
professionals.
Research
    The Scleroderma Foundation budgets at least $1 million a year for 
research funding, its single largest budgeted expense. The Scleroderma 
Foundation takes its fiduciary responsibility to donors very seriously, 
especially with regard to our research grant program.
                           one family's story
    Cheyenne Cogswell is an 8-year old third-grader living in the 
poverty-stricken town of Falmouth, Kentucky. Cheyenne was diagnosed at 
age six with a severe case of systemic scleroderma. The disease has 
caused kidney failure and significant damage to her digestive system, 
making it difficult for the body to receive the proper nutrition needed 
for a growing child. She has undergone several life-saving operations 
and numerous hospitalizations. Her skin and other internal organs, such 
as the heart and lungs, are also affected. Cheyenne's treatment first 
consisted of hospitalization and intense chemotherapy. She continues 
with daily chemotherapy injections, now given by her mother, to help 
suppress her immune system and slow the progression of the disease. 
Cheyenne is being raised by a single mother who has faced extreme 
consequences from the financial burden created by scleroderma, losing 
her job in the economic downturn, as well as the family's home. Doctors 
doubted if Cheyenne would survive beyond her seventh birthday, but she 
continues to beat the odds. Chronic diseases like scleroderma are 
unpredictable in their course, and the family--together with their 
close circle of friends--continues to fight and hope for the best. 
Their road is uncertain and illustrates why funding for NIH and its 
research programs are vital to so many people whose lives are impacted 
by chronic illness such as scleroderma.
               centers for disease control and prevention
    Early recognition and an accurate diagnosis of scleroderma can 
improve health outcomes and save lives. CDC in general and the NCCDPHP 
specifically have programs to improve public awareness of scleroderma 
and other rare, life-threatening conditions. Unfortunately, budgetary 
challenges at CDC have pushed the agency to focus resources on 
combating a narrow set of ``winnable battles.'' Please increase funding 
for CDC and NCCDPHP so that the agency can invest in additional, 
critical education and awareness activities that have the potential to 
improve health and save lives.
                     national institutes of health
    NIH has worked with the Foundation to lead the effort to enhance 
our scientific understanding of the mechanisms of scleroderma with the 
shared-goal of improving diagnosis and treatment, and ultimately 
finding a cure. Since scleroderma is a systemic fibrotic disease it is 
inexorably linked to other manifestations of fibrosis such as cirrhosis 
and pulmonary fibrosis that occurs during a heart attack. Scleroderma 
is a prototypical manifestation of fibrosis as it impacts multiple 
organ systems. In this way, it is important to promote cross-cutting 
research across such Institutes as NIAMS, NHLBI AND NIDDK.
    Emerging NIH initiatives like the Cures Acceleration Network and 
the Accelerating Medicines Partnership are creating meaningful 
opportunities to advance scleroderma research. Please provide NIH with 
a significant funding increase to the scleroderma research portfolio 
can continue to expand and facilitate key breakthroughs.
  --NHLBI, which is leading Scleroderma Lung Study II, is comparing the 
        effectiveness of two drugs in treating pulmonary fibrosis in 
        scleroderma.
  --NIAMS, is leading efforts to discover whether three gene expression 
        signatures in skin can serve as accurate biomarkers predicting 
        scleroderma, and investigations into progression and response 
        to treatment to clarify the complex interactions of T cells and 
        interleukin-31 (IL-31) in producing inflammation and fibrosis, 
        or scarring in scleroderma.
                 additional medical research activities
    In recent years, scleroderma has been listed as a condition 
eligible for study through the Department of Defense (DOD) Peer-
Reviewed Medical Research Program (PRMRP). Since fiscal year 2005, the 
opportunity for scleroderma researchers to compete for funding through 
this mechanism led to over $10 million in scleroderma research funding 
as well as the initiation of meaningful research projects. Military 
service-associated environmental triggers, particularly silica, 
solvent, and radiation exposure, are believed to be potential triggers 
for scleroderma in individuals that are genetically predisposed to it. 
The scleroderma community urges you to weigh in with your colleagues on 
the Appropriations Committee to actively work to see that scleroderma 
is continues to be listed as a condition eligible for study through the 
PRMRP within the Committee Report accompanying the fiscal year 2017 
Defense Appropriations Bill.
    Thank you again for your time and your consideration of the 
scleroderma community's requests.

    [This statement was submitted by Mr. Robert J. Riggs, Chief 
Executive Officer, Scleroderma Foundation.]
                                 ______
                                 
    Prepared Statement of the Social Security Vocational Expert of 
       International Association of Rehabilitation Professionals
    The International Association of Rehabilitation Professionals' 
Social Security Vocational Expert (SSVE) Section is the only 
professional organization section with a focus on serving SSVEs. Our 
more than 600 members are experienced vocational rehabilitation 
professionals who assist individuals with disabilities to find and 
maintain competitive employment across the country. We are writing to 
express our extreme concern about the integrity and the future of the 
Social Security disability determination process. We request that the 
Subcommittee address an urgent issue that is affecting the ability of 
both disability claimants and taxpayers to continue to rely on an 
accurate, informed determination process going forward.
    Like most VR professionals, SSVEs are small-business owners or 
employees of local small businesses. We work directly with clients, we 
testify in court, and we consult on workers compensation and private-
insurance cases. In addition, on certain days each month, we offer our 
expertise to the Social Security Administration (SSA) as independent 
contractors providing vocational expert testimony in Social Security 
Disability hearings. Last year, VEs offered expert testimony in 800,000 
of the one million hearings held.
    As SSVEs, we provide information concerning the existence of jobs 
in the national economy as well as an individual's ability to perform 
job functions based on work capacity. Administrative Law Judges draw on 
our impartial expert opinions to provide a factual basis for 
determining whether a claimant meets Social Security's strict 
definition of disability and therefore is eligible to receive 
disability benefits. This is a crucial component of the disability-
determination process that helps to assure that ALJs reach a correct 
decision that is supported by evidence.
    And yet, the rate SSA pays for SSVE services through a fixed-rate 
Blanket Purchase Agreement has remained essentially unchanged for 37 
years! In May 2012, the SSA Inspector General in an audit report (A-12-
11-11124) raised concerns about the quality and availability of SSVEs 
and recommended that SSA conduct a compensation study to determine 
whether SSVE fees are reasonable and consistent with VE fees paid in 
the national economy or by other government entities. Despite the IG's 
concerns and recommendations, SSA has declined to conduct any market 
research to establish fair market value, and recently extended the 
current BPA through March of 2018 without any rate increase. This rate 
is less than half of what VEs earn on average for case management and 
less than one-third of what we are paid for other VE testimony. It is 
affecting our ability, and that of other experienced, qualified SSVEs, 
to continue to provide VE services to SSA in the future.
    Current evidence suggests that fewer practicing vocational 
rehabilitation professionals are willing to take time out of their 
schedules to participate in SSA disability hearings. We also are 
concerned that a growing number of SSVEs are no longer actively 
providing vocational rehabilitation services, but instead are using 
their work as SSVEs to supplement their retirement incomes. Of even 
greater concern, anecdotal evidence suggests that some individuals who 
have neither the education nor the professional experience to qualify 
as VEs are none-the-less receiving BPAs and participating in hearings.
    SSA has indicated that it plans to move to a competitive bidding 
process for VE services beyond 2018. While we have significant 
reservations about this new approach, our immediate concern is that 
even 2 more years at the current, 37-year-old rates could have a 
devastating impact on the integrity of the disability-determination 
process. We urge Congress to direct SSA to act now to conduct a 
compensation study of VE rates as recommended by the IG, and then 
promptly take steps to adjust its rates to reflect the results of that 
study. We respectfully request that Congress provide adequate funding 
in SSA's Limitation on Administrative Expenses to compensate SSVEs at a 
fair market rate.
    Thank you for the opportunity to provide our comments to the 
Subcommittee.

    [This statement was submitted by Maria Vargas, Chair, Social 
Security Vocational Expert Section, International Association of 
Rehabilitation Professionals.]
                                 ______
                                 
    Prepared Statement of the Society for Healthcare Epidemiology of
 America and the Association for Professionals in Infection Control and
                              Epidemiology
    The Society for Healthcare Epidemiology of America (SHEA) and the 
Association for Professionals in Infection Control and Epidemiology 
(APIC) thank you for this opportunity to submit testimony on Federal 
efforts to detect dangerous infectious diseases, protect the American 
public from preventable healthcare-associated infections (HAIs) and 
address the rapidly growing threat of antibiotic resistance (AR). We 
ask that you support the following programs: within the Centers for 
Disease Control and Prevention (CDC) National Center for Emerging and 
Zoonotic Infectious Diseases: $427.9 million for Core Infectious 
Diseases including $200 million for the National Strategy and Action 
Plan for Combatting Antibiotic Resistant Bacteria (CARB), $21 million 
for the National Healthcare Safety Network (NHSN), and $30 million for 
the Advanced Molecular Detection (AMD) Initiative. Additionally, we 
request $34 million for HAI research activity conducted by the Agency 
for Healthcare Research and Quality (AHRQ) and $4.7 billion for the 
National Institutes of Health/National Institute of Allergy and 
Infectious Diseases (NIAID).
    According to the CDC, some AR infections are already untreatable. 
Without immediate intervention, minor infections may become life-
threatening and put at risk our ability to perform routine medical 
procedures or treat diseases. The CDC conservatively estimates that 
over two million illnesses and about 23,000 deaths are caused by AR 
infections. In addition, almost 453,000 people each year require 
hospital care for Clostridium difficile (C. difficile) infections. In 
most of these infections, the use of antibiotics was a major 
contributing factor leading to the illness.
               centers for disease control and prevention
    SHEA and APIC request $427.9 million for Core Infectious Diseases 
for fiscal year 2017, which includes funding for the National Strategy 
and Action Plan for CARB, HAI prevention, AR prevention, and the 
Emerging Infections Program (EIP). This investment will allow CDC to 
expand and build upon existing AR and HAI prevention efforts across 
healthcare settings to reduce the emergence of AR pathogens and improve 
antibiotic use in the community. CDC will develop evidence-based 
infection prevention guidelines, work with Federal and private sector 
partners on programming to prevent HAIs and AR, and redesign and expand 
hand hygiene awareness and educational materials for different 
healthcare settings.
    In fiscal year 2017, CDC will expand the EIP, which helps States, 
localities and territories protect the public from known infectious 
disease threats in their communities, maintain our Nation's capacity to 
identify new threats as they emerge, and identify and evaluate 
prevention strategies. CDC will strengthen the EIP program's 
infrastructure in the States and with their partners to ensure 
successful coordination and implementation of tracking and studies. CDC 
will also expand the scope of AR activities in current EIP sites and 
potentially add 1-2 additional EIP sites to the network.
    We urge you to support $200 million for the National Strategy and 
Action plan for CARB, currently in year two of implementation. CDC's 
funding request will allow full implementation of the tracking, 
prevention, and stewardship activities to reach the goals and 
prevention targets outlined in the CARB National Strategy. The fiscal 
year 2017 increase will expand the enacted fiscal year 2016 HAI/AR 
prevention efforts as part of the CARB initiative from 25 States to up 
to 50 States, six large cities, and Puerto Rico, investing in direct 
action to implement proven interventions that reduce emergence and 
spread of AR pathogens and improve appropriate antibiotic use. The CDC 
will award the majority of the fiscal year 2017 funding increase to 
States to effectively address the AR threats facing our country. It 
will also expand the National Healthcare Safety Network (NHSN) 
Antibiotic Use and Resistance (AUR) reporting option from 130 
facilities in 30 States to more than 750 facilities in all 50 States, 
the Department of Defense, and the Department of Veterans Affairs. This 
investment will support better understanding and prevention of the 
spread of potentially preventable and untreatable infections in these 
settings.
    We urge you to support $21 million for CDC's National Healthcare 
Safety Network (NHSN). The CDC estimates that HAIs cost the healthcare 
system up to $45 billion annually; at any given time, one in 25 
hospitalized patients has a HAI. The CDC provides national leadership 
and expertise in HAI prevention and protects patients across the 
healthcare continuum through outbreak detection and control. These 
activities complement and are informed by the NHSN. This request 
represents level funding with the fiscal year 2016 enacted level for 
the NHSN to support HAI prevention and reporting efforts, and will 
support in fiscal year 2017 reporting on AR infections in up to 20,000 
healthcare facilities across the continuum of care. This investment 
will target prevention efforts and support assessment of antibiotic 
prescribing for healthcare facilities, and support of the National 
Action Plan for CARB. These funds will also enable CDC to continue to 
provide data for national HAI elimination, guide prevention to targeted 
healthcare facilities to enhance prevention efforts, and decrease HAI 
rates. This support will also provide NHSN infrastructure and critical 
user support and provide innovative HAI prevention approaches. In 
support of the HHS National Action Plan to Prevent HAIs, CDC will 
continue to track Central Line-Associated Blood Infections (CLABSI), 
Catheter-Associated Urinary Tract Infections (CAUTI), Surgical Site 
Infections (SSI), methicillin-resistant staphylococcus aureus (MRSA), 
and C. difficile infections through NHSN reporting in more than 6,000 
hospitals, and bloodstream infection reporting in more than 7,000 
dialysis facilities.
    We urge your continued support of the President's $30 million 
request for the Advanced Molecular Detection (AMD) Initiative in 
bioinformatics and genomics, which allows CDC to more quickly determine 
where emerging diseases come from, whether microbes are resistant, and 
how microbes are moving through a population. This initiative is 
critical because it strengthens CDC's epidemiologic and laboratory 
expertise to effectively guide public health action. CDC needs 
continued resources to support improvements realized to date, and to 
succeed in the long run beyond its initial success.
               agency for healthcare research and quality
    We request your support of the proposed investment of $34 million 
for AHRQ's HAI research activity. The HAI support includes a total of 
$11 million for three projects using the Comprehensive Unit-based 
Safety Program (CUSP): CAUTI and CLABSI in Intensive Care Units (ICUs); 
Antibiotic Stewardship in Ambulatory and Long-Term Care Settings and 
Hospitals; and Enhanced Recovery Protocol for Surgery. The CUSP for 
Antibiotic Stewardship project is designed to support the National 
Action Plan for CARB and will extend the use of CUSP to promote the 
implementation of antibiotic stewardship programs, which seek to reduce 
inappropriate antibiotic use in ambulatory and long-term care settings 
as well as hospitals.
 national institutes of health (nih)/national institute of allergy and 
                          infectious diseases
    SHEA and APIC support the $4.7 billion requested for the National 
Institutes of Allergy and Infectious Diseases (NIAID) within NIH. NIAID 
plays a key role in advancing the goals of the National Action Plan for 
CARB through research to understand how microbes develop resistance and 
studies to identify novel ways to combat them; translation of 
laboratory findings into potential treatments, vaccines, and new 
diagnostic tests, clinical validation of diagnostic tests, and clinical 
trials to evaluate vaccines and new and existing therapies against 
drug-resistant microbes.
    We thank you for the opportunity to submit testimony and greatly 
appreciate your leadership in the effort to eliminate preventable HAIs, 
combat antibiotic resistance and improve patient safety and outcomes.
                                 ______
                                 
           Prepared Statement of the Society for Neuroscience
    Mr. Chairman and members of the Subcommittee, my name is Hollis 
Cline and I am privileged to offer this testimony in support of 
increased funding for NIH for fiscal year 2017. I offer this testimony 
in my capacity as president of the Society for Neuroscience (SfN). I am 
also the Chair of the Department of Molecular and Cellular Neuroscience 
and the Director of the Dorris Center for Neuroscience, as well as Hahn 
Professor of Neuroscience in the departments of Molecular and Cellular 
Neuroscience, and Chemical Physiology at The Scripps Research Institute 
in La Jolla, CA. My research focuses on determining how the mechanisms 
of sensory experience affect the brain's structure, development, and 
function.
    SfN believes that discoveries in basic science that will lead to 
needed breakthroughs can occur only through strong, consistent, and 
reliable finding to NIH. The Society stands with others in the research 
community in requesting at least $34.5 billion in discretionary 
funding, as part of a 10 percent overall increase, for NIH in the 
fiscal year 2017 Labor/HHS appropriations bill. This level of support 
builds on 2016 and pushes research forward. It is time to return 
research to a trajectory of sustained growth that recognizes its 
promise and its importance for health and that will serve as a 
springboard for economic development. fiscal year 2016 was a great 
first step and we cannot back away from its potential now.
    On behalf of the nearly 40,000 members of SfN, thank you for your 
tremendous support of both the NIH and neuroscience research in the 
past, and especially in fiscal year 2016. The two billion dollar 
increase in Federal support for NIH significantly contributes towards 
getting the agency back on a path of robust, sustained and predictable 
funding to fuel a future of great discovery. Thank you also for your 
support and investment in the NIH portion of the Brain Research through 
Advancing Innovative Neurotechnologies (BRAIN) Initiative. As one 
crucial part of the overall Federal investment in neuroscience, NIH-
funded BRAIN programs promote future discoveries across many areas of 
neuroscience and other research disciplines. As you will see below, 
BRAIN continues to burst with potential and has already borne fruit in 
the field of scientific tool development. For the reasons below, 
continuing your strong and consistent support of NIH is critically 
important.
    SfN's mission is to advance the understanding of the brain and 
nervous system. We believe this understanding occurs through a better 
and deeper grasp of basic science. By its nature, basic science is more 
curiosity-driven than translational research, allowing for greater 
experimentation. By employing the wide range of experimental systems 
and animals models not used elsewhere in the drug development pipeline, 
basic scientists have the ideal platform for making unexpected 
discoveries that lead to greater knowledge of biological processes. 
Increasing our basic understanding of the human brain and the diseases 
that affect it affords neuroscientists the best opportunity to identify 
new biological targets and then find and test compounds to treat brain 
disorders affecting countless people around the world.
    SfN leads efforts to disseminate and discuss emerging neuroscience 
discoveries, hosting one of the world's largest annual scientific 
meetings and publishing two leading scientific journals. SfN is also 
committed to actively educating the public about the brain, both in 
health and in illness, and to engaging policymakers regarding the 
tremendous progress and potential of brain research.
                    cross-disciplinary neuroscience
    Now entering its third year, the Brain Research through Advancing 
Innovating Neurotechnologies (BRAIN) Initiative continues to push 
cross-disciplinary research in neuroscience. Drawing on knowledge from 
the life sciences, physical sciences, and engineering, brain research 
is among the most promising and productive areas of science today. 
Combining the talents of chemists, engineers, computational scientists 
and neuroscientists, the basic research funded by NIH at universities 
and hospitals across the Nation leads to discoveries that will inspire 
scientific and medical progress for generations. Past NIH-supported 
projects helped neuroscientists make tremendous strides that led to 
advances in the diagnosis and treatment of neurological and psychiatric 
disorders. The following examples are just a small selection of the 
many success stories made possible by brain research funded by 
investment in NIH.
Repairing the Brain
    My own NIH-funded research investigates how an injured brain can be 
repaired to address conditions such as glaucoma and brain damage. I 
look to mechanisms involved in brain growth and development for 
possible answers and treatments. In order to understand how the brain 
grows and matures, I study how input from the body's senses affects the 
development of the brain's structures and their function. For example, 
my work looks at the visual systems in tadpoles to see how sensory 
system stimulation can help trigger the birth of new cell growth, which 
can change the growing brain and help the injured brain recover 
function. Future research in this field will attempt to use genes and 
pathways related to neuronal growth to better understand how the brain 
may be able to heal itself.
Affecting Behavior at the Cell Level
    How neurons interact with each other is the basis of all our 
thoughts and behaviors. One key to understanding the brain is studying 
the communication between neurons. DREADD 2.0, an upgrade of a widely-
used technology (also called DREADD--Designer Receptors Exclusively 
Activated by Designer Drugs), developed in part with long-term NIH 
funding, allows researchers to turn neurons ``on'' and ``off''. Using 
DREADD 2.0, researchers are able to both change the activity of neurons 
and learn how neuron communication changes when they are active or 
silent. This new technology brings specific neurons under the direct 
control of a scientist, who can then test the function of those neurons 
and the behaviors they produce like never before. Currently limited to 
mice, DREADD 2.0 and other technologies set the stage for a deeper and 
more thorough exploration of the brain and behavior. This research will 
help seed discovery of potential treatments for disorders of the 
nervous system, like Alzheimers Disease and schizophrenia, which are 
thought to occur when neuron communication breaks down.
High Resolution Reconstruction of Mouse Cortex on a Nanometer Scale
    A collaboration of several researchers funded by the BRAIN 
Initiative produced a database of information about the cells in a 
small part of the mouse cerebral cortex. Using this database as a 
digital model for the larger brain, researchers are able to explore the 
physical properties of neurons and learn more about how brain cells 
interact and communicate. This new knowledge will help researchers 
understand a wide range of neurological diseases in which this 
communication suffers. The approaches used in this work, and the 
results it has produced thus far, address multiple goals of the NIH 
BRAIN Initiative, including cross-disciplinary efforts to develop 
technologies to better characterize different types of cells and their 
connections throughout the brain. This fundamental knowledge is 
essential in order to understand how the brain differs between healthy 
people and those with brain diseases.
               neuroscience: an investment in our future
    Sustained investment to stimulate and speed these discoveries is 
essential to American healthcare and economic well-being. Funding for 
research supports quality jobs and increases economic activity. NIH 
supports approximately 400,000 jobs and $58 billion in economic output 
nationwide. Eighty-five percent of NIH's budget funds extramural 
research in communities located in every State.
    Moreover, major investment in basic and translational neuroscience 
is not only fueling an enduring and vital scientific endeavor, it is 
the essential foundation for understanding and treating diseases that 
strike nearly one billion people worldwide. There are more than 1,000 
debilitating neurological and psychiatric diseases that strike over 100 
million Americans each year. This, in turn, produces severe hardship 
for millions of families and costs the U.S. economy at least $760 
billion a year, with future expenses reaching the trillions looming for 
several conditions. Advances made possible by publicly-funded research 
will help us maintain, and perhaps someday restore, healthy brain 
function. With funding from NIH, researchers are working towards 
lifesaving breakthroughs.
    Finally, without robust, sustained investment, America's status as 
the preeminent leader in biomedical research is at risk. Other 
countries are investing heavily in biomedical research to take 
advantage of new possibilities. Even with growing philanthropic 
support, the private sector cannot be expected to close the gap. The 
lag-time between discovery and profitability means that the 
pharmaceutical, biotechnology, and medical device industries need 
federally-funded basic (also known as fundamental) research to develop 
products and treatments. The foundation that basic research provides is 
at risk if federally-funded research declines.
                               conclusion
    We live at a time of extraordinary opportunity in neuroscience. A 
myriad of questions once impossible to consider are now within reach 
because of new technologies, an ever-expanding knowledge base, and a 
willingness to embrace many disciplines. Thank you for this opportunity 
to testify.

    [This statement was submitted by Hollis Cline, President, Society 
for Neuroscience.]
                                 ______
                                 
     Prepared Statement of the Society for Women's Health Research
    The Society for Women's Health Research (SWHR) is pleased to 
submit the following testimony to the Committee urging a renewed 
investment in scientific and medical research within the National 
Institutes of Health (NIH). For over 25 years, SWHR has been widely 
considered the thought-leader in promoting research on biological 
differences in disease; dedicated to transforming women's health 
through science, advocacy, and education. We believe that Congress has 
a duty to appropriately fund a Federal research agenda inclusive of 
women's health and sex differences research. To accomplish this goal, 
we ask for a minimum of $34.5 billion for NIH appropriations in fiscal 
year 2017 including specific funding for the following Institutes and 
Offices:
  --Office of Research on Women's Health (ORWH)-$43 million
  --National Institute on Minority Health and Health Disparities 
        (NIMHD)-$302 million
  --National Institute of Environmental Health Sciences (NIEHS)-$732.2 
        million
  --Eunice Kennedy Shriver National Institute of Child Health and Human 
        Development (NICHD)-$1.441 billion
    Replace the BCA Spending Caps and Sequestration.--SWHR was pleased 
to see an increase to the spending caps as outlined in the Budget 
Control Act of 2015 and would like to thank the Committee for their 
hard work to ensure the topline sequestration levels were raised. One 
of the Federal Government's primary responsibilities is protecting the 
health of the public and investing in basic biomedical research to spur 
the way to the next generation of cures and therapies. Therefore, SWHR 
strongly disapproves of both the President's budget as well as the one 
recently released by Chairman Price of the House Budget Committee. Each 
of these budgets propose significant cuts to nondefense discretionary 
programs; including the lifesaving programs supported by the NIH. This 
means fewer research grants, less opportunities for young scientists to 
enter the field, and fewer innovative discoveries. While reducing the 
Federal deficit is incredibly important, we remain deeply concerned 
with the extent of these cuts and believe these policies should be 
replaced with a consistent and balanced approach to deficit reduction. 
This approach would place equal value on the roles of both nondefense 
and defense discretionary programs in keeping Americans healthy, safe, 
and secure.
    National Institutes of Health.--The NIH is America's premier 
medical research agency; serving as the largest source of funding for 
biomedical and behavioral research in the world. NIH works to promote 
the overall health and wellbeing of Americans through fostering 
creative discoveries and innovative research, train and support 
researchers to ensure continued scientific progress, and expand the 
scientific and medical knowledge base. Over 80 percent of its funding 
is awarded through competitive grants to researchers across the United 
States and around the world. Another 10 percent of funding supports the 
work of researchers within the NIH. Its storied history includes 
providing financial support for the Human Genome Project, without which 
the U.S. would not be able to embark on the Precision Medicine 
Initiative and newly announced ``Cancer Moonshot.'' To foster the next 
generation of cures, SWHR recommends that Congress set, at a minimum, a 
budget of $34.5 billion for NIH for fiscal year 2017.
    Office of Research on Women's Health (ORWH).--ORWH is the focal 
point for coordinating sex differences research at NIH and supports 
innovative mentored career development initiatives such as the Building 
Interdisciplinary Research Careers in Women's Health (BIRCWH) as well 
as supplemental grant funds to assist women and men returning to the 
scientific workforce. In addition, it provides funding through its 
Specialized Centers of Research (SCOR) on Sex Differences and 
Administrative Supplements for Research on Sex/Gender Differences. In 
2015, NIH released a new policy for all pre-clinical research; 
requiring investigators to submit proposals that balance the use of 
male and female cells, animals, and tissues in all funded studies. ORWH 
has been tasked to coordinate and lead data collection on this effort. 
Each of these programs are designed to use interdisciplinary approaches 
to explore sex/gender differences across diseases and disorders. To 
allow ORWH's programs and grants to continued emphasis of sex and 
gender research, Congress must direct NIH continue its support of ORWH 
through continued funding of $42 million.
    National Institute on Minority Health and Health Disparities 
(NIMHD).--NIMHD serves as the leader in scientific research dedicated 
to improving minority health and reducing health disparities. NIMHD 
funds Centers of Excellence and a Research Endowment Program; each of 
which are designed to support research opportunities and build capacity 
within academic institutions to address health disparities. In 
addition, it supports a Community-Based Participatory Research (CBPR) 
initiative to engage the community in research activities. One example 
includes a collaborative effort between Suquamish and Port Gamble 
S'Klallam Tribes and University of Washington researchers to develop a 
culturally-appropriate substance abuse prevention program for Native 
youth. NIMHD is deeply engaged with training young minorities to become 
part of the future scientific workforce through its Minority Health and 
Health Disparities International Research Training (MHIRT) and other 
training programs. As a result, SWHR requests $302 million for NIMHD in 
fiscal year 2017--an increase of $21 million over the fiscal year 2016 
level and President's budget request.
    National Institute of Environmental Health Sciences (NIEHS).--NIEHS 
is the leading institute conducting research to understand the 
environmental influences on health and development; giving it a unique 
role within NIH. The diseases studied by NIEHS scientists and grantees 
range from ADHD to Lupus to Uterine Fibroids; all of which can be 
affected by the air we breathe, food we eat, or environment in which we 
work or play. NIEHS has provided scientific leadership in public health 
emergencies, such as the current water crisis in Flint, Michigan. In 
this case, NIEHS is coordinating research efforts to understand how to 
prevent such occurrences in the future and plans to have a long-term 
role in areas such as supporting health and safety training for pipe 
workers through the NIEHS Worker Training Program. NIEHS is poised to 
generate new discoveries that can protect all Americans from toxic 
environmental exposures. To facilitate such research, we ask that you 
to provide $732.2 million for NIEHS in fiscal year 2017.
    Eunice Kennedy Shriver National Institute of Child Health and Human 
Development (NICHD).--Throughout its 50+ year history, NICHD has 
achieved great successes in research on child development, maternal and 
child health, and women's health and reproductive biology among others. 
Recent studies include understanding the long-term impacts of childhood 
sexual abuse, prenatal exposure to marijuana abuse, and research to 
prevent mother-to-child HIV transmission. NICHD is leading the field in 
supporting clinical trials in pregnant women, who have historically 
been excluded even in studies that would advance knowledge of medical 
conditions and treatments in pregnancy. The development of the crowd-
sourcing application, PregSource, to be unveiled in 2016 will allow 
pregnant women to track their health data from gestation to early 
infancy as well as access evidence-based information about healthy 
pregnancies. Unique to this project will be the ability for researchers 
to connect with NICHD staff to access aggregate data and provide 
information on clinical trials accepting pregnant participants. In 
order to continue the innovative work that NICHD is developing for 
women and children, SWHR asks that Congress appropriate $1.441 billion 
to NICHD in fiscal year 2017.
    In conclusion, Mr. Chairman, we thank you and this Committee for 
its support for medical and health services research and its commitment 
to the health of the Nation. We look forward to continuing to work with 
you to build a healthier future for all Americans.

    [This statement was submitted by Andrea Lowe, Health Policy and 
Public Health Liaison, Society for Women's Health Research.]
                                 ______
                                 
            Prepared Statement of Trust for America's Health
    Trust for America's Health (TFAH), a nonprofit, nonpartisan 
organization dedicated to saving lives by working to make disease 
prevention a national priority, is pleased to provide written testimony 
on TFAH's funding priorities. As this subcommittee works to develop a 
fiscal year 2017 Labor, Health & Human Services, Education and Related 
Agencies (LHHS) appropriations bill, I urge you to ensure adequate 
funding for public health, prevention and preparedness programs at the 
Centers for Disease Control and Prevention (CDC) and other public 
health agencies.
    Every American should have the opportunity to be as healthy as he 
or she can be, but today this is not the case. The effects of 
sequestration and years of funding cuts as a result of discretionary 
budget caps under the Budget Control Act and related law have 
fundamentally eroded our ability to respond to disasters, prevent 
chronic diseases, reduce health disparities, and ensure the health of 
all Americans. Preventable chronic diseases such as cancer, diabetes, 
lung disease, heart disease and stroke are responsible for seven out of 
10 deaths and cost $1.3 trillion in healthcare and lost productivity 
costs every year. While funding for some community prevention remains, 
notably the Racial and Ethnic Approaches to Community Health (REACH) 
program, we were disappointed that Congress has indicated that the 
Partnerships to Improve Community Health (PICH) program will not be 
funded following fiscal year 2016.
    In 2015 and early 2016, the Nation experienced the first domestic 
cases of Zika virus, and increasingly severe cold and drought, 
wildfires, tornados, and mudslides. These events illustrated persistent 
gaps in the country's preparedness for diseases, disasters, and 
bioterrorism. Each of these required a public health and healthcare 
response, but Federal, State, and local budget cuts have threatened 
more than a decade of progress.
    Finally, prescription drug abuse has quickly grown into a full-
blown epidemic, with more than 6.1 million Americans abusing or 
misusing prescription drugs. Prescription drug related deaths now 
outnumber those from heroin and cocaine combined and drug overdose 
deaths exceed motor vehicle-related deaths in a majority of States. 
Addressing this epidemic requires investments in prevention and 
treatment of those suffering from substance abuse addiction. Building a 
public health system prepared to meet the challenges of protecting 
Americans from natural and man-made threats and preventing disease can 
only occur with a strong and steady baseline of funding. Below are 
TFAH's recommendations for meeting that challenge.
The Prevention and Public Health Fund (PPHF)
    TFAH was pleased to see Congress continue to exercise its authority 
to allocate the Prevention and Public Health Fund in fiscal year 14-16, 
and we urge the Committee to do so again in the fiscal year 2017 
appropriations bill. To date, PPHF has invested more than $6 billion to 
support State and local efforts to transform communities, build 
epidemiology and laboratory capacity, address healthcare associated 
infections, train the Nation's public health and health workforce, 
screen for and prevent cancer, expand access to vaccines, reduce 
tobacco use, and help control the obesity epidemic.
Centers for Disease Control and Prevention (CDC)
    From fiscal year 10-13, the CDC saw its budget authority cut by 18 
percent. The fiscal year 2016 Omnibus Appropriations measure provided 
CDC with an increase of just over $277 million, including $892.3 
million from the Prevention and Public Health Fund, but included a $22 
million decrease for chronic disease programs. The President's fiscal 
year 2017 budget cuts that number by nearly an additional $60 million. 
Scarce resources means CDC will be forced to make extremely difficult 
choices. We urge the Committee to oppose the overall $164 million 
program level decrease included in the President's budget for fiscal 
year 2017 and appropriate $7.8 billion for CDC programs.
National Center for Chronic Disease Prevention and Health Promotion 
        (NCCDPHP)--CDC
    We must continue to engage not only health systems but other 
sectors of society, such as education, housing, business, planning, and 
faith-based institutions, to help communities to make the healthy 
choice the easy choice for everyone. CDC's Chronic Disease Center has 
made progress in moving away from the traditional categorical approach 
to funding disease prevention and toward more coordinated, cross-
cutting strategies. We encourage the Committee to fund the Chronic 
Disease Center's Division of Nutrition, Physical Activity, and Obesity 
at $61 million. This increase of $11.08 million would permit CDC to 
increase enhanced support to State health departments in the remaining 
18 States and the District of Columbia. TFAH also recommends that the 
Racial and Ethnic Approaches to Community Health (REACH) program be 
funded at $51 million to fund new 3-year cooperative agreements to 
eligible grantees. This investment would ensure the continued success 
of this community-based program aimed at reducing health disparities 
amongst minority populations.
National Center for Environmental Health (NCEH)--CDC
    Critical programs conducted at the CDC National Center for 
Environmental Health support our chronic disease prevention and public 
health preparedness efforts. Yet it remains one of the most critically 
underfunded parts of CDC. The Center's Health Tracking Program funds 25 
States and one city to collect and share data for cancer, reproductive 
health outcomes, birth defects and demographics and socioeconomic 
status, outdoor air quality, drinking water quality, hospitalizations 
for asthma, cardiovascular disease, carbon monoxide poisoning, 
childhood lead poisoning, community design, and developmental 
disabilities. The Flint, Michigan water crisis underscores the need for 
a stronger environmental health surveillance program. We recommend that 
you fund the Health Tracking Program at $50 million in fiscal year 
2017. This amount would represent a down payment towards fully funding 
the Network within the next 3 years.
Public Health Emergency Preparedness (PHEP) Cooperative Agreements--CDC
    The Public Health Emergency Preparedness (PHEP) program, 
administered by CDC, is the only Federal program that supports the work 
of State and local health departments to prepare for all types of 
disasters, including bioterror attacks, natural disasters, and 
infectious disease outbreaks The grants fund all 50 States, as well as 
territories and cities, to develop core capabilities like laboratory 
testing, surveillance and epidemiology, and incident management. TFAH 
recommends that the Public Health Emergency Preparedness Cooperative 
Agreements continue to be funded at $675 million in fiscal year 2017 to 
help States and localities address vulnerabilities in their 
preparedness capabilities.
Hospital Preparedness Program--ASPR
    The Hospital Preparedness Program (HPP), administered by the 
Assistant Secretary for Preparedness and Response (ASPR), provides 
funding and technical assistance to prepare the health system to 
respond to and recover from a disaster. The grants support nearly 500 
healthcare coalitions with 24,000 participating facilities from across 
the health system, an increase of 47 percent in membership since 2013. 
ASPR supports coalitions to develop key capabilities, including health 
system preparedness and recovery, emergency operations coordination, 
information sharing, medical surge and responder safety. Most 
jurisdictions receive no other Federal or State support for health 
system preparedness. TFAH recommends $300 million for fiscal year 2017 
for HPP, as it marks the beginning of the new project period which will 
shift the focus of the program from supporting establishment of 
healthcare coalitions to ensuring they are ready to respond to 
emergencies.
Global Health Protection
    The CDC's Division of Global Health Protection (DGHP) protects 
Americans and people around the world from the leading public health 
threats. The Division builds the capacities of local, national and 
regional public health to detect emerging threats, prevent disease and 
prepare for and respond to public health emergencies. The centerpiece 
of the division is the Global Disease Detection (GDD) program, which 
supports GDD Centers in 10 countries (Bangladesh, China, Egypt, Georgia 
and the South Caucasus, Guatemala and Central America, India, 
Kazakhstan and Central Asia, Kenya, South Africa and Thailand) to 
conduct outbreak response, pathogen discovery, training and 
surveillance. The regional center in Guatemala has been assisting with 
the Zika response, including surveillance and outbreak investigation 
support. TFAH recommends $65.2 million for the Division of Global 
Health Protection, including a $5 million increase for Global Disease 
Detection to establish a new GDD center.
Combating Opioid Abuse--CDC & SAMHSA
    Over the past several years, the overuse and misuse of opioids, 
both prescribed and illicit, has become a public health epidemic. 
Deaths from prescription painkillers have quadrupled since 1999, 
killing more than 28,000 people in the U.S. in 2014. TFAH supports the 
President's budget request for $80 million for the CDC Injury Center's 
Injury Prevention Activities line. The $10 million increase in fiscal 
year 2017 will allow the CDC to disseminate opioid prescribing 
guidelines for chronic pain, which are currently under development. 
These guidelines will be an important tool for prescribers to make 
informed decisions about when opioid treatment is necessary, with the 
understanding that some patients suffering from chronic pain do need 
access to these medications. This will also allow the Injury Center to 
continue their work supporting support drug overdose prevention 
programs in all 50 States.
    TFAH also recommends $20 million for the Substance Abuse and Mental 
Health Services Administration (SAMHSA) to continue the Grants to 
Prevent Prescription Drug/Opioid Overdose Related Deaths (PDO) program, 
an increase of $8 million, which will would allow SAMHSA to expand the 
reach of this program to at least eight additional States which are 
heavily impacted by opioid abuse and help equip and train State and 
local health departments, drug treatment and recovery programs, 
community-based overdose prevention programs and first responders with 
devices that rapidly reverse the effects of opioids.
    TFAH supports $50 million (a $25 million increase) for SAMHSA to 
expand access to medication assisted treatment, which is currently 
unavailable for many Americans who desperately need it. Additionally, 
TFAH recommends a $50 million increase for the Substance Abuse 
Prevention and Treatment Block Grant (SAPTBG) to help expand access to 
substance abuse treatment. While there has been more than a five-fold 
increase in treatment admissions in the past decade, millions more are 
going untreated. While SAPTBG received a much needed increase in fiscal 
year 2016, it had been flat funded for the past several years and has 
not kept up with inflation.
Conclusion
    Approximately seventy-five percent of the CDC's annual budget flows 
to States, communities, Tribes, and territories in the form of grants 
and contracts to State and local public health departments, and 
community partners to give them the tools they need to conduct critical 
public health and prevention activities, such as protecting us from 
infectious diseases by combating healthcare-associated infections by 
delivering immunizations, ensuring adequate public health emergency 
preparedness, and conducting nonstop disease surveillance. Investing in 
disease prevention is the most effective, common-sense way to improve 
health and address our long-term deficit. Thank you for your 
consideration.

    [This statement was submitted by Richard Hamburg, Interim President 
and CEO, Trust for America's Health.]
                                 ______
                                 
           Prepared Statement of the Tuberculosis Roundtable
    The TB Roundtable, a coalition of over 15 research, public health 
and health professional associations working to support global and 
domestic tuberculosis (TB) control and research, thanks Chairman Blunt 
and Ranking Member Murray and fellow members of the committee for this 
opportunity to provide written testimony to discuss important health 
threats to our country and opportunities that lie within government to 
address them. Our testimony will outline the importance of TB research 
and development dollars to domestic public health preparedness. We 
recognize that you face many challenging decisions about expenditures 
but given the urgent need to address drug-resistant TB (DR-TB), we are 
writing to encourage you to prioritize anti-TB efforts. Specifically, 
we request that in any final version of fiscal year 2017 appropriations 
language, you strongly urge BARDA to include TB in their new emerging 
infectious disease efforts and invest in the development of new TB 
diagnostics, drugs and vaccines as part of the Combating Antibiotic 
Resistant Bacteria (CARB) initiative and the Emerging Infectious 
Disease program at BARDA.
    TB causes more deaths than any other single infectious disease 
agent, with 9.6 million new illnesses and 1.5 million deaths in 2014. 
Approximately 480,000 of those cases were multidrug-resistant (MDR), 
including 9.7 percent that were extensively drug-resistant (XDR). Only 
about 10 percent of people with MDR-TB in 2014 were successfully 
treated, according to the World Health Organization.\1\ While these 
statistics are alarming, even more concerning is the lack of research 
funding going towards new, improved tools and treatments for one of 
humanity's oldest diseases.
    While Zika and Ebola have captured headlines and funding 
commitments, TB's domestic and global health impact is much more costly 
and deadly. Because TB is airborne, TB can be contracted by inhaling 
the bacteria when a person with active TB disease of the lungs or 
throat coughs or sneezes--it's only necessary to inhale a few of these 
germs to become infected. The only available vaccine for TB, Bacille 
Calmette-Guerin (BCG), is only moderately effective in preventing TB in 
infants and young children--and it doesn't adequately protect teens and 
adults who suffer most of the disease burden. Current treatment 
regimens are long, expensive, and difficult to implement. Treatment 
side effects are serious and long-lasting, including permanent hearing 
loss. Even our current diagnostics are inadequate, with rapid, accurate 
drug susceptibility testing only available for just one TB drug out of 
the several required for an effective regimen.
    TB does not just impact the rest of the world. Every State in the 
U.S. continues to report cases of TB each year and cases of TB 
occasionally make the news when diagnosed, with recent examples in 
Sturgis, Michigan; \2\ Marion, Alabama,\3\ El Paso, Texas; \4\ or 
DeKalb County Georgia.\5\ In March 2015, 27 people tested positive for 
TB in a high school located in Olathe, Kansas, prompting the testing of 
more than 300 students and staff.\6\ Last year, an individual with XDR-
TB was treated at the National Institutes of Health after traveling to 
and through the U.S. These travels included a long flight from India to 
Chicago, and then driving through Illinois, Tennessee, and Missouri, 
visiting friends and relatives, while infectious with a drug-resistant 
strain of this deadly airborne disease.\7\ Just a few weeks ago, the 
CDC released figures showing the first increase in TB cases 
domestically in 23 years.\8\ We know that TB anywhere can be TB 
everywhere.
---------------------------------------------------------------------------
    \1\ The World Health Organization, 2015 Global Tuberculosis Report, 
Executive Summary,
Page 1.
    \2\ Sturgis Journal, Case of Tuberculosis Treated in Sturgis, Oct. 
23, 2015, http://www.sturgisjournal.com/article/20151023/NEWS/
151029514.
    \3\ The New York Times, In Rural Alabama, Longtime Mistrust of 
Medicine Fuels a TB Outbreak, Jan. 18, 2016, http://www.nytimes.com/
2016/01/18/us/in-rural-alabama-a-longtime-
mistrust-of-medicine-fuels-a-tuberculosis-outbreak.html?--r=0.
    \4\ KKTV, El Paso County Jail Inmate Tests Positive for Latent TB, 
Oct. 22, 2015, http://www.kktv.com/home/headlines/El-Paso-County-Jail-
Inmate-Tests-Positive-For-Latent-
Tuberculosis-335346171.html.
    \5\ 11 Alive, Student Tests Positive for TB at Dekalb Co. School, 
Oct. 22, 2015, http://legacy.11alive.com/story/news/local/brookhaven/
2015/10/22/student-tests-positive-tb-dekalb-co-school/74414390/.
    \6\ CBS News, Tuberculosis Infects Dozens at Kansas High School, 
March 28, 2015, http://www.cbsnews.com/news/tuberculosis-infects-
dozens-at-kansas-high-school/.
    \7\ NBC News, Exclusive: Patient With Extreme Form of TB Sent to 
NIH, June 9, 2015, http://www.nbcnews.com/health/health-news/exclusive-
patient-extreme-form-tb-sent-nih-n371806.
    \8\ Centers for Disease Control and Prevention (CDC), Weekly 
Mortality and Morbidity Report, March 25, 2016, http://www.cdc.gov/
mmwr/volumes/65/wr/pdfs/mm6511a2.pdf.
---------------------------------------------------------------------------
    Although the medical community has made strides to combat TB, the 
threat of this epidemic is growing, in part because of the spread of 
dangerous strains of MDR-TB and XDR-TB around the world, which we are 
trying to fight with 20th century technologies. While MDR-TB is 
resistant to at least two of the key front-line drugs used to treat TB, 
XDR-TB is resistant to nearly all current drug options. The costs to 
treat MDR- and XDR-TB are enormous. In the U.S., a case of MDR-TB costs 
about 15 times the amount that is needed to treat drug sensitive TB, 
often requiring 20-26 months of treatment. And treating a single case 
of XDR-TB could cost more than half a million dollars--enough to wipe 
out a city's total public health budget for a year.\9\ Underscoring the 
urgent need for new tools to combat this disease, the CDC cited MDR and 
XDR-TB as serious antibiotic resistant threats in its 2013 report on 
antibiotic resistance in the U.S.
---------------------------------------------------------------------------
    \9\ CDC, Take on Tuberculosis Infographic, 2015. http://
www.cdc.gov/tb/publications/infographic/default.htm.
---------------------------------------------------------------------------
    Efforts at BARDA are currently underway to establish an Emerging 
Infectious Disease Division to focus on naturally occurring infectious 
diseases. Including TB in BARDA's new emerging infectious disease 
efforts to invest in the development of a TB vaccine and new TB drugs 
and diagnostics as part of the CARB initiative and the Emerging 
Infectious Disease program will be a critical step to ensuring that new 
vaccine, treatment and diagnostic options are developed and available 
for use. We respectfully urge Congress to place more attention on the 
threat of TB and invest more time and resources in developing 21st 
century solutions to an age-old problem. As fortunate as we are to live 
in a nation that has the adequate infrastructure and resources to 
combat a host of disease threats, with TB we are leaving American and 
global citizens with outdated treatment to an ever-changing threat.

    [This statement was submitted by Nuala Moore, Associate Director of 
Government Relations, American Thoracic Society.]
                                 ______
                                 
                   Prepared Statement of Tulsa CARES
    We are pleased to submit this testimony to the Members of this 
Subcommittee on the urgency of continuing to support the Ryan White 
Program through the Appropriations process and increasing funding for 
the domestic HIV/AIDS portfolio in fiscal year 2017. This support and 
funding will be decisive for achieving the goals of the National HIV/
AIDS Strategy (NHAS) 2020, the AIDS Free Generation and halting the 
devastating effects of the HIV Treatment Cascade.
    Tulsa CARES is part of a nationwide coalition, the Food is Medicine 
Coalition, of food and nutrition services providers, affiliates and 
their supporters across the country that provide food and nutrition 
services to people living with HIV/AIDS (PWH) and other chronic 
illnesses. In our service area, we provide nutrition, farmer's market, 
and food pantry services to 475 individuals annually. Collectively, the 
Food is Medicine Coalition is committed to increasing awareness of the 
essential role that food and nutrition services (FNS) play in 
successfully treating HIV/AIDS and to expanding access to this 
indispensable intervention for people living with other severe 
illnesses.
            Why Food and Nutrition Services (FNS) Matter for PWH
    While adequate food and nutrition are basic to maintaining health 
for all persons, good nutrition is crucial for the management of HIV 
infection. Proper nutrition is needed to increase absorption of 
medication, reduce side effects, and maintain healthy body weight. 
Research has identified the virus as an independent risk factor for 
cardiovascular, liver and kidney disease, cancer, osteoporosis and 
stroke. Several HIV medications can cause nausea and vomiting and some 
can affect lab results that test lipids and kidney and liver function. 
These compounding health effects, caused by the virus and its 
medications, reinforce the important role a nutrient-rich diet plays in 
a patient's overall care plan. In addition, providing food and 
nutrition services can serve to facilitate access and engagement with 
medical care, especially among vulnerable populations.
    The Food and Nutrition Services category within the Ryan White 
Program includes medical nutritional therapy (MNT) and food and 
nutrition services (FNS). MNT covers nutritional diagnostic, therapy, 
and counseling services focused on prevention, delay or management of 
diseases and conditions, and involves an in-depth assessment, periodic 
reassessment and intervention provided by a licensed, Registered 
Dietitian Nutritionist (RDN) outside of a primary care visit. The range 
of FNS provided through the Ryan White program complements the needs of 
PWH at any stage of their illness. For those who are most mobile, there 
are congregate meals, walk-in food pantries and voucher programs. For 
those whose disease has progressed, home-delivered meals and home-
delivered grocery bags complement their medical treatment.
    Since 2006, HRSA has included MNT and FNS, provided under the 
guidance of RDNs, as a clinically effective core medical service in the 
Ryan White Program. These services play a critical role in ensuring 
that PWH enter and continue in primary medical care, adhere to their 
medications, and ultimately achieve viral suppression.
            FNS as a Care Completion Service Unique to Ryan White
    Social and economic interventions, most often in the form of care 
completion service like food and nutrition services, are fundamental to 
making healthcare work for PWH. Support services for PWH are not 
covered in any comprehensive way by Medicaid or other public insurance 
initiatives that have been expanded by the Affordable Care Act. As the 
HIV epidemic in the United States increasingly impacts low-income 
individuals, support services help stabilize individuals living with or 
at risk of HIV. When needs are met, and life's emergencies are held at 
bay, PWH are poised to remain connected to care and treatment.
            Access to FNS and the Triple Aim
    Access to appropriate food and nutrition services (FNS) are 
increasingly recognized as key to accomplishing the triple aim of 
national healthcare reform for PWH.
Better Health Outcomes
    When clients get effective FNS and become food secure, they then 
keep scheduled primary care visits, score higher on health functioning, 
are at lower risk for inpatient hospital stays and are more likely to 
take their medicines.\1\ Studies show both the health benefits of 
access to MNT and/or nutrition counseling for people with HIV 
infections \2\ and the resulting decreases in their healthcare costs. 
Compare these outcomes to PWH who are food insecure, who have:
---------------------------------------------------------------------------
    \1\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014. Available at https://www.health.ny.gov/diseases/aids/
ending_the_epidemic/docs/key_resources/housing_and_supportive_services/
chain_factsheet3.pdf.
    \2\ Academy of Nutrition and Dietetics (formerly American Dietetic 
Association). HIV/AIDS Nutrition Evidence Analysis Project at http://
www.adaevidencelibrary.com/conclusion.cfm?
conclusion_statement_id=250707 Accessed 29 July 2012.
---------------------------------------------------------------------------
  --Lower CD4 counts & lower likelihoods of having undetectable viral 
        loads \3\
---------------------------------------------------------------------------
    \3\ AidaIa A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011); Singe AW, Weiser SD McCoy, SI. Does Food Insecurity Undermine 
Adherence to Antiretroviral Therapy? A Systematic Review. AIDS Behav 
(2015) 19:1510-1526.
---------------------------------------------------------------------------
  --More ER visits \4\ & increased morbidity and mortality \5\
---------------------------------------------------------------------------
    \4\ Ibid.
    \5\ Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact 
of food insecurity on survival among HIV-positive injection drug users 
receiving antiretroviral therapy in a Canadian cohort. 141st APHA 
Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277.
---------------------------------------------------------------------------
  --More missed primary care appointments & reduced use of 
        antiretroviral therapy. \6\
---------------------------------------------------------------------------
    \6\ Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team 
(2011).
---------------------------------------------------------------------------
Lower Healthcare Costs
    Millions of dollars in healthcare expenditures are saved through 
the provision of FNS to PWH. A recent study comparing participants in a 
medically-tailored FNS program vs. a control group within a local 
managed care organization found that average monthly healthcare costs 
for PWH fell 80 percent in first 3 months after receiving FNS.\7\ If 
hospitalized, nourished clients' costs were 30 percent lower, their 
hospital length of stay was cut by 37 percent and they were 20 percent 
more likely to be able to be discharged to their homes rather than a 
more expensive institution.\8\ Furthermore, FNS are a very inexpensive 
intervention. For each day in a hospital saved, you can feed a person a 
medically-tailored diet for half a year.
---------------------------------------------------------------------------
    \7\ Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty 
N. Examining Health Care Costs Among MANNA Clients and a Comparison 
Group. J Prim Care Community Health. (2013) 4:311-317.
    \8\ Ibid.
---------------------------------------------------------------------------
Improved Patient Satisfaction
    Studies show nutrition counseling improves quality of life.\9\ 
Members overwhelmingly report that our services help them live more 
independently, eat more nutritiously and manage their medical treatment 
more effectively.
---------------------------------------------------------------------------
    \9\ Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, 
Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial 
evaluating nutrition counseling with or without oral supplementation in 
malnourished HIV-infected patients. J Am Diet Assoc. (1998) 98: 434-
438; Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive 
treatment to nutritional counseling in malnourished HIV-infected 
patients: randomized controlled trial. Clinical Nutrition (1999) 18(6): 
371-374.
---------------------------------------------------------------------------
            FNS and the National HIV/AIDS Strategy (NHAS)
    Access to FNS for PWH is fundamental to fulfilling the goals of the 
NHAS.
  --NHAS Goal: Reducing new HIV infections: PWH who are food insecure 
        are less likely to have undetectable viral loads in a 
        statistically significant way. Undetectable viral loads prevent 
        transmission 96 percent of the time,\10\ thus, FNS is key to 
        prevention.\11\
---------------------------------------------------------------------------
    \10\ M. S. Cohen et al., Prevention of HIV-1 Infection with Early 
Antiretroviral Therapy. N. Engl. J. Med.(2011) 365, 493-505 . HPTN 052.
    \11\ Palar K, Laraia B, Tsai A, Weiser SD Food insecurity is 
associated with sexually transmitted infections and HIV serostatus 
among low income adults in the National Health and Nutrition 
Examination Survey (NHANES) (1999-2010). Presented at the American 
Public Health Association 141st Annual Meeting, Boston, MA, November 5, 
2013.
---------------------------------------------------------------------------
  --NHAS Goal: Increasing access to care and improving health outcomes 
        for people living with HIV: PWH who receive effective FNS are 
        more likely to keep scheduled primary care visits, score higher 
        on health functioning, are at lower risk for inpatient hospital 
        stays and are more likely to take their medicines.\12\
---------------------------------------------------------------------------
    \12\ Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study 
Team. Food and Nutrition Services, HIV Medical Care, and Health 
Outcomes. New York State Department of Health: Resources for Ending the 
Epidemic, 2014.
---------------------------------------------------------------------------
  --NHAS Goal: Reducing HIV-related disparities and health inequities: 
        By providing FNS to PWH who are in need largely because of 
        poverty, we improve health outcomes, thereby reducing health 
        disparities.\13\
---------------------------------------------------------------------------
    \13\ Available at Weiser SD, Frongillo EA, Ragland K, Hogg RS, 
Riley ED, Bangsberg DR. Food insecurity is associated with incomplete 
HIV RNA suppression among homeless and marginally housed HIV-infected 
individuals in San Francisco. J Gen Intern Med. (2009) 24(1):14-20.
---------------------------------------------------------------------------
  --NHAS Goal: Achieving a more coordinated national response to the 
        HIV epidemic: There remains a tremendous variation by State in 
        coverage of food and nutrition services both inside and outside 
        of Ryan White, making support for Ryan White HIV Program all 
        the more needed. Ultimately, if we are going to achieve a more 
        coordinated national response to the HIV epidemic and our quest 
        to reduce healthcare spending nationwide, FNS must be included 
        in all healthcare reform efforts, including Ryan White and the 
        ACA.
Conclusion
    We are deeply aware of the difficult decisions that face the 
members of the Subcommittee in the current fiscal environment. Yet, 
research shows that investment in FNS, with the great return in 
prevention and retention in HIV care, are vital to lowering the number 
of new infections in the domestic HIV epidemic and ultimately reducing 
healthcare costs and preserving healthcare resources for the future. A 
client's diet can literally have life and death consequences. When 
people are severely ill, good nutrition is one of the first things to 
deteriorate, making recovery and stabilization that much harder, if not 
impossible. Early and reliable access to medically-appropriate FNS 
helps PWH live healthy and productive lives, produces better overall 
health outcomes and reduces healthcare costs.
    Along with our colleagues, we appreciate the opportunity to offer 
this testimony regarding the fiscal year 2017 Appropriations process. 
We are also pleased to offer our assistance and expertise, including 
information from our Research Library.
    Thank you.

    [This statement was submitted by R. Shannon Hall, Executive 
Director, Tulsa CARES.]
                                 ______
                                 
            Prepared Statement of U.S. Action Working Group
_______________________________________________________________________

    We request:

  --CDC: Restore funding for ME/CFS in fiscal year 2017 budget--$6 
        million
  --HHS/Assistant Secretary for Health--Office of Women's Health: 
        Continue funding for Chronic Fatigue Syndrome Advisory 
        Committee--$300,000
  --NIH: Follow through on recent statements to patients by providing 
        significant and specific funding for ME/CFS research, including 
        RFA's
_______________________________________________________________________

    I present this testimony on behalf of the members listed below of 
the U.S. Action Working Group, a coordinating committee for a number of 
non-profit organizations and patient/advocates working to advance 
research on the disease Myalgic Encephalomyelitis/Chronic Fatigue 
Syndrome (known as ME/CFS). ME/CFS affects up to 2.5 million people in 
the U.S., according to the Institute of Medicine, and approximately 17 
million more around the world and has been reported in people younger 
than 10 years of age and the elderly (over 70 years). We represent 
organizations which provide information on governmental and other 
programs to patients and advocates; educate government officials, 
medical professionals, and patients about ME/CFS; and provide direct 
services to patients.
                              about me/cfs
    Two major reports, both funded by government agencies, were 
published in 2015, the NIH's Pathways to Prevention (P2P) report, 
``Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue 
Syndrome,'' and the Institute of Medicine (IOM) report, ``Beyond 
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an 
Illness.''
    Myalgic encephalomyelitis/chronic fatigue syndrome, commonly 
referred to as ME/CFS, is a disease characterized by profound fatigue, 
cognitive dysfunction, sleep abnormalities, autonomic manifestations, 
pain, and other symptoms that are made worse by exertion of any sort. 
ME/CFS can severely impair patients' ability to conduct their normal 
lives, yet many struggle with symptoms for years before receiving a 
diagnosis. Fewer than one-third of medical school curricula and less 
than half of medical textbooks include information about ME/CFS. 
Although many healthcare providers are aware of ME/CFS, they may lack 
essential knowledge about how to diagnose and treat it.
    The Institute of Medicine report states:
    ``Myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) 
        are serious, debilitating conditions that impose a burden of 
        illness on millions of people in the United States. At least 
        one-quarter of ME/CFS patients are house- or bed-bound at some 
        point in their lives. The direct and indirect economic costs of 
        ME/CFS to society have been estimated at $17 to $24 billion 
        annually . . . High medical costs combined with reduced earning 
        capacity often have devastating effects on patients' financial 
        status.'' (IOM, pp. 1 092)
    ``Patients with ME/CFS have been found to be more functionally 
        impaired than those with other disabling illness, including 
        type 2 diabetes mellitus, congestive heart failure, 
        hypertension, depression, multiple sclerosis, and end-stage 
        renal disease.'' (IOM, p. 31)
    This devastating disease is not limited to adults. Children and 
adolescents also get ME/CFS, but there are almost no existing trained 
medical professionals to give them proper care. One mother writes:
    ``Both of my children have ME/CFS. As a parent, it has been 
        heartbreaking to watch them suffer from this debilitating 
        illness. My son, now age 20, became sick when he was 12. He 
        missed most of junior and senior high school because he was too 
        sick to physically attend school. My daughter, now age 17, also 
        became sick at the age of 12 and is also too sick to attend 
        school. My children have lost an enormous amount--their health, 
        the social experience of high school, and the ability to 
        participate in things they love like sports and music. It took 
        years of doctor visits and consultations with specialist to 
        receive a diagnosis, and the utter lack of treatments for ME/
        CFS is incredibly frustrating.''
    For most of the last 30 years, patients with this disease have 
received little support from the Federal agencies with the most power 
to help them--NIH and CDC; only very small amounts of funding have been 
dedicated to researching or finding treatments for the disease or 
educating the medical community about it. In addition, some of the 
treatment recommendations provided by the CDC were based on research 
that is now under review, and have been harmful to patients.
    Because of the lack of medical care providers who are properly 
educated about ME/CFS, and the lack of medical research leading to 
better understanding of the disease and effective treatments, patients 
with ME/CFS are often stigmatized or ``treated with skepticism, 
uncertainty, and apprehension'' (P2P, p. 4). As a result, most patients 
are not able to obtain adequate medical care for their illness, either 
not getting an accurate diagnosis or receiving inappropriate or no 
treatment, thereby leaving more than 2 million citizens largely 
disabled for decades.
                                  cdc
    The patient community was very disturbed to see that the already 
tiny allocation of $5.4 million for the CDC's ME/CFS program was zeroed 
out in the President's budget for fiscal year 2017, a year in which the 
CDC is scheduled to complete its 4-year multi-site study and begin a 
new initiative to educate medical professionals about ME/CFS based on 
the recent findings of Institute of Medicine. The multi-site study will 
provide a tremendous amount of new information regarding this disease 
and it is critical that it be completed.
    We, therefore, join in asking this Committee to recommend a 
restoration of the CDC budget for ME/CFS at a level of no less than $6 
million and urge the CDC to use that to complete its multi-site study, 
and leverage the recommendations from both the Institute of Medicine 
and the Chronic Fatigue Advisory Committee to provide to develop and 
execute a new, broad-based medical education campaign.
    To address the lack of access to clinical care, we also ask the 
Committee to urge the CDC to work with the NIH and other agencies 
within the Department of Health and Human Services to find creative 
ways to fund multiple Centers of Excellence (there are none now) and 
include in them a clinical care component so that patients nationwide 
might have improved access to expert ME/CFS medical professionals.
                                  nih
    There are NO FDA-approved drugs to treat this disease. In 2014, 
there were at least 32 FDA-approved drugs to treat HIV/AIDS and nine 
for Multiple Sclerosis. Why is this? Because essentially no research 
dollars are going toward finding new treatments, new drugs, and other 
useful symptom-reducing interventions.
    Today, research funding from NIH for ME/CFS is far below funding 
for similarly disabling illnesses with similar or lower prevalence:
  --ME/CFS (2 million patients): Only $3 per patient in NIH funding--$6 
        million in 2015
  --Multiple sclerosis (400,000 patients): About $235 per patient; $94 
        million 2015
  --HIV/AIDS (1.2 million patients): About $2500 per patient ($3 
        billion in 2015)
    ME/CFS patients are cautiously hopeful to see the recent focus on 
this disease at the National Institutes of Health, with support from 
Dr. Francis Collins, Director, and Dr. Walter Koroshetz, Director of 
the National Institute of Neurological Diseases and Stroke. A Trans-NIH 
Working Group has been established for this disease, and NIH has also 
begun planning for an intramural study to begin in the summer of 2016. 
We recognize the intention of the NIH to expand the extramural research 
program and applaud the goal of bringing new researchers into the 
field. However, this will not happen without funding allocated 
specifically to this disease.
    We join in asking this Committee to recommend that the NIH make 
funding for ME/CFS research commensurate with disease burden. This 
funding is necessary to jump-start the field through a set of 
intramural and extramural investments that include Requests for 
Applications (RFAs) for biomarkers and treatment trials, set-aside 
funding for investigator initiated studies (including for hypothesis 
generation), regional Centers of Excellence, and support for a network 
of researchers to develop a research strategy with defined milestones 
and to reach consensus on a research case definition and research 
standards.
    We further ask that NIH act aggressively to implement these 
required actions and to collaborate with disease researchers, 
clinicians, and patients and their advocates in doing so with full 
transparency for best results.
           department of health and human services (hhs) and
                     assistant secretary for health
    The Chronic Fatigue Syndrome Advisory Committee is a Federal 
Advisory Committee with 11 members of the public, including one patient 
representative, and non-voting representatives from 7 agencies within 
HHS. In addition there are up to 3 non-voting ``liaison members'' from 
ME/CFS patient or research organizations. It is an important vehicle by 
which patients can communicate face-to-face and engage in discussions 
with the agencies. Its charter must be renewed every 2 years, or it 
will cease to exist.
    We join in asking this Committee to urge HHS and the Assistant 
Secretary for Health to continue support of the Chronic Fatigue 
Syndrome Advisory Committee (CFSAC) with a budget of $300,000 including 
direct expenses and staff support, to renew its charter in September, 
2016, and to accelerate progress on CFSAC's recommendations to 
strengthen research, education, training, care, and services to better 
address the needs of two million Americans living with ME/CFS. Further, 
to address the gaps in medical care highlighted by the recent Institute 
of Medicine Report, we ask the Committee to urge HHS to find creative 
ways to fund regional Centers of Excellence that include both a 
research component and direct clinical care component.
    We close with Cheryl's story.
    ``CFS is an invisible disability. When you look at me, you won't 
see my broken aerobic metabolism that has cost me my muscle strength, 
flexibility and endurance. You won't see that taking a shower or 
preparing a simple meal causes me to exceed my anaerobic threshold, 
creating lactic acid build-up, exhaustion and pain. You won't see how 
my sleep is disrupted every night, restless and unrefreshing. You won't 
see the chronic and debilitating muscle and joint pain, headaches, sore 
throat, or the intolerance to noise, bright lights, chemicals and foods 
that were easily tolerated before CFS. You won't see my lost sense of 
productivity, accomplishment and contribution that I got from career 
that I loved and was so much of my identity. Or my lost sense of 
connection with others because socializing exceeds my energy limits. Or 
that I can no longer be counted on to help family or friends in need, 
or be an equal partner and companion to my husband. You can't see my 
uncertainty about the future. You can't see my heart yearning to live 
fully, while my body and brain deteriorate. But it's real, and it's my 
CFS story.''
    On behalf of Cheryl and all other ME/CFS patients, we urge this 
Committee to take the actions we have outlined above. Thank you.
                members of the u.s. action working group
    Massachusetts CFIDS/ME & FM Association
    New Jersey ME/CFS Association, Inc.
    Solve ME/CFS Initiative
    Adriane Tillman, California
    Claudia Goodell, Race to Solve ME/CFS, New Mexico
    Denise Lopez-Majano, Speak Up About ME, Pennsylvania
  Erica Verrillo, Executive Director, American Myalgic 
        Encephalomyelitis and Chronic Fatigue Syndrome Society, 
        Massachusetts
    Gail Cooper, JD, California
    Jean Harrison, Mothers Against ME, Massachusetts
    Lily Chu, MD, MSHS, California
    Lori Chapo-Kroger, RN, Pandora Org, Michigan
    Margaret Lauritson-Lada, Cambridge, Massachusetts
    Mary Dimmock, Connecticut
  Meghan-Morgan Shannon MS, Medical Professional with ME and CFSIDS, 
        Pennsylvania
    Nansy Mathews, Maryland
    Robert and Courtney Miller, 30-year patient and advocate, Reno, 
Nevada
    Sonya Heller Irey, MPIA, Patient-Advocate, Arizona
    Terri L. Wilder, ME Advocate/Person living with ME, New York
                                 ______
                                 
    Prepared Statement of the U.S. Hereditary Angioedema Association
              summary of fiscal year 2017 recommendations
_______________________________________________________________________

  --Provide $34.5 billion for the National Institutes of Health (NIH)
  --Support the NIH hereditary angioedema research portfolio
  --Encourage the Centers for Disease Control and Prevention (CDC) to 
        advance hereditary angioedema education and awareness
_______________________________________________________________________

    Thank you for the opportunity to present the views of the U.S. 
Hereditary Angioedema Association (U.S. HAEA) regarding fiscal year 
2017 funding for the National Institutes of Health (NIH) and the 
Centers for Disease Control and Prevention (CDC). On behalf of U.S. 
HAEA, I urge Congress to support hereditary angioedema research and 
public awareness.
    U.S. HAEA is a non-profit patient advocacy organization dedicated 
to serving the estimated 6,000 HAE sufferers in the U.S. We provide a 
support network and a wide range of personalized services for patients 
and their families. We are also committed to advancing clinical 
research designed to improve the lives of HAE patients and ultimately 
find a cure.
    Hereditary angioedema (HAE) is a painful, disfiguring, 
debilitating, and potentially fatal genetic disease that occurs in 
about 1 in 30,000 people. Symptoms include episodes of swelling in 
various body parts including the hands, feet, face and airway. Patients 
often have bouts of excruciating abdominal pain, nausea and vomiting 
that is caused by swelling in the intestinal wall. The majority of HAE 
patients experience their first attack during childhood or adolescence. 
Approximately one-third of undiagnosed HAE patients are subject to 
unnecessary exploratory abdominal surgery. About 50 percent of patients 
with HAE will experience laryngeal edema at some point in their life. 
This swelling is exceedingly dangerous because it can lead to death by 
asphyxiation. The historical mortality rate due to laryngeal swelling 
is 30 percent.
           research through the national institutes of health
    U.S. HAEA recommends that Congress provide an overall funding level 
of $34.5 billion for NIH in fiscal year 2017. In addition. U.S. HAEA 
urges Congress to include recommendations in accompanying committee 
reports emphasizing the importance of advancing HAE research per the 
findings of the October 2014 scientific conference, Expanding 
Boundaries of our HAE Knowledge.
    In October 2014, the NIH National Institute of Allergy and 
Infectious Diseases (NIAID), the National Center for Advancing 
Translational Sciences (NCATS), and U.S. HAEA partnered on the state-
of-the-science conference, Expanding Boundaries of our HAE Knowledge. 
This conference brought together top HAE researchers as well as other 
medical researchers across disciplines in order to identify promising 
avenues for future research. NIH should capitalize on this conference 
by issuing requests for applications or other opportunities for HAE 
research based on the findings of the conference.
    As a rare disease community, HAE patients are also stakeholders of 
the Office of Rare Diseases Research (ORDR) and may benefit from 
programs like the Therapeutics for Rare and Neglected Diseases (TRND) 
program. U.S. HAEA also urges Congress to robustly support NCATS and 
the NIH rare disease portfolio in fiscal year 2017.
        cdc public awareness and education to prevent hae deaths
    In order to prevent deaths, eliminate unnecessary surgeries, and 
improve patients' quality of life, it is critical that CDC pursue 
programs to educate the public and medical professionals about HAE in 
fiscal year 2017.
    HAE patients often suffer for many years and may be subject to 
unnecessary medical procedures and surgery prior to receiving an 
accurate diagnosis. Raising awareness about HAE among healthcare 
providers and the general public will help reduce delays in diagnosis 
and limit the amount of time that patients must spend without treatment 
for a condition that could, at any moment, end their lives.
    Once diagnosed, patients are able to piece together a family 
history of mysterious deaths and episodes of swelling that previously 
had no name. In some families, this condition has come to be accepted 
as something that must simply be endured. Increased public awareness is 
crucial so that these patients understand that HAE often requires 
emergency treatment, and disabling attacks no longer need to be 
passively accepted. While HAE cannot yet be cured, the use of available 
treatments can help patients lead a productive life. Education and 
awareness is needed to reach patients and providers with this message.
    Thank you for the opportunity to present the views of the HAE 
patient community. I hope Congress will support research and education 
on HAE.
                 additional medical research activities
    For many years (including fiscal year 2016), Congress has included 
HAE as a condition eligible for study through the Department of Defense 
Peer-Reviewed Medical Research Program. This opportunity has led to 
many researchers successfully competing for funding with meritorious 
research projects that have advanced our scientific understanding of 
HAE. Further, emerging research has linked HAE episodes to Post-
Traumatic Stress Disorder (PTSD) and general anxiety disorder, both of 
which have a higher prevalence in military service member populations. 
To capitalize on recent progress and opportunities in this area, please 
work with your colleagues on the Appropriations Committee to ensure HAE 
is once again recognized as a condition eligible for study in fiscal 
year 2017.

    [This statement was submitted by Anthony Castaldo, President, U.S. 
Hereditary Angioedema Association.]
                                 ______
                                 
            Prepared Statement of United Spinal Association
    I am Alexandra Bennewith, Vice President, Government Relations with 
United Spinal Association and I am writing to support the National 
Council on Independent Living's request for Congress to reaffirm your 
commitment to the more than 57 million Americans disabilities by 
increasing funding in the HHS appropriations for Centers for 
Independent Living (CILs). I am asking that you increase funding by 
$200 million, for a total of $301 million for the Independent Living 
line item in fiscal year 2017.
    United Spinal Association is the largest disability-led national 
non-profit organization founded by paralyzed veterans in 1946 and has 
since provided service programs and advocacy to improve the quality of 
life of those across the life span living with spinal cord injuries and 
disorders (SCI/D) such as multiple sclerosis, amyotrophic lateral 
sclerosis (ALS), post-polio syndrome and spina bifida. United Spinal 
represents over one million individuals with spinal cord injuries and 
disorders, 50 chapters, 103 rehabilitation hospital members and close 
to 200 support groups nationwide. Throughout its history, United Spinal 
Association has devoted its energies, talents and programs to improving 
the quality of life for these Americans and for advancing their 
independence. United Spinal Association is also a VA-recognized 
veterans service organization (VSO) serving veterans with disabilities 
of all kinds.
    CILs are cross-disability, non-residential, community-based, 
nonprofit organizations that are designed and operated by individuals 
with disabilities. CILs are unique in that they are directly governed 
and staffed by people with all types of disabilities, including people 
with mental, physical, sensory, cognitive, and developmental 
disabilities. Each of the 365 federally funded centers provides five 
core services: information and referral, individual and systems 
advocacy, peer support, independent living skills training, and 
transition services, which were added with the passage of the Workforce 
Innovation and Opportunity Act (WIOA). From 2012-2014, CILs provided 
the core services to nearly 5 million people with disabilities, and 
provided additional services such as housing assistance, 
transportation, personal care attendants, and employment services to 
hundreds of thousands of individuals. During this same period, prior to 
transition being added as a core service, CILs transitioned 13,030 
people with disabilities from nursing homes and other institutions into 
the community.
    Transition services were added as a fifth core service with the 
2014 reauthorization of the Rehabilitation Act within the Workforce 
Innovation and Opportunity Act. Transition services include the 
transition of individuals with significant disabilities from nursing 
homes and other institutions to home and community-based residences 
with appropriate supports and services, assistance to individuals with 
significant disabilities at risk of entering institutions to remain in 
the community, and the transition of youth with significant 
disabilities to postsecondary life. This core service is vital to 
achieving full participation for people with disabilities.
    Every day, CILs are fighting to ensure that people with 
disabilities gain and maintain control over our own lives. We know that 
this cannot occur when people reside in institutional settings. 
Opponents of deinstitutionalization say that allowing people with 
disabilities to live in the community will result in harm. We know that 
the 13,030 people with disabilities who CILs successfully transitioned 
out of nursing homes and institutions from 2012-2014 prove otherwise. 
Additionally, when services are delivered in an individual's home, the 
result is a tremendous cost savings to Medicaid, Medicare, and States. 
Community-based services enable people with disabilities to become less 
reliant on long-term government supports, and they are significantly 
less expensive than nursing home placements. We are grateful that 
Congress demonstrated their understanding and support for community-
based services when WIOA was passed and transition was added as a fifth 
core service.
    Since transition services were added as a core service, the need 
for funding is critical. Moreover, CILs need additional funding to 
restore the devastating cuts to the Independent Living program, make up 
for inflation costs, and address the increased demand for independent 
living services. In 2016, the Independent Living Program is receiving 
$2.5 million less in funding than it was in 2010. It is simply not 
possible to meet the increasing demand for services and effectively 
provide transition services without additional funding. Increased 
funding should be reinvested from the billions currently spent to keep 
people with disabilities in costly Medicaid nursing homes and 
institutions and out of mainstream society.
    Centers for Independent Living play a crucial role in the lives of 
people with disabilities, and work tirelessly to ensure that people 
with disabilities have a real choice in where and how they live, work, 
and participate in the community. Additionally, CILs are an excellent 
service and a bargain for America, keeping people engaged with their 
communities and saving taxpayer money. NCIL is dedicated to increasing 
the availability of the invaluable and extremely cost-effective 
services CILs provide, and they have submitted written testimony with a 
similar request. I strongly support NCIL's testimony.
    If you have any questions, please contact me at 
abennewith@unitedspinal.org.
    Sincerely.

    [This statement was submitted by Alexandra Bennewith, MPA, Vice 
President, Government Relations with United Spinal Association.]
                                 ______
                                 
       Prepared Statement of the United Tribes Technical College
    United Tribes Technical College (UTTC) has for 47 years, and with 
the most basic of funding, provided postsecondary career and technical 
education and family services to some of the most impoverished high 
risk Indian students from throughout the Nation. Despite such 
challenges we have consistently had excellent retention and placement 
rates and are fully accredited by the Higher Learning Commission. We 
are proud to be preparing our students to participate in the energy 
economy in North Dakota and to be part of building a strong middle 
class in Indian Country by training the next generation of law 
enforcement officers, educators, medical providers, and administrators. 
We are governed by the five Tribes located wholly or in part in North 
Dakota. We are not part of the North Dakota University System and do 
not have a tax base or State-appropriated funds on which to rely. The 
funding requests of the UTTC Board for fiscal year 2017 are:
  --$10 million for base funding authorized under Section 117 of the 
        Carl Perkins Act for the Tribally Controlled Postsecondary 
        Career and Technical Institutions program. This is $1.7 million 
        above the fiscal year 2016 level. These funds are awarded 
        competitively and distributed via formula. We are seeking a 
        change to the formula that is not so reliant on Indian Student 
        Count in order to avoid dramatic swings in annual awards.
  --$30 million in discretionary funds as requested by the American 
        Indian Higher Education Consortium for Title III-A (Section 
        316) of the Higher Education Act, $2.4 million above the fiscal 
        year 2016 level.
  --Support the scheduled proposed $1.8 billion increase in the Pell 
        Grant program and the reinstatement of Year-Round Pell Grant 
        eligibility.
    Section 117 Perkins Funding.--Tribally Controlled Career and 
Technical Institutions. We appreciate the $500,000 increase for Section 
117 Perkins in fiscal year 2016. This funding level finally brought 
Section 117 Perkins back to its fiscal year 2012 pre-sequestration 
level. Funding for other programs authorized under the Perkins Act was 
restored several years ago. Perhaps Section 117 was overlooked as a 
source of career readiness and job training because it had been moved 
to the Higher Education portion of the budget, rather than staying in 
the Career and Technical Education account. We all realize the urgent 
need to better prepare a workforce to meet industry and other emerging 
needs. We are part of that undertaking, but need more resources to come 
closer to our potential.
    Acquisition of additional base funding is critical. We struggle to 
maintain course offerings and services to adequately provide 
educational services at the same level as our State counterparts. 
Perkins funds are central to the viability of our core postsecondary 
education programs. Very little of the other funds we receive may be 
used for core career and technical educational programs; they are 
competitive, often one-time targeted supplemental funds. Our Perkins 
funding provides a base level of support while allowing the college to 
compete for desperately needed discretionary funds.
    We highlight several relatively recent updates of our curricula to 
meet job market needs. Indeed, the ramifications of the North Dakota 
Bakken oil boom are apparent as we have seen faculty and students leave 
education in pursuit of jobs in the Bakken region. At the certificate 
level, UTTC recognized the need for more certified welders and heavy 
equipment operators in relation to the oil boom and expanded these 
programs in response to the workforce need. UTTC is now the only 
welding test site in a multi-State region approved by the American 
Welding Society. The hospital facilities in the regions were unable to 
hire certified Medical Coding & Billing personnel so we developed and 
currently offer this certificate as one of our online offerings. We are 
now able to train students for good paying in-demand employment with a 
focus on career rather than just a job. Lastly, we recently received 
Higher Learning Commission approval to offer a Bachelor's Degree in 
Environmental Science that will provide experiential research 
opportunities for our students.
    Funding for United Tribes Technical College is a good investment. 
We have:
  --Renewed unrestricted accreditation from the Higher Learning 
        Commission for July 2011 through 2021, with authority to offer 
        all of our full programs on-line. We offer 16 Associate 
        degrees, 5 Certificates, and 3 Bachelor degree programs of 
        study (Criminal Justice; Elementary Education; Business 
        Administration). Six of the programs are offered online.
  --Services including a Child Development Center, family literacy 
        program, wellness center, area transportation, K-6 elementary 
        school, tutoring, counseling, family and single student 
        housing, and campus security.
  --A projected return on Federal investment of 20-1 (2005 study).
  --A semester retention rate of 58 percent and a graduate placement 
        rate of 82 percent.
  --Students from 37 Tribes represented at UTTC.
  --Our students are very low income, and 67 percent of our 
        undergraduate students receive Pell Grants.
  --An unduplicated count of 536 undergraduate degree-seeking students: 
        828 continuing education students; and 24 dual credit 
        enrollment students for a total of 1,283 students for 2014-
        2015.
  --A dual-enrollment program targeting junior and senior high school 
        students, providing them an introduction to college life and 
        offering high school and college credits.
  --A critical role in the regional economy. Our presence brings at 
        least $34 million annually to the economy of the Bismarck 
        region. A North Dakota State University study reports that the 
        five Tribal colleges in North Dakota made a direct and 
        secondary economic contribution to the State of $181,933,000 in 
        2012.
    Title III-A (Section 316) Strengthening Institutions.--The Title 
III-A Strengthening Institutions funding is very important for all the 
Tribal colleges and we support American Indian Higher Education 
Consortium's request of $30 million for discretionary funding, $2.4 
million above fiscal year 2016. This is in addition to the $30 million 
in (Part F) mandatory funding. While these are not operational funds, 
they are critical for developmental activities and provide an 
opportunity for a modest amount of construction funding. Funds are 
distributed via a formula with up to 30 percent of funds authorized to 
be set-aside for competitive funding for facility construction and 
maintenance. We share with the other Tribal colleges serious issues of 
inadequate physical infrastructure.
    We are constantly in need of additional student housing, including 
family housing. Some of our students have to utilize private housing in 
Bismarck, and an offshoot of the oil boom in North Dakota is that 
housing prices have gone sky high. A two bedroom apartment in Bismarck 
rents for $1,200-$1,400 per month. With the completion of a Science, 
Math and Technology building on our South Campus on land acquired with 
a private grant, we urgently need housing for up to 150 students, many 
of whom have families. While we have constructed three housing 
facilities using a variety of sources in the past 20 years, 
approximately 50 percent of students are housed in the 100-year-old 
buildings of what was Fort Abraham Lincoln, as well as housing that was 
donated by the Federal Government along with the land and Fort 
buildings in 1973. These buildings require major rehabilitation. New 
buildings are actually cheaper than rehabilitating the old buildings 
that now house students.
    Title III funds provide much needed support to strengthened 
academic offerings. Specifically, Title III has been instrumental in 
the College's efforts to provide baccalaureate programs, online 
Associate programs, and increase the technology infrastructure 
necessary to support student learning and campus management functions. 
Professional development activities has been supported by Title III, 
increasing the intellectual and technical capacity of faculty and 
staff. Additional activities carried out with support of Title III 
funding have been associated with increasing the College's 
Institutional Resources capabilities in order to strengthen 
relationships with alumni and forming relationships with organizations 
and individuals who may become supporters of the College. With the 
current Title III award, the College is anticipating expanding academic 
offerings through the development of a Master's level program. The 
support of Title III will be critical for attaining accreditation 
approval, program development, and acquiring highly qualified faculty.
    Pell Grants.--We support the proposed $30 billion for the Pell 
Grant program (a $1.8 billion increase), including the proposal to 
reinstate year-round Pell Grant eligibility, thus allowing students the 
opportunity to earn a third semester of Pell Grant funding during an 
academic year if they have already completed a full-time course load of 
24 credit hours. As noted above, 67 percent of our undergraduate 
students receive Pell Grants. This resource makes all the difference in 
whether many of our students can attend college.
    The Duplication or Overlapping Issue.--As you know in March 2011, 
the Government Accountability Office issued two reports regarding 
Federal programs which may have similar or overlapping services or 
objectives (GAO-11-474R and GAO-11-318SP). Funding from the Bureau of 
Indian Education and the Department of Education's Carl Perkins Act for 
Tribally Controlled Postsecondary Career and Technical Education were 
among the programs listed in the reports. The full GAO report did not 
recommend defunding these programs; rather, it posed the possibility of 
consolidation of these programs to save administrative costs. We are 
not in disagreement about possible consolidation of our funding 
sources, as long as program funds are not cut.
    The Perkins funds supplement, but do not duplicate, the BIE funds. 
Both sources of funding are necessary to the frugal maintenance of our 
institution. We actively seek alternative funding to assist with 
academic programming, deferred maintenance, and scholarship assistance, 
among other things. The need for career and technical education in 
Indian Country is so great and the funding so small that there is 
little chance for duplicative funding. United Tribes Technical College 
and Navajo Technical University, who focus on career and technical 
education, received combined only $15.1 million in fiscal year 2016 
Federal operational funds ($8.2 million from Perkins; $6.9 million from 
the BIE). That is not an excessive amount for two campus-based 
institutions who offer a broad array of programs geared toward the 
educational and cultural needs of their students and who teach job-
producing skills.
    We invite the Chair, Ranking Member and all members of this 
Subcommittee to visit United Tribes Technical College--we are in close 
proximity to the Bismarck airport. We would be honored and pleased to 
arrange such a visit.
    Thank you for your consideration of our requests.

    [This statement was submitted by Leander ``Russ'' McDonald, PhD, 
President, United Tribes Technical College.]
                                 ______
                                 
           Prepared Statement of the Usher Syndrome Coalition
    My name is Anne Croy and my daughter's name is Maliea Croy. Maliea 
lives in New York City and works as an assistant art gallery director. 
Her stepfather and I reside in St. Louis, Missouri. As a very concerned 
parent and a member of the Usher Syndrome Coalition, I write on behalf 
of the Usher syndrome community to respectfully request this committee 
support the inclusion of report language prioritizing research into 
treatment of Usher syndrome at the National Institutes of Health (NIH).
    The Usher syndrome community across the country is aware of and 
appreciates your support since our report language first appeared in 
the 2014 omnibus spending bill. But as I am sure you agree, Usher 
syndrome needs to become a higher priority at NIH until we have viable 
human treatments. Despite 3 years of appropriations language urging NIH 
to make Usher syndrome a higher priority, spending on Usher actually 
decreased by 11.6 percent from 2014 to 2015.
    As you prepare the fiscal year 2017 Labor, Health and Human 
Services, Education bill, we respectfully request that you include the 
following report language with the objective of better defining the 
plan and measurements for the delivery of vision loss treatments for 
those with Usher syndrome:
  --Usher syndrome.--The Committee continues to urge the NIH to 
        prioritize Usher syndrome research at NEI and NIDCD. The 
        Committee requests an update in the fiscal year 2017 budget 
        request on steps NIH has taken to date and future plans to 
        accelerate treatment options and improve patient outcomes for 
        those with Usher syndrome. The update should include a 
        description of the criteria in use by NIH to evaluate Usher 
        syndrome related grant submissions to ensure the prioritization 
        of those that accelerate human treatment options. The update 
        should also include a timeline and deliverables that will be 
        used to evaluate the progress made towards viable treatments 
        for those with Usher syndrome.
    Usher syndrome is the most common genetic cause of combined 
deafness and blindness. In the United States, it is estimated that 
nearly 50,000 people have this rare genetic disorder. Maliea is one of 
those people. She was born with a moderate to severe hearing loss and 
has worn digital hearing aids in both ears since the age of 1 1/2 
years. It is imperative that she be constantly fitted with improved 
aids to maintain her level of hearing and this is a cost not covered by 
insurance. Our last pair of aids was $6500.
    At the age of 20 years and while attending college, Maliea began 
struggling with vision issues. Multiple tests revealed an Usher 
syndrome diagnosis. It was devastating to her and our family, but after 
much research, counseling and renewed family solidarity, we determined 
that our only choice was to begin planning and move forward as a strong 
unit. Maliea has lost a donut shape of vision in each eye. Her 
peripheral vision is dim and cloudy at best. She travels by subway to 
work in NYC with cane in hand. She is determined, but knows her 
limitations. She knows her days in the art field are limited due to 
reliance on visual accuracy. She is making plans to change careers next 
fall and has been accepted to Columbia University to earn a Master's 
degree in Social Work. She wants to be a counselor.
    We know that the progression of this disease can cut those dreams 
short and this is why we plead for your help. Not just for our 
daughter, but for every individual with Usher syndrome, that their 
dreams at living a productive and rewarding life may not be squelched.
    People with Usher syndrome share the same range of intelligence and 
work ethic as any American. Yet they suffer from an 82 percent 
unemployment rate. People with Usher syndrome are born with the same 
emotional strength as any other. Yet they have a suicide rate that is 2 
= times greater than the general population. People with Usher syndrome 
not only have the capacity to contribute to America's future, they 
thirst for it. They want to be active members of society. Yet our 
country spends an estimated $139 billion annually in direct and 
indirect costs for people with eye disorders and vision loss. That 
doesn't even include the costs associated with hearing impairment.
    Excellent, timely and promising research on Usher syndrome is 
happening worldwide. As a country, we need to make the work of these 
dedicated scientists and doctors both plausible and meaningful in their 
progression. It is the future of many at stake.
    Last year, my husband and I started a small company where a portion 
of the proceeds will be dedicated yearly to the Usher Syndrome 
Coalition. There are many independent groups at work to support those 
with the disease and help drive research. Now we need the support of 
the National Institutes of Health to fine-tune our directives. Usher 
genes are complex, long protein cells, which require significant 
investment in research if we are ever to find a cure or treatment. We 
can't do it alone.
    Until very recently, there was no way of knowing how much money NIH 
invested in Usher syndrome research. Through the efforts of the Usher 
Syndrome Coalition, this rare disease has been added as a new category 
in the NIH Categorical Spending list, the Estimates of Funding for 
Various Research, Condition, and Disease Categories (RCDC). Through the 
RCDC system, we now have visibility into the total dollars spent on 
Usher syndrome, as well as the specific grants that were funded. More 
important to us than increasing the dollars invested in Usher syndrome 
research is ensuring those dollars are invested in the most impactful 
manner.
    We would like to see a strategic plan put forth by the National 
Institutes of Health developed with both internal and external 
expertise containing clear measurements of progress. NIH investment 
should target those research areas that will most quickly bring about 
viable human treatments for the vision loss phenotype in Usher 
syndrome. There are technologies and techniques available today to 
manage the hearing loss and vestibular issues faced by those with Usher 
syndrome. These are not perfect and more investment is needed, but the 
priority should be to provide treatments that allow people with Usher 
syndrome to manage the vision loss as well as they currently manage the 
hearing and vestibular losses.
    The dollars invested in Usher syndrome research are precious to all 
of us. We want to make sure they are spent as wisely as possible. The 
researchers are there, waiting to discover what now is just a dream. 
All we are asking for is a chance; a chance at the sight most of us 
take for granted.
    Thank you very much.

    [This statement was submitted by Anne Croy, Member, Usher Syndrome 
Coalition.]
                                 ______
                                 
       Prepared Statement of the Washington State Long-Term Care
                           Ombudsman Program
    I am pleased to present this testimony on behalf of residents 
residing in Washington State's licensed long-term care facilities in 
collaboration with the National Association of State Long-Term Care 
Ombudsman Programs (NASOP). Thank you for your past support of the 
Long-Term Care Ombudsman Program (LTCOP) and all the vulnerable 
citizens that it serves. This statement and the following funding 
recommendations are submitted for the fiscal year 2017 for the Long-
Term Care Ombudsman Programs administered through the Administration 
for Community Living (ACL).
    Thank you for your recent support of the Older American Act 
reauthorization. The bill is awaiting the President's signature. This 
legislation, which had strong bipartisan support, does several 
important things to strengthen and improve the Long-Term Care Ombudsman 
Program, including:
  --Mandating the program to serve all residents of long-term care 
        facilities, including those individuals with disabilities, 
        which expands our services to residents under the age of 60;
  --Enabling the program to advocate for residents who cannot provide 
        informed consent and have no resident representative--the 
        Ombudsman can now advocate for the best interests of the 
        resident;
  --Improving our ability to advocate for residents who are victims of 
        guardianship abuse.
    In addition, Congress' reauthorization of the Older Americans Act 
continues to encourage regular, non-compliant facility visits, which 
are a cost effective vehicle to identify and resolve problems, avoiding 
the more costly regulatory system.
    In addition, new Federal regulations for the Long-Term Care 
Ombudsman Program reinforce the reauthorized Older Americans Act. All 
of these tools will increase our ability to serve residents in the 
growing number of assisted living facilities caring for the baby boomer 
generation. In order to adequately serve the growing number of long-
term care facility residents, NASOP asks for the following:
    First, we request $5 million to support the work of the LTCOP under 
the Elder Justice Act. This appropriation would allow States to hire 
additional staff and leverage that staff to recruit additional 
volunteers to help support the investigation of complaints of abuse, 
neglect, and exploitation of residents of nursing home and assisted 
living facilities. To date, no EJC funds have been provided for the 
LTCOP.
    Second, we request $20 million to support 333 additional Ombudsman 
(salaried staff) at an estimated $60,000 average annual salary/fringe 
benefits and necessary staff training. The requests adds new ombudsman 
positions specifically dedicated to providing Ombudsman services to 
residents of assisted living facilities and other community-based long-
term care delivery systems, which currently suffer from a significant 
lack of personnel resources around the country.
    Third, we request $16.83 million authorized under Title VII of the 
Older Americans Act for LTCOPs to restore funding back to the fiscal 
year 2011 level. Programs in every district and State are suffering 
from recent cuts. These funds would help in a partial way to restore 
our reduced ability to visit residents in nursing homes.
    The primary function of the LTCOP in the Federal OAA is to 
identify, investigate, and resolve complaints that relate to action, 
inaction or decisions that may adversely affect the health, safety, 
welfare, and rights of residents of long-term care facilities. 
Ombudsman representatives work with the consent and at the direction of 
residents in the resolution of their problems. They visit residents 
living in nursing homes and residential care homes. Ombudsman 
representatives ask them about problems or concerns they have and if 
they need or want our help to resolve these issues. Ombudsman 
representatives act as their advocates. We strongly believe that our 
work not only improves the quality of life for millions of long-term 
care facility residents, but also saves Medicare and Medicaid resources 
by avoiding unnecessary costs associated with poor quality care.
    Nationally, in fiscal year 2014, nearly 8,200 volunteers, including 
individuals certified to investigate complaints, and 986 staff (full-
time equivalent) served in the LTCOP. Ombudsman representatives 
investigated and worked to resolve 188,599 complaints made by 125,642 
individuals. Ombudsmen were able to resolve or partially resolve 76 
percent, or more than three out of every four complaints investigated. 
In addition, Ombudsman representatives provided information or 
consultation on rights, care and related services approximately 490,000 
times.
    The Washington State LTCOP (WA-LTCOP) is the first line of 
protection for thousands of individuals living in licensed long-term 
care facilities. The Washington State Long-Term Care Ombudsman Program 
is responsible for advocating for residents residing within the State's 
3,548 long-term care facilities. Our State Program consists of the 
State Long-Term Care Ombudsman, an Assistant State Ombudsman and one 
Program Administrator. However, we subcontract with several Area 
Agencies on Aging, Community Action Programs and other private not-for-
profits to deliver local ombudsman services to thousands of vulnerable 
adults living across the State. Currently the program has 16 full-time 
equivalent paid Ombudsman staff, working in fourteen local Regional LTC 
Ombudsman Programs. The local programs oversee an amazing corps of 
approximately 320 volunteers who are trained and certified as 
ombudsmen. Many of our volunteers are retirees who wish to ``give 
back'' to their communities by donating their time and skills to 
improving the lives of vulnerable adults. In Federal fiscal year 2015, 
WA-LTCOP investigated 4,500 complaints made by or on behalf of 
residents. Last Federal fiscal year, ombuds volunteers and staff made 
16,652 in-person visits to care facilities and provided 53,773 
consultations to residents, facility staff, resident family members and 
others. We are a vital direct service for the frail and isolated living 
in facilities.
    Although we have a great team of regional ombuds and volunteers, 
our program has not been able to visit every one of the 3,548 
facilities in Washington. Nearly 48 percent of facilities do not have 
routine Ombudsman visits which are the hallmark of the program and 
important to building trusting relationships and confidence with 
residents and caregiving staff. As one of the first demonstration 
States of the ombudsman program in the mid 1970's, funding levels 
throughout the decades has never been sufficient to meet the Federal 
and State mandates. The program advocates for thousands of residents in 
facilities and we do this with a small number of paid staff. We are 
grateful for the staffing that we do have, and believe that our 
successes are just a drop in the bucket. According to two national 
studies about the Long-Term Care Ombudsman Program from the Institute 
of Medicine and the Bader Report, best practice is for States to have 
one full-time long-term care ombudsman for every 2,000 long-term care 
beds or residents. To meet this recommendation, Washington State needs 
to more than double the number of full-time paid staff from 16, to 34. 
Currently our ratio of ombudsmen to beds is 1 to 4,300 (total number of 
licensed beds is 68,818). With an increase in paid ombudsmen, we would 
increase our numbers of ombudsmen volunteers to strengthen coverage of 
all care facilities. An increase would ensure that all individuals 
residing in long-term care would have immediate access to an advocate 
who can represent their interests.
    We understand that this Subcommittee faces a strained financial 
situation, but a continued commitment to Ombudsman programs advocating 
for the healthcare needs and safety of millions of older adults living 
in nursing homes and assisted living facilities across the Nation 
should remain a high priority. Since 1978, the LTCOP has been a core 
program of the OAA. It is the only program in the OAA that specifically 
serves residents of nursing homes and assisted living facilities. We 
all appreciate and value the importance of living in one's own home. 
The OAA provides critically needed home and community based services 
that often delay institutionalization. However, some elders can no 
longer live safely in their own homes and must move at some point in 
their lives to either an assisted living facility or a nursing home. 
These residents are usually frail and extremely vulnerable and rely on 
the advocacy services of the LTCOP.
    Demand for our services and advocacy is growing. The number of 
complex and very troubling cases that long-term care ombudsmen 
investigate has been steadily increasing. In addition, there continues 
to be a disturbing increase in the frequency and severity of citations 
for egregious regulatory violations by long-term care providers. These 
violations put long-term care residents in jeopardy of harm. This trend 
suggests a frightening decline in the quality of long-term care 
services. Ombudsmen are needed now more than ever in nursing homes, 
board and care facilities, State veteran's homes and in assisted living 
communities. As well, the demand placed on the program by the need to 
assist residents who are relocating from long-term care facilities that 
are downsizing or closing their doors continues to put strain on 
ombudsman daily operations and overall resources.
    Administrators in many long-term care facilities have recognized 
the value and benefit of having ombudsmen assist with staff training 
and consultation and this form of outreach has also placed an 
increasing strain on available advocacy resources. In order to improve 
advocacy and services available to residents of long-term care 
facilities, Washington's Office of the State Long-Term Care Ombudsman 
and NASOP supports the aforementioned funding levels.
    Overall, Ombudsmen offer valuable consumer protections to residents 
and provide a voice for those unable to speak for themselves. Every day 
in America, 10,000 more persons reach the age of 65 years. With a 
rapidly growing older population, LTCOPs can continue to enhance the 
quality of life, improve the level of care, protect the individual's 
rights and promote the dignity of Americans across the Nation. NASOP, 
formed in 1985 as a non-profit organization, is composed of State long-
term care ombudsmen representing their State programs created by the 
Older Americans Act (OAA).
    Thank you for your ongoing support.

    [This statement was submitted by Patricia Hunter, Member, National 
Association of State Long-Term Care Ombudsman Programs.]
                                 ______
                                 
               Prepared Statement of WestCare Foundation
    WestCare Foundation respectfully submits this testimony to the U.S. 
Senate Appropriations Subcommittee on Labor, Health and Human Services, 
and Education, and Related Agencies (LHHS) regarding fiscal year 2017 
funding for the Center for Disease Control (CDC), and Substance Abuse 
and Mental Health Services Administration (SAMHSA) to address the 
opioid and prescription drug epidemic.
    Each day, 46 people in the United States die from overdose of 
prescription painkillers.\1\ According to the CDC, people in rural 
communities are nearly twice as likely to overdose on prescription pain 
medications as people in cities.\2\ Prescription drug and opioid abuse 
is a public health crisis of significant proportion, in which 
underserved, rural areas are hit the hardest. Offering a full continuum 
of services to individuals with substance use disorders (SUD), 
including evidence-based prevention, early intervention and treatment 
efforts, is a necessary and comprehensive approach to combatting 
prescription drug overdose and sustaining recovery.
---------------------------------------------------------------------------
    \1\ Center for Disease Control (CDC): http://www.cdc.gov/
vitalsigns/opioid-prescribing/(2014).
    \2\ Center for Disease Control (CDC): http://www.cdc.gov/
vitalsigns/painkilleroverdoses/(2011).
---------------------------------------------------------------------------
    WestCare Foundation provides a wide array of health and human 
services in both outpatient and residential environments in nearly 20 
States and the Pacific and Caribbean Islands. The Foundation provides 
comprehensive, wrap-around substance abuse and mental health services 
for children, adolescents, adults, and families, with a focus on 
underrepresented populations in rural areas. WestCare programs have 
shown significant outcomes in treating veteran and criminal justice 
populations returning to their communities through recovery supports 
such as housing, education, employment and other transitional services.
    As a national substance use disorder provider, WestCare Foundation 
recognizes the magnitude of the prescription drug and opioid public 
health crisis our Nation faces, and emphasizes the collaborative role 
of States, local communities, and service providers in preventing 
prescription drug overdoses, in addition to the importance of a 
continuum of care in effectively curbing substance use and mental 
health disorders through affordable, timely and accessible care.
                       center for disease control
    WestCare Foundation supports the Administration's fiscal year 2017 
request for $80 million for prescription drug overdose prevention 
programming at the Centers for Disease Control (CDC), $10 million above 
fiscal year 2016 enacted levels.
    The Center for Disease Control's (CDC) Prescription Drug Overdose 
Prevention for States Program (Prevention for States) is an initiative 
implemented in 2015 to provide State health departments with resources 
and support needed to advance interventions for preventing prescription 
drug overdoses. Due to the effectiveness of the program and the rising 
need, CDC received substantial increases in fiscal year 2015, of $20 
million, and in fiscal year 2016, of $50 million dollars, to expand 
State prevention activities to a national scale. To ensure 
accountability, CDC is undergoing an evaluation of the program in order 
for measures to inform program improvements to achieve the highest 
public health impact possible as this program continues to grow and 
expand.
    In fiscal year 2017, the President's budget requests $80 million 
for prescription drug overdose prevention to promote opioid prescribing 
guideline dissemination and uptake. The Administration's budget 
proposal includes funding to continue and expand State support for 
Prescription Drug Overdose Prevention for States Programs in all 50 
States, and to continue to allow rigorous monitoring and evaluation and 
improvements in data quality.
    In fiscal year 2017, WestCare Foundation supports the 
Administration's appropriations request for prescription drug overdose 
prevention of $80,000,000. This investment will increase accountability 
for States and allow States to advance and expand interventions for 
preventing prescription drug overdoses.
    Given the prevalence of prescription drug and opioid abuse in rural 
areas throughout the Nation, WestCare recommends CDC outline a new 
strategic goal within the Prescription Drug Overdose Prevention for 
States Program dedicated to rural outreach, engaging underserved 
communities through the existing U.S. Department of Agriculture (USDA) 
Cooperative Extension Service program (Extension Program).
    By utilizing existing infrastructure such as Extension Programs, we 
can build on and connect services already underway such as SAMHSA Block 
Grants, SAMHSA Drug Free Communities, CDC Prevention for States, and 
HRSA grantees and streamline Federal efforts to increase local and 
Federal collaboration. Lack of local-Federal and interagency 
coordination has impeded efficient, collaborative efforts among local 
stakeholders.
    In February 2016, Secretary Tom Vilsack of USDA announced the 
``Rural America Opioid Initiative'' to address the shortage in 
substance abuse services in rural areas. This interagency initiative 
has potential to serve as an effective vehicle in coordinating Federal 
efforts. Through interagency coordination between the CDC and USDA, 
States and local communities can capitalize on existing programs like 
the USDA Extension Program and the CDC Prevention for States Program. 
Specifically, WestCare recommends that the CDC Prevention for States 
Program require grantees to provide Extension Offices with the 
resources, best practices, and technical expertise necessary to guide 
and assist local communities and rural SUD treatment providers in 
expanding treatment capacity and coordinating Federal, State, and local 
opioid initiatives and funding streams at the local level.
    WestCare respectfully recommends the following report language be 
inserted into the fiscal year 2017 Labor, Health and Human Services, 
Education, and Related Agencies Appropriations Bill: ``the Committee 
directs the agency [CDC] to offer a new Prescription Drug Overdose 
Prevention for States Program competition [in fiscal year 2017] that 
incorporates a strategic goal to implement effective prescription drug 
overdose prevention in underserved rural areas, provided that up to 2 
percent of funds under the program may be retained for an annual 
national summit on opioid treatment in rural communities.''
       substance abuse and mental health services administration
    In fiscal year 2017, WestCare Foundation supports increased 
investment to address prescription opioid abuse and heroin use, and is 
encouraged by the significant attention to substance use disorder 
treatment expansion, provided that medication-assisted-treatment is 
coupled with the full continuum of behavioral therapy and recovery 
support services. As physicians become gate keepers, it is imperative 
that they are qualified to diagnose behavioral health disorders, treat 
addiction as a disease, properly prescribe pain, provide person-
centered recovery, and make appropriate referrals to behavioral 
specialists as they would for another health disorder.
    WestCare Foundation applauds the Administration's and Congress' 
attention to the opioid and heroin epidemic, but recommends that any 
investment in medication-assisted treatment provide flexibility for 
individualized, patient-centered behavioral and recovery support. 
Substance addiction is a chronic, relapsing disease with prescribed 
care regimens that are often comparable to diabetes or heart disease, 
requiring patient education, treatment, rehabilitation, and consistent 
management of the disease upon recovery. Treatment modality, length of 
stay and service provisions must be taken into consideration and will 
vary depending on the duration, dose and type of substance use, as well 
as the age of first initiation, experience with trauma, and other 
physical and mental health co-occurring disorders. SUDs are present on 
a wide spectrum of severity, often with co-occurring mental health and 
primary care health issues. To address the range of issues, WestCare 
provides differentiated programs across the continuum of care--services 
to accompany medication-assisted treatment. WestCare's services consist 
of outpatient and residential treatment programs that include 
assessment, individual and group counseling, and case management; 
family and transitional education; vocational education; recreational 
therapy; holistic health promotion; permanent and temporary supportive 
housing; and other community and peer supports.
    One of the most pressing barriers to comprehensive services is 
workforce capacity and access to treatment. People seeking treatment 
are usually at their lowest point and impressionable. When forced to 
wait for treatment service, hopelessness can manifest and increase the 
likelihood for relapse. Unfortunately, the existing community-based 
system of care for heroin and opioid disorders is restricted by the 
Institute of Mental Disease (IMD) Exclusion at a time when greater 
capacity is an essential respond to the crisis.
    Medication-assisted-treatment has been shown to improve patient 
survival, increase retention in treatment, decrease illicit opiate use 
and other criminal activity among people with substance use disorders, 
increase patients' ability to gain and maintain employment, improve 
birth outcomes among women who have substance use disorders and are 
pregnant.\3\
---------------------------------------------------------------------------
    \3\ SAMHSA Treatment Episode Data Set (TEDS) 2002-2010: http://
store.samhsa.gov/product/2000-2010-National-Admissions-to-Substance-
Abuse-Treatment-Services/SMA12-4701.
---------------------------------------------------------------------------
    Despite this evidence-based approach and proven effectiveness, 
medication-assisted-treatment is greatly underused. According to 
SAMHSA, the number of heroin admissions with treatment plans that 
included receiving medication-assisted opioid therapy fell from 35 
percent in 2002 to 28 percent in 20103. Slow adoption of these 
treatment options is partly due to misconceptions about substituting 
one drug for another and lack of training for physicians. Now, 
medication-assisted treatment is being looked to as a primary and 
sustainable method to provide comprehensive treatment.
    The CDC Guideline for Prescribing Opioids for Chronic Pain released 
in March of 2016 recommends clinicians ``offer or arrange evidence-
based treatment (usually medication-assisted treatment with 
buprenorphine or methadone in combination with behavioral therapies) 
for patients with an opioid use disorder.'' \4\ As an extension, the 
CDC points to studies that suggest using behavioral therapies, in 
combination with treatments like methadone maintenance therapy or 
buprenorphine, can reduce opioid misuse and increase retention during 
maintenance therapy and improve compliance after detoxification.
---------------------------------------------------------------------------
    \4\ CDC Guideline for Prescribing Opioids for Chronic Pain--United 
States, 2016: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
---------------------------------------------------------------------------
    As both providers and policy-makers look to medication-assisted 
treatment models, the importance of behavioral therapy and full 
recovery support cannot be overstated. Therefore, WestCare Foundation 
respectfully requests that any funding appropriated by Congress for 
medication-assisted treatment include report language explicitly 
stating ``medication-assisted treatment in conjunction with behavioral 
and recovery support services'' as an allowable use of medication-
assisted treatment funds. The intention is to provide sufficient 
flexibility to allow substance use disorder treatment providers to meet 
local needs of their individual communities and target vulnerable 
populations such as pregnant women and veterans.
    In closing, WestCare Foundation recognizes the fiscal realities of 
the Federal budget but remains encouraged by Congress' strong 
commitment to addressing our Nation's public health crisis. We support 
the highest possible funding for mental health and substance use 
disorder treatment in fiscal year 2017, and believe that through 
greater coordination of existing programs we can improve and better 
document treatment outcomes. We strongly encourage the Subcommittee not 
to overlook the need of coordination, capacity-building, and the break-
down of Federal funding silos at the most local levels. We further urge 
the Subcommittee not to view medication-assisted treatment as a 
``silver bullet,'' quick solution to the opioid public health crisis--
medication must be paired with complementary behavioral support to 
achieve sustainable recovery. We look forward to collaborating on the 
fiscal year 2017 appropriations process as Congress looks to invest and 
direct resources to this critical, national issue.
                                 ______
                                 
            Prepared Statement of the Women's Heart Alliance
    Women's heart disease is the number one killer of women in the 
United States and is responsible for the deaths of one in every three 
women in the United States.\1\ Even though a woman's heart is different 
than a man's and the disease affects women differently, for the last 50 
years, the treatment of women's hearts has largely been based on 
medical research on men.
---------------------------------------------------------------------------
    \1\ Heron M. Deaths: Leading Causes for 2013. National vital 
statistics reports. Hyattsville, MD: National Center for Health 
Statistics. 2016;65(2):22. Available from: http://www.cdc.gov/nchs/
data/nvsr/nvsr65/nvsr65_02.pdf.
---------------------------------------------------------------------------
    In fact, despite the sex differences in physiology and in the 
manifestation of cardiovascular disease, only 35 percent of 
participants in all heart-related studies are women.\2\ Therefore, far 
too many women are dying from a largely preventable disease and not 
enough is being done to recognize the differences and appropriately 
treat heart disease in women.
---------------------------------------------------------------------------
    \2\ Melloni C, Mark DB, Douglas PS, et al. Representation of Women 
in Randomized Clinical Trials of Cardiovascular Disease Prevention. 
Circulation: Cardiovascular Quality and Outcomes. 2010;3:135-142. 
Available at: http://circoutcomes.ahajournals.org/content/3/2/135.long.
---------------------------------------------------------------------------
    Women are dying at high and often unrecognized rates from the 
disease. Consider:
  --Heart diseases claims more than 400,000 women's lives each year. 
        That's nearly one death every 80 seconds.\3\
---------------------------------------------------------------------------
    \3\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman 
M, et al.; on behalf of the American Heart Association Statistics 
Committee and Stroke Statistics Subcommittee. Heart disease and stroke 
statistics--2016 update: a report from the American Heart Association. 
Circulation. 2016;133:e148. Available from: http://
circ.ahajournals.org/content/early/2015/12/16/
CIR.0000000000000350.full.pdf.
---------------------------------------------------------------------------
  --Although slightly more men (402,851) than women (398,086) died from 
        heart disease and stroke in 2013 (the most recent year for 
        which data are available), women fare worse than men in a 
        number of critical ways.\4\
---------------------------------------------------------------------------
    \4\ Ibid.
---------------------------------------------------------------------------
    --For example, women are at greater risk of dying in the year 
            following a heart attack than are men. Indeed, 1 in 4 women 
            will die within 1 year of their heart attack, compared to 1 
            in 5 men.\5\
---------------------------------------------------------------------------
    \5\ CDC Feature: Women and Heart Disease [Internet]. Atlanta: CDC; 
c2015. [Updated: 2 February 2015; cited: 31 August 2015]. Available 
from http://www.cdc.gov/features/wearred/index.html.
---------------------------------------------------------------------------
  --Nearly half of African American women ages 20 and older (48.3 
        percent) have heart disease \6\, yet only 1-in-5 thinks she is 
        personally at risk, and just half are aware of the signs and 
        symptoms of a heart attack.\7\
---------------------------------------------------------------------------
    \6\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman 
M, et al.; on behalf of the American Heart Association Statistics 
Committee and Stroke Statistics Subcommittee. Heart disease and stroke 
statistics--2016 update: a report from the American Heart Association. 
Circulation. 2016;133:e151.
    \7\ Heart Disease in African American Women [Internet]. Dallas 
American Heart Association--Go Red For Women; Available from: https://
www.goredforwomen.org/about-heart-disease/
facts_about_heart_disease_in_women-sub-category/african-american-
women/.
---------------------------------------------------------------------------
  --Breast cancer kills one in 32 women, while heart disease kills one 
        in three, yet only a small fraction ($246 million) of the 
        National Institutes of Health budget is spent on women's heart 
        disease research.\8\
---------------------------------------------------------------------------
    \8\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman 
M, et al.; on behalf of the American Heart Association Statistics 
Committee and Stroke Statistics Subcommittee. Heart disease and stroke 
statistics--2016 update: a report from the American Heart Association. 
Circulation. 2016;133:e148.
---------------------------------------------------------------------------
  --Blacks develop high blood pressure more often, and at an earlier 
        age, than whites and Hispanics. More black women than men have 
        high blood pressure.\9\
---------------------------------------------------------------------------
    \9\ Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman 
M, et al.; on behalf of the American Heart Association Statistics 
Committee and Stroke Statistics Subcommittee. Heart disease and stroke 
statistics--2015 update: a report from the American Heart Association. 
Circulation. 2015;131:e98-e110.
---------------------------------------------------------------------------
  --Sixty-four percent of women who die suddenly of coronary heart 
        disease have no prior symptoms.\10\
---------------------------------------------------------------------------
    \10\ Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden 
WB, et al. Heart disease and stroke statistics--2012 update: a report 
from the American Heart Association. Circulation. 2012;125(1):e2--220.
---------------------------------------------------------------------------
  --Obesity, diabetes, high blood pressure, stress, lack of exercise, 
        and other factors put young women at risk of dying from heart 
        disease. Recent data show that CVD rates and the prevalence of 
        CVD risk factors are increasing among young women.\11\
---------------------------------------------------------------------------
    \11\ Lee et al., Ogden et al., Geiss et al., and Pope et al.
---------------------------------------------------------------------------
    Increasing investment in research to discover why sex differences 
occur in heart disease must be a priority in the National Institutes of 
Health (NIH) budget. An October 2015 Government Accountability Office 
(GAO) report highlights the desperate need to close the gender gap in 
research and to improve our understanding of the impact of disease on 
women.
    The Women's Heart Alliance requests that Congress appropriate 
sustained funding for NIH and the Centers for Disease Control and 
Prevention (CDC) to improve cardiovascular disease research, prevention 
and treatment and reduce the unnecessary suffering and death from 
cardiovascular disease in both women and men.
Capitalize on Investment for the National Institutes of Health (NIH) 
        and the National Heart, Lung, and Blood Institute (NHLBI)
    As was emphasized in our recently submitted letter from the NHLBI 
Constituency Group, of which we are a member organization, we are 
grateful for the significant funding increase for the National 
Institutes of Health during the fiscal year 2016 congressional 
appropriations process. In the fiscal year 2017 Labor-HHS-Education 
Appropriation bill, we request at least $34.5 billion for the National 
Institutes of Health and $3.4 billion for NIH's National Heart, Lung, 
and Blood Institute.
    A funding level of this amount would allow the NIH to continue to 
restore its purchasing power. Despite the fiscal year 2016 funding 
increase for NIH, the agency's purchasing power is 19 percent less than 
in fiscal year 2003 (constant 2015 dollars). An fiscal year 2017 
appropriation of at least $34.5 billion for the NIH, including $3.4 
billion for NHLBI would permit the NIH to capitalize on its ability to 
enhance health, create jobs, boost economic growth and innovation and 
promote science. Stable and sustained funding will help secure a solid 
return on Congress' investment in NIH.
    It is critical that, as the GAO recommended, stronger steps are 
taken to understand the impact of sex and gender on disease in NIH-
funded clinical research trials. When medical research, analysis and 
reporting takes into account differences between men and women, new 
findings translate into better diagnosis and treatment for women. 
Improvements in reporting and interpreting subgroup analysis and in 
clinical trail design are needed to give statistically meaningful 
results for men and for women.
    We request the Committee invest money, as deemed appropriate, to 
enforce GAO recommendations, including policies that:
  --Require women to be represented in clinical trials in proportion to 
        the number of women affected by the disease being studied.
  --As part of NIH's regular biennial report to Congress on the 
        inclusion of women and minorities in research, include specific 
        detailed reporting by institute, by disease category and by 
        study. Such reporting should include an analysis of the number 
        of women included in each clinical trial in proportion to the 
        number of women affected by the disease being studied.
  --As part of NIH's regular biennial report to Congress on the 
        inclusion of women and minorities in research, NIH should track 
        and report where we have made discoveries on sex differences 
        and where gaps still exist.
    In particular, more work is needed on the areas of persistent 
increased risk for heart disease in younger women; the higher 
procedural complications and bleeding complications in women; and the 
social determinants of cardiovascular health across the lifespan. A 
multi-Institute, multidisciplinary collaborative effort in this area 
that may include support for centers of excellence should also be 
strongly considered.
    Recognizing the need for continued groundbreaking research on heart 
disease and particularly new discoveries on women's heart disease, we 
appreciate and support NHLBI as the lead research institution on heart 
disease.
    The NHLBI has a long history of achievements in improving the 
health of your constituents. Over the past 68 years, the NHLBI has made 
important progress in the treatment and prevention of heart disease, 
stroke, asthma, emphysema, sickle cell disease, Cooley's anemia, 
diabetes, sleep disorders and other diseases.
    However, challenges remain because heart, lung, blood, and blood 
vessel diseases account for more than 40 percent of all deaths in the 
United States. These diseases kill more than 1 million Americans each 
year and cost our Nation an estimated $441 billion in medical expenses 
and lost productivity in 2012-2013.\12\
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    \12\ National Heart, Lung, and Blood Institute. Unpublished 
tabulation. April 2016.
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    As the worldwide leader in research on heart, lung, blood and blood 
vessel diseases as well as sleep disorders, the NHLBI effectively 
translates research results to the American public. An fiscal year 2017 
appropriation of $3.4 billion for the NHLBI would allow the Institute 
to enhance current programs and pursue promising planned innovative 
basic, clinical, translational and prevention research initiatives to 
better diagnose, treat and prevent these diseases.
Increase Funding for the Centers for Disease Control and Prevention
    According to the CDC's Division for Heart Disease and Stroke 
Prevention, cardiovascular disease (CVD) costs the United States $320 
billion in annual healthcare costs and lost productivity.\13\ 
Unfortunately, the toll is only growing. By 2030, more than four in 10 
Americans are projected to have cardiovascular disease, with total 
costs expected to triple to more than a trillion dollars.\14\
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    \13\ Business Pulse [Internet]. Atlanta: CDC Foundation; c2015 
[cited 22 Dec 2015]. Available from: http://www.cdcfoundation.org/
businesspulse/heart-health-infographic.
    \14\ Heidenriech PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, 
Ezekowitz MD, et al. Forecasting the future of cardiovascular disease 
in the United States: a policy statement from the American Heart 
Association. Circulation. 2011;123(8):933--44.
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    Heart disease is 80 percent preventable.\15\ And it's clear the 
benefits of putting more resources into prevention far outweigh the 
costs.
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    \15\ Akesson A, Larsson SC, Discacciati A, Wolk A. Low-Risk Diet 
and Lifestyle Habits in the Primary Prevention of Myocardial Infarction 
in Men: A Population-Based Prospective Cohort Study. J Am Coll Cardiol. 
2014;64(13):1299-1306. doi:10.1016/j.jacc.2014.06.1190. Available from: 
http://content.onlinejacc.org/article.aspx?articleid=1909605.
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    We join the CDC Coalition in requesting $7.8 billion for the agency 
and $37 million for WISEWOMAN for expansion to additional and 
currently-funded States. WISEWOMAN provides low-income, under-insured 
or uninsured women with chronic disease risk factor screening, 
lifestyle programs and referral services in an effort to prevent 
cardiovascular disease and stroke. Scaling up programs like this would 
only help rein in the costs associated with heart disease. We also ask 
for $5 million for Million HeartsTM, a national initiative 
with an ambitious goal to prevent 1 million heart attacks and strokes 
by 2017, of which WHA is a member. This will allow Million Hearts to 
enhance efforts to prevent, detect, treat, and control blood pressure--
a key reason for heart attack and stroke.
                               conclusion
    Cardiovascular disease and its precursors are an unnecessary and 
heavy burden on America's people and budget. Boosting funding for the 
prevention, research and treatment of women and heart disease through 
NIH and CDC is not only an effective step toward improving the health 
of American women, but also a smart economic move for the country. We 
respectfully ask the Committee to approve these recommendations that 
will foster the health and wellbeing of the American people.

    [This statement was submitted by British Robinson, Chief Executive 
Officer, Women's Heart Alliance.]
                                 ______
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