[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
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DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2014
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
________
SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES,
EDUCATION, AND RELATED AGENCIES
JACK KINGSTON, Georgia, Chairman
RODNEY ALEXANDER, Louisiana ROSA L. DeLAURO, Connecticut
MICHAEL K. SIMPSON, Idaho LUCILLE ROYBAL-ALLARD, California
STEVE WOMACK, Arkansas BARBARA LEE, California
CHARLES J. FLEISCHMANN, Tennessee MICHAEL M. HONDA, California
DAVID P. JOYCE, Ohio
ANDY HARRIS, Maryland
NOTE: Under Committee Rules, Mr. Rogers, as Chairman of the Full
Committee, and Mrs. Lowey, as Ranking Minority Member of the Full
Committee, are authorized to sit as Members of all Subcommittees.
Susan Ross, John Bartrum, Allison Deters,
Jennifer Cama, and Lori Bias,
Subcommittee Staff
________
PART 6
Page
Health and Human Services Public Health and Research
Organizations..................................................... 1
Addressing Social Security Administration's Management Challenges
in a Fiscally Constrained Environment............................. 269
Children's Mental Health......................................... 335
Budget Hearing--Department of Health and Human Services.......... 413
S
________
Printed for the use of the Committee on Appropriations
?
Part 6
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION,
AND RELATED AGENCIES APPROPRIATIONS FOR 2014
?
?
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2014
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
________
SUBCOMMITTEE ON THE DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES,
EDUCATION, AND RELATED AGENCIES
JACK KINGSTON, Georgia, Chairman
RODNEY ALEXANDER, Louisiana ROSA L. DeLAURO, Connecticut
MICHAEL K. SIMPSON, Idaho LUCILLE ROYBAL-ALLARD, California
STEVE WOMACK, Arkansas BARBARA LEE, California
CHARLES J. FLEISCHMANN, Tennessee MICHAEL M. HONDA, California
DAVID P. JOYCE, Ohio
ANDY HARRIS, Maryland
NOTE: Under Committee Rules, Mr. Rogers, as Chairman of the Full
Committee, and Mrs. Lowey, as Ranking Minority Member of the Full
Committee, are authorized to sit as Members of all Subcommittees.
Susan Ross, John Bartrum, Allison Deters,
Jennifer Cama, and Lori Bias,
Subcommittee Staff
________
PART 6
Page
Health and Human Services Public Health and Research
Organizations..................................................... 1
Addressing Social Security Administration's Management Challenges
in a Fiscally Constrained Environment............................. 269
Children's Mental Health......................................... 335
Budget Hearing--Department of Health and Human Services.......... 413
S
________
Printed for the use of the Committee on Appropriations
________
U.S. GOVERNMENT PRINTING OFFICE
86-214 WASHINGTON : 2014
COMMITTEE ON APPROPRIATIONS
HAROLD ROGERS, Kentucky, Chairman
C. W. BILL YOUNG, Florida \1\ NITA M. LOWEY, New York
FRANK R. WOLF, Virginia MARCY KAPTUR, Ohio
JACK KINGSTON, Georgia PETER J. VISCLOSKY, Indiana
RODNEY P. FRELINGHUYSEN, New JerseyJOSE E. SERRANO, New York
TOM LATHAM, Iowa ROSA L. DeLAURO, Connecticut
ROBERT B. ADERHOLT, Alabama JAMES P. MORAN, Virginia
KAY GRANGER, Texas ED PASTOR, Arizona
MICHAEL K. SIMPSON, Idaho DAVID E. PRICE, North Carolina
JOHN ABNEY CULBERSON, Texas LUCILLE ROYBAL-ALLARD, California
ANDER CRENSHAW, Florida SAM FARR, California
JOHN R. CARTER, Texas CHAKA FATTAH, Pennsylvania
RODNEY ALEXANDER, Louisiana SANFORD D. BISHOP, Jr., Georgia
KEN CALVERT, California BARBARA LEE, California
JO BONNER, Alabama ADAM B. SCHIFF, California
TOM COLE, Oklahoma MICHAEL M. HONDA, California
MARIO DIAZ-BALART, Florida BETTY McCOLLUM, Minnesota
CHARLES W. DENT, Pennsylvania TIM RYAN, Ohio
TOM GRAVES, Georgia DEBBIE WASSERMAN SCHULTZ, Florida
KEVIN YODER, Kansas HENRY CUELLAR, Texas
STEVE WOMACK, Arkansas CHELLIE PINGREE, Maine
ALAN NUNNELEE, Mississippi MIKE QUIGLEY, Illinois
JEFF FORTENBERRY, Nebraska WILLIAM L. OWENS, New York
THOMAS J. ROONEY, Florida
CHARLES J. FLEISCHMANN, Tennessee
JAIME HERRERA BEUTLER, Washington
DAVID P. JOYCE, Ohio
DAVID G. VALADAO, California
ANDY HARRIS, Maryland
----------
1}}Chairman Emeritus
William E. Smith, Clerk and Staff Director
(ii)
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED
AGENCIES APPROPRIATIONS FOR 2014
----------
Tuesday, March 5, 2013.
HEALTH AND HUMAN SERVICES PUBLIC HEALTH AND RESEARCH ORGANIZATIONS
WITNESSES
PATRICK CONWAY, M.D., DIRECTOR, CENTER FOR CLINICAL STANDARDS AND
QUALITY, REPRESENTING MEDICARE AND MEDICAID INNOVATION
FRANCIS S. COLLINS, M.D., PH.D., DIRECTOR, NATIONAL INSTITUTES OF
HEALTH
TOM FRIEDEN, M.D., M.P.H., DIRECTOR, CENTERS FOR DISEASE CONTROL AND
PREVENTION
CAROLYN M. CLANCY, M.D., DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY
MARY WAKEFIELD, PH.D., R.N., ADMINISTRATOR, HEALTH RESOURCES AND
SERVICES ADMINISTRATION
Mr. Kingston. Good morning. I welcome everyone to the first
hearing for the year for Labor, Health and Human Services,
Education, and Related Agencies. We look forward to a good and
vigorous hearing schedule. We will actually, you know, finish
up, we think, in April. So we will go at a pretty fast clip. We
will have a second hearing this week.
We are starting this hearing without the White House
budget. The House budget, of course, has not been passed
either, but we are going to go ahead and get to work on it.
We want to have good and nonpartisan hearings. We want to
learn all about the agencies, and we want to have a good
relationship with the agencies not necessarily always agreeing,
but always communicating and there will be a lot of back and
forth. And we know that you answer to lots and lots of
constituencies, as do we. And so as we are hearing the outside
noise and getting all kinds of advice, we will just work
together in the best way we can.
I had mentioned to the panelists earlier that we are
concerned about reprogramming, making sure that in this tight
environment now that there is flexibility but also that we are
not over-abusing reprogramming. And we want all the agencies to
review programs and propose eliminations in terms of
duplications and erring and straying from the normal mission
statements, and we will talk more about that during the
hearing.
At today's hearing, we will have the panelists from five of
the key HHS organizations and those witnesses are Dr. Patrick
Conway, Director of the Center for Clinical Standards and
Quality and CMS Chief Medical Officer, who is here to represent
and discuss the mission of CMS Innovation Fund activity; Dr.
Francis Collins, Director of the National Institutes of Health;
Dr. Tom Frieden, Director of the Centers for Disease Control
and Prevention; Dr. Carolyn Clancy, Director of the agency for
Healthcare Research and Quality, who has recently announced she
is going to be stepping down in the coming months. I do not
know what you will be doing with your time, but I know you will
find lots of it after that job. Dr. Mary Wakefield, who is the
Administrator of Health Resources and Services Administration.
So this is the first time that we will receive an overview
from the full group of you at once. So we are excited about
that. And I am looking forward to this.
We will ask you to have your opening statements in 3
minutes. If you have to go a little bit longer, we will go
maybe 3 and a half, but that will be about it. And then we will
jump into Q&A.
With that, I yield to my good friend and ranking member,
Ms. DeLauro.
Ms. DeLauro. Thank you very much, Mr. Chairman. And I am
proud to join you here today and obviously welcoming our
speakers and waiting for their testimony today.
Just a very, very quick word, and I am going to apologize
to the audience for this, but a week ago we had a wonderful
gathering with staff and members to get acquainted with what
the chairman proposed. And at that time, I was not able to
bring any Italian pastry from New Haven, Connecticut, but I
have got to say for staff and for the witnesses, there is
Italian pastries from the Libby's Bakery on Olive Street in New
Haven, Connecticut. To the audience, my apologies. [Laughter.]
Ms. DeLauro. Today we will review the mission and the
programs of several of the major health agencies under the
purview of the subcommittee. It is my hope that the discussion
will serve to demonstrate the irrationality of the budget
policies currently being pursued by the House majority. The
agencies here today accomplish work that is critical to the
health of all of us. This includes the basic medical research
by the NIH, the CDC's efforts to detect and control dangerous
diseases, HRSA's programs to expand access health care, the
Agency for Health Research Quality, AHRQ's, work to improve the
quality of health care. It includes the research and the
demonstration work at CMS that tries to develop ways of
delivering better and more effective health care at the same or
lower cost.
Much of the work is vital to the health of the economy. For
example, independent of all of the many health benefits, NIH
research is vital to maintaining our Nation's leadership in
emerging fields like biotechnology. That means good jobs and
economic growth. According to one estimate, every dollar
invested in the NIH generates well over $2 in economic
activity.
Many of the things these agencies do also help to reduce
health-related costs while improving health. For example, AHRQ
studies how to deliver health care more effectively, and both
AHRQ and NIH sponsor research into which treatments work best
for which patients. CDC supports screening for diseases like
cancer and HIV, education and outreach to help people better
manage chronic conditions like diabetes and asthma, and efforts
to expand immunizations that can prevent serious infectious
diseases. HRSA works to expand the availability of primary care
in underserved rural and urban communities, care designed to
find and treat problems before they become crises. HRSA also
works to expand the number of health professionals delivering
that primary care in the places that they are most needed.
And despite the importance of these and other missions, the
budgets for many of these programs have seriously eroded over
the last decade. In many cases, funding has failed to keep up
with the costs, and for some programs, funding has been cut in
actual dollar terms.
For NIH, the purchasing power of its appropriation has
dropped about 16 percent since 2003 after adjustment for rising
costs of biomedical research. The number of NIH research
project grants has fallen from a peak of just over 37,000 in
2004 to about 34,000 last year. NIH's work alleviates pain and
saves lives, which is why we worked together in a bipartisan
way to provide the funding that made it the gold standard for
biomedical research not only in the United States but in the
world. But we are now in jeopardy of ceding that leadership to
other countries.
At HRSA, basic health professions training programs have
been cut by $37,000,000 since 2010. That is in actual dollars
before any adjustments for costs or need. Discretionary
appropriations for health centers are down $623,000,000, 28
percent since 2010. Thankfully that cut has been offset with
funds made available through the Affordable Care Act, but the
intended purpose of those funds was to expand sources of
primary care, not to backfill for cuts in appropriation for
ongoing operations. Adjusted for inflation and population
growth, the overall HRSA appropriation has lost $2,000,000,000
in purchasing power since 2002.
CDC. Discretionary funding is down by more than
$700,000,000 since 2010, including the cuts of $149,000,000 to
chronic disease prevention programs, and $104,000,000 to
programs that improve the capacity of State and local health
departments to respond to emergencies.
Under the 10-year caps on discretionary spending that are
already in law, it will be extremely difficult to turn this
situation around. In fact, before the decade is out, the cuts
we have made will take non-defense discretionary spending to
the lowest level as a share of GDP on record, and records go
back 50 years.
Yet, some people are demanding further reductions in caps
which would mean the shortfalls just get worse. And because a
majority refused to act last week, we now have sequestration,
an indiscriminate 5 percent cut to everything on top of all
these cuts that have already been made. The sequester will take
another $1,500,000,000 from the NIH, $325,000,000 from CDC, and
so on. All of this will be bad for the health and the well-
being of American families.
I hope our witnesses today will convey to us what their
agencies do, why it is important, and how their efforts will be
impacted by all of the cuts that are on the table. I thank you
and I look forward to your testimony.
Thank you, Mr. Chairman.
Mr. Kingston. Thank you very much.
Mr. Simpson, Ms. Roybal-Allard, do you have any statements?
With that, Dr. Conway.
Dr. Conway. Chairman Kingston, Ranking Member DeLauro and
members of the subcommittee, thank you for this opportunity to
highlight the efforts of the Centers for Medicare and Medicaid
Services to strengthen public health. As Chief Medical Officer
of CMS and practicing physician and a health services
researcher, I am excited to discuss public health and research.
CMS has been focused on improving the quality of health
care, keeping beneficiaries healthy, and ensuring payments
reward value and excellent care.
While CMS primarily deals with the clinical health care
delivery system, a 2010 Institute of Medicine report noted the
importance of integrating the clinical delivery system with the
public health system. CMS has multiple programs to support this
integration. Today I will specifically discuss three areas: new
payment initiatives aimed at improving quality while lowering
cost; quality measurement and improvement; and data to support
research into public health.
Through the Innovation Center, CMS has launched numerous
innovative care delivery models designed to improve
beneficiaries' health outcomes and reduce costs. The 30-day
all-cause readmission rate has dropped from approximately 19
percent or more for many years to 17.8 percent in the last
quarter of 2012. This decrease is an early sign that our
payment delivery system improvements are having an impact.
In 2012, we launched Medicare Accountable Care
Organizations, groups of providers working together to redesign
care processes for high quality and efficient care delivery. To
date, there are more than 250 Medicare ACO's in operation
serving about 4,000,000 beneficiaries in almost every State.
Our Innovation Center is selecting and testing the most
promising innovative payment and service delivery models and
can expand those that are successful. Some of the models being
tested are intended to reduce unnecessary hospital admissions
among residents of nursing homes, improve care coordination for
beneficiaries with end-stage renal disease, decrease premature
births, and incentivize primary care providers to offer high
quality coordinated care.
The Innovation Center has also partnered with the CDC to
launch the Million Hearts Initiative, which is focused on
preventing a million heart attacks and strokes over 5 years.
Million Hearts has engaged partners across the Nation. It
includes both clinical and community health goals. It has the
potential to help Americans live longer and healthier lives.
Next I will discuss quality measurement and improvement.
CMS funds numerous initiatives in all 50 States focused on
improving the quality and the health of all Americans. Quality
improvement organizations are working with physician practices
to help these practices improve the health of their patients.
Through large-scale learning networks, QIO's accelerate the
pace of change and rapidly spread best practices. Some of the
QIO current initiatives include contributing to reductions in
hospital-acquired conditions, working with nursing homes to
reduce pressure ulcers, and boosting population health by
improving the use of EHR's to increase preventive services.
Consistent with the national quality strategy, CMS is
implementing quality measures related to population health and
prevention across its programs. Examples include influenza and
pneumonia vaccination and smoking cessation.
CMS has also launched health care-acquired infection
measures in numerous quality reporting and payment programs.
AHRQ, under Dr. Carolyn Clancy's leadership, has played a
leading role in developing the evidence base and funding
quality improvement science on how to decrease HAI's that we
have collaboratively scaled nationally. We have benefitted from
Tom Frieden and CDC's collaboration on reliable measurement of
HAI's, supporting public reporting and links to State and local
public health departments. Nationally this work, in
collaboration with hospitals and other stakeholders, has led to
a greater than 40 percent reduction in central line blood
stream infections, meaning thousands of lives saved.
Finally, I will discuss data support research and public
health. CMS is providing data to support health services
research and the improvement of public health. CMS has launched
a new office to provide data to health services researchers, as
well as public use files for easy download. CMS has implemented
an initiative requiring the provision of claims data to
qualified entities across the country for the evaluation of
performance and to support transparency efforts.
In conclusion, CMS is taking major steps to help transform
the delivery system to achieve the best possible health
outcomes for all Americans. While CMS is an agency that
primarily deals with the clinical delivery system, we
understand that the integration of the clinical delivery system
and the public health infrastructure will allow our overall
health system to be more effective and efficient and, most
importantly, to improve the health of all Americans.
Thank you.
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Mr. Kingston. Thank you, Dr. Conway.
Dr. Collins.
Dr. Collins. Good morning, Chairman Kingston, Ranking
Member DeLauro, and members of the subcommittee. This
subcommittee has long supported NIH's mission and we are happy
to be here with you with our distinguished colleagues this
morning.
Our mission is to seek fundamental knowledge and apply it
in ways that enhance human health, lengthen life, and reduce
suffering.
NIH is the world's leading supporter of biomedical research
in the world, investing more than $30,000,000,000 annually in
medical research for the American public. In fiscal year 2012,
about 84 percent of NIH's appropriation supported scientists in
all 50 States. NIH-funded advances in basic and translational
science have fueled a revolution in the diagnosis, treatment,
and prevention of disease. Let me share just three of our many
stories of success.
First, the mortality rate due to stroke is less than a
third of what it was in 1950. Less than a third, and it is
still continuing to decline.
Second, since the mid-1990's, U.S. cancer death rates have
fallen about 1 percent each year. Each percentage drop saves
our Nation an estimated $500,000,000.
Third, a diagnosis of HIV/AIDS is no longer a death
sentence but is now compatible with an almost normal lifespan.
In fact, you may have recently seen in press reports (about a
very special two-and-a-half-year-old in Mississippi) that HIV/
AIDS may even in some instances be curable. With effective
prevention and treatment strategies, an AIDS-free generation
may truly be within our grasp.
Innovation in medical research not only saves lives, it
sparks economic growth, strengthening our global
competitiveness. In fiscal year 2011, NIH research supported an
estimated 432,000 jobs across the country, and directly spawned
more than $62,000,000,000 in new economic activity.
What is more, discoveries arising from NIH research serve
as the foundation for our Nation's biotech and pharmaceutical
industries which employ another 7,500,000 U.S. citizens.
But NIH does much more than stimulate our economy.
Groundbreaking innovations are now happening at an accelerating
and breathtaking pace. Time is short, so I will just mention
one.
We just passed through our annual health challenge called
influenza. In an average year, the flu claims about 24,000
American lives and costs the U.S. economy about
$87,000,000,000. But it does not have to be that way. The
outside of the flu virus, if you look at it under an electron
microscope, is studded with these tiny nail-shaped proteins.
Current vaccines target the head of the nail which is
constantly mutating. So to keep up, a new vaccine has to be
produced each year, requiring people to get an annual flu shot.
And despite best efforts, the vaccine is not always ideal, and
each year many Americans go unvaccinated.
In collaboration with our CDC colleagues, NIH is working on
a universal flu vaccine that would protect people against
virtually all strains of the flu for extended periods of time.
The goal is to teach the immune system to ignore the head and
target the stem of that viral protein because that part of the
virus remains relatively unchanged from strain to strain. This
would protect us from multiple flu strains and eliminate the
need for an annual flu shot. It could also help protect against
a future global influenza pandemic. This universal flu vaccine
is not science fiction. Early clinical trials are already under
way.
In closing, I just want to thank you for holding this
hearing, and I welcome any questions the subcommittee members
may have.
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Mr. Kingston. Thank you very much.
Dr. Frieden.
Dr. Frieden. Mr. Chairman, Ranking Member DeLauro, members
of the subcommittee, thank you so much for this opportunity to
discuss CDC's unique role working 24/7 to protect Americans
from health threats. I am honored to be Director of the CDC at
a time of both particular vulnerability and the crucial window
of opportunity for health progress.
CDC is at the forefront of finding and stopping the spread
of threats to health, whether they are things like Ebola or
antivirus or emerging problems in this country. We respond to
emergencies, including by deploying resources within hours, as
we did for Superstorm Sandy.
CDC also provides childhood vaccines, many of them
developed through NIH's research. This program has been a
stunning success saving millions of lives and billions of
dollars. Each year we estimate that the childhood vaccines we
give prevent 42,000 deaths, save more than $13,000,000,000 in
health care costs, and return nearly $70,000,000,000 to the
economy.
Because we have worked to find these disease outbreaks
where they emerge and stop them before they spread, we invest
heavily in supporting State and local entities. And in fact,
most of our budget goes to support work in your communities. We
have staff in all 50 States and funding to all 50 States.
To give you two examples of this, during the deadly
listeria outbreak in 2011, it was CDC's supportive work at the
Colorado Health Department that identified the listeria in
cantaloupe, which had never been found before, within days, got
the product off the shelves. And we know that even a slight
delay could have doubled what was already one of the most
deadly outbreaks that we have seen.
Similarly, last year, we had a fungal meningitis outbreak
which has now affected more than 700 people and killed 48. That
infection was identified first by a CDC-trained epidemiologist
in Tennessee working with her CDC-funded staff to identify the
problem. It was then identified in the laboratory in Virginia
by a staff person who had been trained by CDC. We at CDC had
our laboratorians, who are state-of-the-art scientists, work
around the clock to develop a PCR test for this rare infection.
We have done about 1,000 of them. We also worked with health
departments in 23 States to inform 14,000 patients that they
had been exposed, and we convened daily conference calls to
give doctors the best advice that they could have to take the
best possible care of their patients. The result was fewer
serious infections, fewer deaths, lower health care costs, and
a lot of suffering avoided.
Microbes evolve in minutes, and we at CDC work to keep pace
with them using scientific breakthroughs such as analyzing the
microbial genome to find outbreaks sooner and stop them
earlier. Most U.S. health care costs are spent treating
preventable conditions. CDC promotes evidence-based prevention
initiative as the most effective, common sense way to improve
health and reduce health care costs.
Most of the information you see about the health status of
the U.S. comes from CDC. We have a unique role in definitive
health monitoring used by doctors, businesses, insurers and
others.
We also prevent health threats that begin overseas from
reaching our borders. The movie ``Contagion'' was fiction, but
in real life, our scientists and disease detectives have
investigated more than 1,000 outbreaks and identified at least
five new organisms in recent year. These outbreaks include
organisms that are resistant to just about all antibiotics such
as extensively drug-resistant tuberculosis and organisms that
kill most of the people they infect like hemorrhagic fevers.
CDC is unique. No other organization in the world has our
capacity to detect and respond to outbreaks. No other
organization in the world leads an interconnected global
network at the cutting edge of health security with disease
detectives in labs to keep people safe from food-borne illness,
bio-security threats, and other health threats.
In sum, CDC puts science into action to saves lives today,
prevent illness tomorrow, and increase our productivity. I am
honored to work at CDC.
I am happy to answer your questions.
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Mr. Kingston. Thank you, Dr. Frieden.
Dr. Clancy.
Dr. Clancy. Good morning, Chairman Kingston and Ranking
Member DeLauro, and members of the subcommittee. I am very
pleased to be here to discuss the role that AHRQ plays in
creating a health care system in which the care provided is
consistently safe, high quality, and affordable.
AHRQ is the only Federal agency whose sole mission is
improving health care. AHRQ supports research that builds a
solid evidence base on how to make care safer and of high
quality. We work with our partners, which include providers,
patients, hospitals, States, and other Federal agencies like my
distinguished colleagues, to get these lessons implemented into
practice.
For example, today we are releasing a report identifying
the top 10 patient safety strategies ready for immediate use.
This report provides a clear road map for high priority areas
where the health care system is failing, and these 10
strategies, if widely implemented, have the potential to vastly
improve patient safety and save lives.
Today I would like to highlight our efforts related to
health care-associated infections. AHRQ supports practical
studies to help eliminate infections in the real world. We
translate this research into practical solutions that have
saved lives and lowered health care costs. For example, an
AHRQ-funded project had very gratifying results, and Dr. Conway
mentioned a moment ago how that had been scaled up, courtesy of
the Innovation Center. But in our project the over 1,100
intensive care units nationwide that implemented this program
achieved a 41 percent reduction in the rate of these deadly
infections, saving over 500 lives and avoiding more than
$36,000,000 in excess costs. Neonatal ICU's saw a 58 percent
reduction in these infections, avoiding 41 infant deaths and
more than $2,000,000 in health care costs.
So our research helps the health system where the rubber
meets the road by outlining how to spread and implement proven
methods of infection prevention and on the impact prevention
efforts.
Two other unique areas for us in patient safety include
work to support the development and use of health care teams.
Health care professionals often speak of teams metaphorically.
In fact, they have had no training in how to do that. And this
training has now literally been part of every military health
care facility worldwide and a vast number of civilian hospitals
in this country. The other area is in the use of simulation to
make care safer. Everyone should be able to have a surgical or
other procedure without having to think about am I the first
person here, confident that their clinician has been well
trained and practiced in a laboratory.
Armed with critical information from the Centers for
Disease Control about these infection rates and AHRQ's
practical evidence-based solutions to reducing these
infections, CMS has used payment incentives to help establish a
new normal for hospitals and other settings. My colleague,
Jonathan Blum from CMS was here speaking to the Senate last
week about the tangible results that Medicare patients have
seen right now.
Ensuring that patients are not harmed when they receive
health care services is a shared goal among AHRQ and its sister
agencies, and we each play specific but interrelated roles in
making sure that happens. Each piece of the puzzle needs to be
completed and connected for health care to improve.
Mr. Chairman, thank you again for inviting me to discuss
AHRQ's efforts to make health care safer. I appreciate this
opportunity and look forward to answering any questions.
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Mr. Kingston. Dr. Wakefield.
Ms. Wakefield. Thank you, Mr. Chairman and Ranking Member,
for the opportunity to highlight the important work of the
Health Resources and Services Administration.
While some may not be familiar with HRSA, they nevertheless
often know about the organizations that we support in their
local communities and States. They know, for example, their
local community health center, their colleges' health care
workforce training programs. They might know about the poison
control centers that are called in emergencies, among other
programs that we support.
Across the Nation in every State and in almost every
congressional district, more than 3,100 local nonprofits,
faith- and community-based organizations receive HRSA grants
that enable them to provide health care to millions of people
to train the next generation of health care providers and to
maintain and even strengthen the health care safety net.
HRSA's investments in communities and States are important,
both for the people who are served and for local economies. For
example, our funding to community health centers enables 8,900
primary health care clinics to provide care to more than
20,000,000 people. And health centers are also important local
economic engines, employing more than 138,000 people from
doctors and dentists to medical assistants and receptionists.
On another front, the number of National Health Service
Corps clinicians has increased to an all-time high, providing
health care in some of our most underserved urban and rural
areas. Today, nearly 10,000 corps providers are impacting the
health of over 10,000,000 patients and in the process impacting
the economic health of the communities where they work.
Many of HRSA's programs are a lifeline for some of
America's most vulnerable people. Funding through the Ryan
White Program means that more than half a million people with
HIV/AIDS have access to lifesaving services.
We support the Nation's Organ Procurement and Transplant
Network, and Congress has given HRSA the extraordinary
challenge to help meet growing demands for this gift of life.
And HRSA's support of maternal and child health programs
has helped reduce infant mortality in the United States.
HRSA's investments also seed local innovations that can
grow to improve health across the Nation. For example, in terms
of training, Texas A&M's nursing school is using funds to help
veterans build on their military training and move more swiftly
into health careers, and we are working to expand those
training initiatives. And rural communities are using HRSA's
outreach grants to support approaches like mobile dental
clinics to reach more people who do not have access to oral
health care.
Finally, across all of HRSA's programs, we are working to
implement new ways to improve the quality of our agency's work,
from developing new tools for fiscal monitoring and oversight
to using the latest technologies to educate both our staff and
grantees on fraud and waste.
Thank you again, Mr. Chairman, for the opportunity to speak
about our programs and I welcome questions.
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POLIO ERADICATION
Mr. Kingston. Thank you very much, and I thank all of you
for being prompt and quick.
The only thing I am very disappointed about is my friend,
Tom Frieden, did not brag about the polio success, and if you
know those stats off the top of your head or if you have
somebody who can get them out, I think it would be good to
share with the folks real quick. I think it is something that
really is a modern miracle that we are taking for granted, and
it is the work of CDC and Rotary International and so many
other people.
Dr. Frieden. In 1988, CDC and three other partners led an
effort endorsed by the World Health Organization to eradicate
polio forever. At that time, there were about 350,000 cases per
year. That is about 1,000 a day. Polio eradication activities
have benefitted from the support from Rotary International
which has generated more than $1,000,000,000 in support, as
well as supporting the programs around the world. UNICEF and
WHO have been critical partners, and CDC has spearheaded this
for the U.S.
What we have seen is that last year there were just a
little over 200 cases, the fewest there have ever been in the
fewest districts of those countries. And a couple of years ago,
India got over the finish line through an enormous effort and
has not had a case in more than 2 years. So we are closer than
ever to polio eradication. Cases only remain spread in Nigeria,
Pakistan, and Afghanistan.
Mr. Kingston. A great success story.
END OF LIFE CARE
Dr. Conway, I wanted to ask about--and I am not sure that
this comes directly into your sphere of control and study, but
on end of life, what percentage of the Medicare budget is spent
in the last 3 months or 2 months of a patient's life? Do you
know? I have heard it is very high.
Dr. Conway. So I will have to get back to you with an exact
number. The percentage on end-of-life care is significant in
the last 12 months of life. I believe around 20 to 25 percent.
We will get back to you on an exact number on that. And other
colleagues may jump in.
I think at CMS I would highlight that we are committed to
high quality care. We are committed to engaging patients and
families in decision-making. In our quality programs, we
increasingly have quality measures around patient and family
care just to make sure we meet the goals of patients and
families.
Mr. Kingston. And I think what my question would be when
you get back to me is the living will. What is the correlation
between having a living will and not spending as much and
spending a lot not having a living will and what are the
impacts of it? So if that comes under your silo, that would be
very helpful.
Dr. Conway. Yes, sir. We will have to get back to you with
the specifics on that.
[The information follows:]
Dr. Conway: Yes, sir. In CY 2011, spending in the last six
months of life represented about 17% of total spending in
Medicare Parts A and B. CMS does not track utilization of
living wills by beneficiaries.
Mr. Kingston. Okay.
HEALTH SERVICES RESEARCH
And then I have a general question for all of you. In terms
of the health services research, NIH has that under its
jurisdiction and has had about a 58 percent increase in budget
authority since 2008 on it. And yet, AHRQ spends $400,000,000
on it, and CMS Innovation Fund and CDC all have components of
health services research in it. So there is overlap, and how
much of it is duplicative? How well do you coordinate, and how
committed are you in terms of, okay, if you are doing that, we
will do this? We both can join in the middle. But for the time
being, we do not all have to be on a parallel track spending
dollars doing the same thing.
Dr. Collins. Thank you for the question. I will start and
others, no doubt, will want to pitch in.
I do think you raise a very important question. Obviously
we are critically interested in discovering which kinds of
interventions are actually going to produce the best outcomes
in real-world situations. NIH's role in this generally is to
conduct large-scale, randomized clinical trials to assess what
works and to be able to get that information in front of
caregivers and the public.
So take, for instance, the question about atrial
fibrillation, a common form of a cardiac arrhythmia where there
have been serious questions about exactly what is the right
approach. Is this something where you should try to convert
this using some sort of electrical shock? Should you just
basically treat with anticoagulants in order to reduce the risk
of stroke? NIH is in the position to then conduct a randomized
trial where individuals are assigned to one of those outcomes
by their full informed consent and try to see on the large
scale what the outcomes look like. But those are very carefully
controlled situations. Patients need to be free of other kinds
of complicated features, otherwise we are not sure we are
getting a clear answer.
On the other hand, AHRQ--and Carolyn Clancy no doubt will
want to talk about this--will conduct broad-scale analysis of
all of the many studies that have been done in this space to
try to see if you put those all together, many of those
observational, not necessarily interventional, can you draw
conclusions in that regard.
CDC has a critical role working with the States and the
public health agencies to try to then implement whatever seems
to be best practices.
We have been working closely with CMS in the last year and
a half, meeting every quarter with their senior staff, to look
at ways that the Innovation Center can also step in here.
So I think we are actually working pretty closely together.
It is a very complicated landscape in terms of this kind of
research.
Mr. Kingston. Dr. Clancy, unfortunately, we are running out
of time. So we will get back to you on it.
Dr. Clancy. If I could just make one point on our budget,
if anyone is spending a nickel that we might have spent, we
make sure that we find out about it.
Mr. Kingston. Good.
Ms. DeLauro.
Ms. DeLauro. Thank you very much, Mr. Chairman.
And I would just say to all of you, you just continue to--
and I listened to your testimony--reinforce what my view was
all along, that the agencies that you head up and what you are
charged with, quite frankly, is giving the gift of life. And
for that, we are so grateful for the work that you do.
SEQUESTRATION
As you know, the President implemented the sequestration
order. He was required to do that by the Budget Control Act.
What I would like to do is to ask the directors of NIH, CDC,
and HRSA what actions will you be required to take as a result
of the across-the-board budget cuts. What effect will there be
on your ability to carry out your agency's missions? Dr.
Collins, if you could begin.
Dr. Collins. Certainly. So the sequestration order results
in a 5 percent cut to our fiscal year 2013 budget already now
well into the fiscal year, total dollars, $1,545,000,000 that
are now not going to be available for support of research. And
of course, we are concerned about that for this year. We are
particularly concerned about that in the sense that there is a
potential that this could go on for as long as a decade, and
then you could compound the consequences of this.
There are many consequences, but if I could just mention
the one that worries me the most. It is the impact on young
scientists who are looking at this circumstance and wondering
whether there is a career path for them. In a situation where
your ability to get funded by the NIH, which is the main source
of medical research in this country, has been already getting
deteriorated over the course of the last 10 years so that now
an applicant has only one chance in six of getting funded, that
will drop further as a result of the sequester. And if you are
a person in high school or college and you are looking at
medical research as a career and you are seeing those
statistics, how many of those folks will be able to stick it
out? And how many of the ones that are already in training
careers are going to get exhausted by the frustration and
decide to do something else? That is our seed corn. It has been
the strength of America. It is the biomedical research
community, their creativity, their innovative instincts, and we
are putting that at serious risk as we see this kind of
downturn in the support for research.
Ms. DeLauro. Dr. Frieden.
Dr. Frieden. The threats to our health are not decreasing
by 5 percent. So the cut of 5 percent in CDC's budget means
that we will have roughly $300,000,000 less. About two-thirds
of our dollars go out to State and local entities. They are
already, as one health commissioner describes it, at the
breaking point which through State and local reductions, there
are 45,000 fewer staff working at that level. That means our
support will be able to provide assistance to State and local
entities to hire perhaps as many 2,000 fewer disease control
experts, disease detectives. We will have less money for flu,
less money for HIV, less money to protect our children through
things like fluoridation, autism research, asthma prevention,
and decreased ability to detect and respond to outbreaks. This
will cut our outbreak control staff by more than $12,000,000,
and also a decreased ability to keep us safe from global
threats because we will have to cut back on our work in other
countries to find threats before they come to our borders.
Ms. DeLauro. Dr. Wakefield.
Ms. Wakefield. So the overwhelming amount of money that
HRSA receives is then used to support grants that go directly
out to local communities and the States. We have 80-plus
programs and that 5 percent cut will be taken across each of
those programs, policies, and activities. That is the
requirement. So each one will have a 5 percent cut.
You can look at the impact in any one program, but I will
just give you one example. Our ADAP program, AIDS Drug
Assistance Program, as part of our Ryan White Program, will see
a cut to that program as a result of the rescission of about
$45,000,000. That will mean that the ADAP program can serve
about 7,400 fewer patients.
We could not tell you right now, because we are still
working on the numbers, what States would be impacted or where
this might then drive up waiting lists. But what I can tell you
is that since 2011, the fall of 2011, that was sort of our high
water mark. The waiting list to get on the ADAP program across
States had really peaked to about 9,300. And do you know just
within the last couple of months, we have gotten that waiting
list down to 63 people. That is it in two States. And so now
what is going to happen is likely we will see that waiting list
start to expand, go that direction again. What will happen then
in local States? Well, States are going to have to scramble.
Case managers will have to scramble to try and find patient
assistance programs that will be able to accommodate those
patients. And that means that those costs then will be shifted
to manufacturing, drug manufacturing companies, et cetera to
try and provide those resources, pharmaceutical resources, for
those patients.
That is just one example. But cuts proportionate to each
one of our programs.
Ms. DeLauro. Thank you very much for the time.
Mr. Kingston. Mr. Simpson.
Mr. Simpson. Thank you, Mr. Chairman.
And I thank all of you for being here today. This is the
first time I have ever seen where we have five doctors. It is
kind of intimidating for all of us to have all these doctors on
the panel.
But I have several questions that, as you might expect,
deal with dentistry to some degree but I am not going to ask
most of those because they deal with the budget that is not out
yet, so we do not have a chance to do that. I have been to most
of these places, but I will tell you for any of the Members of
Congress that want to see what Government does and does right,
they need to get out to some of these agencies and see what
goes on. I have been out to NIH several times. It has been a
couple years since I have been there. I need to get back out
there because it is just awe-inspiring what goes on in these
programs.
And I would be remiss if I did not thank Dr. Frieden for
maintaining the oral health division as we have talked about
over the last couple years. It has been one of your smallest
divisions, but they obviously play an important role in
dentistry.
PHS EVALUATION FUNDS
Now, let me turn to a question with several statements to
start with. The HHS Secretary is authorized to tax or as HHS
refers to it, ``tap'' PHS Act-authorized programs up to 1
percent of their appropriation in order to conduct program
evaluations. The administration has requested language to
increase the tap over time.
The fiscal year 2013 budget we can talk about because it
was last year--the budget request attempted to take tap to 3.2
percent, or $1,300,000,000 of the resources. The House bill
reduced tap to the authorized level of 1 percent last year.
The public perception is that NIH received $30,600,000,000
in fiscal year 2012 and that NIH is using $30,600,000,000 for
biomedical research. But because NIH is subjected to the tap,
over $700,000,000 was shifted to other activities within HHS
outside of NIH, in essence allowing HHS to count the funds
twice. In fact, the fiscal year 2013 President's budget
request, once adjusted for tap increases, actually proposes to
cut NIH by about $250,000,000. So NIH would have only about
$29,600,000,000 last year to spend on biomedical research under
the President's proposal.
In addition, HHS recently began to expand its definition of
what programs are subject to tap to include mandatory programs
which effectively results in the conversion of mandatory funds
to discretionary funds. The intent of this authority is to
provide the support for program evaluations.
I know in fiscal year 2012, CDC received over $370,000,000
of tap funding while AHRQ received $400,000,000 in tap funds.
Can you explain to me how much of these funds are actually
going to program evaluation and how much of them are going to
expanded programs? And why does it need to be 3.2 percent, as
requested by the administration, as opposed to the 1 percent
which decreases the amount we are actually spending on
research?
Dr. Clancy. So it is my understanding, Mr. Simpson, that
the actual tap is something that was a decision made by the
Congress, which is why AHRQ is funded out of that tap. I am
less familiar with----
Mr. Simpson. At 1 percent.
Dr. Clancy. And AHRQ has had a significant proportion of
its budget funded by that 1 percent tap since 2003 and even
before 2003, since the agency was created in 1989, and since
2003, it has been all of the evaluation tap.
Frankly, this has not been our decision. Our commitment has
been to make sure that American taxpayers get the best value
and return on that investment.
Mr. Simpson. Could you tell me how much of those funds are
actually in program evaluation?
Dr. Clancy. Well, what I can tell you is that almost every
study that we invest in--about 80 percent of the money goes out
the door to universities, to research firms, and so forth--is
actually evaluating various aspects of how health care is
delivered and how we could make it better. So I think to some
extent that depends on the definition of program evaluation.
Dr. Frieden. The resources that are used from the
evaluation funds at CDC include the National Institute for
Occupational Safety and Health, the National Center for Health
Statistics, and some of the basic surveys that all of HHS
benefits from. So, for example, our National Health and
Nutrition Examination Survey receives funds from many other
parts of the Federal Government and coordinates that work so
that we do not have to do it in multiple places but can get
definitive information that the entire Government can use to
evaluate programs.
Mr. Simpson. Is the 3.2 percent requested in the last
budget request by the administration a necessary increase, or
is the 1 percent sufficient? And will the sequestration affect
the tap funds or not?
Dr. Clancy. Yes, it will.
Mr. Kingston. The gentleman's time has expired.
We have now been joined by the ranking member, Ms. Lowey,
and we would like to yield the floor to you.
Mrs. Lowey. Well, thank you very much, Chairman Kingston
and Ranking Member DeLauro. This is one of my most favorite
places to be because of all the good work you do, and I have
had the opportunity to interact with so many of you and I thank
you. And I remember when we first were looking at the genome
map and it was blank, and now it is just extraordinary. So
thank you, thank you. I am in awe of your commitment and your
hard work. Thank you.
As we listen to the testimony, I hope that all of the
members contemplate the impact to our communities. Extramural
grants fund groundbreaking research, and as Dr. Collins will
testify, every $1 of the NIH funding generates $2.21 in local
economic growth. In 2011, the CDC obligated more than
$473,000,000 in funds to public health initiatives throughout
New York, nearly three-quarters of which was for vaccines for
children and infectious disease programs. These are vital
services that this subcommittee has responsibility to support.
But one of the best ways for me to illustrate the
importance of the work that is led by our witnesses is to
examine HIV programs. This weekend doctors announced that 2-
year-old child born with HIV and treated with the
antiretroviral drugs in the first days of life no longer has
detectable levels of the virus, despite not taking HIV
medication for 10 months. The two pediatric experts who led the
research received funding from the NIH.
Dr. Frieden and I have had numerous conversations about
CDC's significant efforts on HIV both at home and abroad.
HRSA is another leader through the Ryan White Program which
provides medical care, pharmaceutical support services to more
than 500,000 Americans living with HIV/AIDS.
And while AHRQ strives to improve health care for all,
CMS--I know we get tired of these acronyms, but it saves a
couple of minutes----
[Laughter.]
Mrs. Lowey [continuing]. Provides coverage to tens of
thousands of Americans with HIV/AIDS.
Each agency plays an important but distinct role in our
fight against this terrible disease, and these are services
that need greater investments, not cuts.
This is one of many reasons why I hope my colleagues and I
will pass a balanced solution to prevent the full impact of
sequestration.
Thank you. Thank you to our witnesses. I am so
appreciative. And I just want to say in closing--oh, I have got
2 minutes. Okay. [Laughter.]
Mrs. Lowey. I do want to say in closing I was in a meeting
with several of our major hospitals in the New York
metropolitan area, and they were talking to me about how
critical are the hundreds of millions that they get in
research. And I just want to emphasize again it is not just the
research that is saving lives. Whether it is cancer, whether it
is autism, whether it is Alzheimer's or heart disease--we can
go on and on--these are jobs. And when you see what the
sequester will do--it is estimated--and we cannot be fooled
because it is a slope, not a cliff--that it will cost us
750,000 jobs. This research, these investments is economic
development in our future. So I just wanted to emphasize that.
BIOMEDICAL RESEARCH
And perhaps it would be helpful if you share with us how
we, the United States of America--and I always feel we are the
beacon of hope to the world. How long have we been leaders and
will we continue to be leaders? And what investments are other
countries making in biomedical research? I apologize that I
missed the statements. So I will go on to the next question if
they answered that. Would you like to tell me about that in a
minute, 20 seconds?
Dr. Collins. I will tell you a quick story. I am honored to
serve as the chairman of a group, a rather informal one, called
the Heads of International Research Organizations. It is the
major supporters of biomedical research around the world. We
get together every 6 months. It is sort of group therapy, but
it is also an opportunity to talk about our dreams and our
hopes and what our various countries are doing. And when we go
and sit around the table and I hear from South Korea, and I
hear from China, and I hear from India, I hear from Germany, I
hear from the United Kingdom, from Brazil about how they are
ramping up their support of biomedical research because they
have read our playbook and then it comes to me and I say, well,
I hope maybe we could be flat this year, they are shaking their
heads. They are wondering what happened. You are supposed to be
the country that leads us forward. We are learning from you.
Surely you must be able to do something to support this kind of
economic growth as well as health.
Mrs. Lowey. Thank you.
Mr. Kingston. It is hard to stop you. We are just trying to
stay on track.
Ms. Roybal-Allard, you are next. And I want to make sure
everyone knows I am trying to do this in the order of arrival.
NEWBORN SCREENING
Ms. Roybal-Allard. Welcome to all of you.
I would like to direct my first question to Dr. Wakefield.
Congressman Simpson and I have worked together for many years
to promote strong standards in newborn screening, and we are
currently preparing to introduce a bill to reauthorize the
Newborn Screening Saves Lives Act that was signed into law in
2007.
As you know, the Newborn Screening Act codified the
Advisory Committee on Heritable Disorders in Newborns and
Children to help address the vast discrepancy between the
number and quality of State screening tests. The committee's
recommended standards of newborn screening has led to
lifesaving treatments and interventions for at least 12,500
newborns diagnosed with genetic and endocrine conditions each
year.
Congressman Simpson and I are very concerned by HRSA's plan
to disband the Secretary's advisory committee in April. Pompe's
disease was scheduled to be evaluated by the advisory committee
in May. Including a treatable disease on the panel's list for
newborn screening could save approximately 100 babies who
otherwise would die before their first birthday.
Dr. Wakefield, I have a series of questions. I want to try
and get them all in and see if you can respond to them.
First, as a nurse, can you briefly highlight the value of
this advisory committee?
As Director of HRSA, can you tell us what will happen to
the review of diseases such as Pompe's disease if the committee
is disbanded in April?
Does HRSA have an alternative plan to address future
lifesaving screening tests if the committee no longer exists to
make recommendations?
And third, Congressman Simpson and I are working to pass a
reauthorization bill this year, and in the meantime, will you
use the authority of the Secretary of HHS under the Public
Health Service Act to extend the committee charter?
Ms. Wakefield. Sure. Thank you very much for that question.
As you indicated, the Newborn Screening Act needs to be
reauthorized at the end of April, and the Secretary's Advisory
Committee on Heritable Disorders sunsets without that
reauthorization. So what we are doing is going ahead and moving
up more quickly a meeting that will occur before that sunset in
April so that they can continue their work on Pompe's disease,
as you had mentioned that specific illness.
We highly value and hold in high regard the expertise of
the national experts that come from across the United States to
do that really important work of the Secretary's Advisory
Committee on Heritable Disorders. So it is critically
important.
What we are doing right now is to look at the options that
we have available should that law not be reauthorized and
should that committee be sunsetted. We are looking at our
internal options and working through them right now.
Ms. Roybal-Allard. The question is as we are working to
reauthorize the bill, will the Secretary use her authority
under the Public Health Service Act to extend the committee at
least until a decision has been made and we are able to pass
that bill.
Ms. Wakefield. We have had a lot of conversations about
using that authority internally and we are absolutely looking
at that option and looking at how that could be done. I could
not give you specifics because we do not have them yet. But we
are looking at that vehicle as a possibility to extend that
committee. We absolutely are exploring that option right now,
working with counsel and so on. I have been involved in those
meetings myself.
Ms. Roybal-Allard. I know you know this, and I understand
that some of the decision is based on cost savings. But it
would come at a cost of both human suffering, lives lost, and
future costs that would be incurred in having to take care of
those that are affected by these newborn diseases.
Ms. Wakefield. To your point, we do not have another source
of this type of information. It is a critically important
source of experts to us.
Ms. Roybal-Allard. What I will do is I will just yield the
rest of my time and ask my questions in the second round. We
will have second rounds, Mr. Chairman?
Mr. Kingston. Yes.
Ms. Roybal-Allard. Yes.
Mr. Kingston. Thank you.
Mr. Joyce.
Mr. Joyce. Thank you, Mr. Chairman.
I appreciate you all being here today.
BIOMEDICAL RESEARCH WORKFORCE
Dr. Collins, I have heard you express your concern about
the future of biomedical scientists going forward. I was
wondering what NIH is doing to ensure that we have an adequate
supply in the next generation of biomedical scientists and what
we are doing to ensure that we have advanced the translational
and clinical research that they are doing.
Dr. Collins. Thanks. I appreciate the question.
We recently conducted, over a period of about a year and a
half, a fairly detailed analysis of the state of the biomedical
research workforce and particularly the way in which young
scientists are coming to join us. It is clear that there is
great interest out there in young people who are seeing that
science right now is at a remarkable time of discovery and are
interested in participating in it. But it is also clear that
these are not easy times for people coming to join us. People
who are, in fact, trained through graduate school and through
post-doctoral fellowships often do not have an easy time
finding the kind of dream job they were looking for. Over the
last 10 years, the support for biomedical research through NIH,
which is the largest supporter of universities, having lost
about 17 or 18 percent of its purchasing power, many
universities have cut back in terms of their hiring of new
faculty. So many of these highly trained individuals find
themselves taking other kinds of positions. That, of course, is
good. We want to populate other situations in industry, in
teaching, in science policy, and so on.
But clearly we are at a point where there is a bit of a
crisis emerging as the ability to continue to support the
number of individuals that I think would be good for our future
is not quite clearly there anymore. If you are a young person
looking at the situation, I think the consequence of that is
increasing anxiety about whether this is a career path that is
actually going to be one you want to choose.
Young scientists oftentimes, because of this, end up
spending many, many years in training. The average age at which
somebody comes to NIH for their first independent grant and
successfully gets it is age 42. That is not a good picture. We
are basically keeping young talented scientists in less than
independent positions for too long. We are working hard to try
to do something about that. I started a new program that allows
the most independent-minded scientists to go directly from
their Ph.D.'s to an independent position instead of a long
period of post-doctoral training.
The other area that we are very intensely looking at is the
lack of diversity in our workforce. Despite many programs over
many years, we have not achieved a situation where the best and
brightest from all groups are coming to join us. We have a bold
new set of programs to try to make that more appealing for
individuals who traditionally choose other pathways, who do not
have role models from their own communities. And we are
optimistic that is going to change that dynamic, but it is
going to be a long path to make that come true.
Mr. Joyce. Thank you very much. I yield back.
Mr. Kingston. Ms. Lee.
Ms. Lee. Thank you very much.
First, let me just thank all of you so much on behalf of my
constituents, on behalf of my family. On a personal level, my
mother has COPD. My sister has multiple sclerosis. So I know
your work very intimately and I just have to take this moment
to thank you so much because all of you are doing life-
affirming work.
And, Dr. Collins, I just have to say I remember your speech
at the Prayer Breakfast in 2007. I think it was one of the most
profound speeches that I have ever heard from a scientist.
Let me ask you, Dr. Frieden. First, I also thank you for
your work on domestic and global efforts to prevent diseases,
including cancer, hepatitis B, HIV and AIDS which all
disproportionally affect minorities. Your agency is a leader in
many initiatives such as--and I want to call one to your
attention. It is the Racial and Ethnic Approaches to Community
Health. I think it is called the REACH program, which really
aims to eliminate racial and ethnic disparities in health. How
do you anticipate sequestration affecting these programs and
the populations that they serve?
And then secondly, let me just ask you about HIV
criminalization laws. You know, we have 32 States and U.S.
territories that have criminal statutes based on perceived
exposure to HIV. These laws have been on the books since the
1980's and most of them need to be modernized to reflect
current scientific advances in AIDS research. And last year the
UN body which I sit on--we issued a report against these laws,
and the President's Advisory Committee on HIV--you know, they
cited a direct impact that these laws have on public health and
the fear that they instill in people who seek HIV testing and
counseling. And so I know you have been working on a review of
these laws and the implications for public health, and I would
like to find out the status of that and can you give us an
update?
Dr. Frieden. Thank you very much.
REACH AND SEQUESTRATION
In terms of the REACH program and sequestration,
sequestration would affect virtually every program at CDC with
a decrease of approximately 5 percent. So it would be that much
less that we would be able to do to address communities, that
particular need for health programs that would reduce health
disparities. We focused on trying to reduce disparities. We
released for the first time what is called a surveillance
summary or monitoring report on inequalities and disparities in
health status in the U.S. We identified some of the leading
disparities and some of the specific things that can be done to
reduce them.
HIV CRIMINALIZATION LAWS
In terms of the HIV laws, we look at this very broadly. We
found that many laws have been out of date, ranging from
testing to monitoring to some of the criminal sanctions that
are in existence. So what we have done working with other
groups is to just survey what is the lay of the land out there.
What are people doing? What are the laws that exist? And we
believe that that should go through a peer review process and
be published in the medical literature. So we can get back to
you with the exact timeline of that, but I understand that the
review is largely finished and we are now finalizing with the
goal of ensuring that whatever laws are there at least address
or are cognizant of the latest scientific information.
Ms. Lee. Okay. Are you looking at the impact, though, on
public health of these laws, I mean, what it means, for
instance, in terms of stigmatization, in terms of people
willing to come forward to get testing knowing that they could
be put in jail?
Dr. Frieden. I would have to get back to you on that in
terms of how that would be looked at and what they have done in
that area.
Ms. Lee. Okay.
NIH WORKFORCE DIVERSITY
And, Dr. Collins, let me just follow up on the issue that
was discussed earlier with regard to the whole inclusion of
minorities. Specifically in the RO1 grants, can you kind of
elaborate on that and how this will impact--how these RO1
grants and the whole effort to diversity will impact the health
disparities issue?
Dr. Collins. I appreciate the question.
So a couple of years ago, there was a publication
indicating that African American individuals who come to NIH
seeking their first RO1 had a lower success rate than
individuals from other groups, and you cannot account for that
by the number of correlates that people would have assumed
might have played some role in terms of previous training,
publication record, and so on. We are continuing to look
closely at that to try to understand it. It certainly sent a
shock wave through our community.
I have organized an effort, through my advisory committee
to the director led by Reed Tuckson and John Ruffin and Larry
Tabak, to look at our whole area of diversity in our workforce.
And they concluded that we have a problem which is beyond
simply looking at success rates of investigators who have
already made it into the position of applying to NIH for a
grant, but also why are there so few of those individuals.
We have just begun and we will be spending substantial
funds, even in very difficult budgetary times, on several new
programs to try to assist us. One is to try to make it possible
for individuals from under-represented groups to have a real
research experience as undergraduates, together with some
tuition rebates to make this more financial possible. Another
is to set up a national research mentoring network because it
is clear that one of the problems that we see is that under-
represented groups do not have that same network of support
that the majority, folks do. We think that could be a very
important part of it.
There are several other parts. I see my time is up. I would
love to talk to you more about that.
Ms. Lee. Thank you very much.
Mr. Kingston. Dr. Harris.
Dr. Harris. Thank you very much.
First, I want to echo the ranking member with her comments,
you know, thanking you all for being around to protect and
improve the life and health of not only Americans but really
people throughout the world. And I have taken a leadership role
in that.
I do want to echo, though, the chairman because I do have
some concerns about duplications that are occurring. You know,
the GAO reports multiple duplications in the Federal
Government. Our goal really in this time of contracting
resources is to look for efficiency and effectiveness. So I am
going to ask very specific questions. I just need a kind of a
yes or no from Dr. Clancy, Dr. Collins, Dr. Conway.
PATIENT SAFETY RESEARCH
Do each of your entities fund patient safety research?
Dr. Clancy. Yes.
Dr. Harris. Dr. Collins.
Dr. Collins. A very small amount.
Dr. Harris. Dr. Conway.
Dr. Conway. Only if it relates to payment and delivery
system----
Dr. Harris. So it does. Okay.
Dr. Frieden and Dr. Collins, do you fund obesity research?
Dr. Frieden. We do surveillance on obesity and support
communities in their work on that.
Dr. Collins. Yes.
Dr. Harris. Dr. Collins, Dr. Frieden, are there other areas
of research in other disease processes, hypertension or
whatever? So Dr. Frieden, do you also survey hypertension,
other disease processes as well?
Dr. Frieden. Surveillance, yes.
Dr. Harris. So you do. Okay.
And AHRQ and NIH fund telemedicine research?
Dr. Clancy. Moderate, a little bit, yes.
Dr. Harris. You do. So there is a little bit of
duplication.
Look, I have held grants from DOD health grants, worked on
VA health grants. So I understand that there are multiple areas
in the Government that actually look at very similar things,
and that is some concern. So I just want to mention that again
as we look toward effectiveness and efficiency.
VACCINES FOR CHILDREN
Now, I want to ask in the last remaining minutes, Dr.
Frieden, I have a great deal of concern about a document my
office got from the White House that talked about the cuts that
were going to occur due to Republicans and affecting children.
And I am going to read their quote about vaccines for children.
It says, in Maryland, about 2,050 fewer children will receive
vaccines due to reduced funding for vaccinations of about
$140,000. Did the CDC assist the White House in preparing that
estimate?
Dr. Frieden. I would have to get back to you on that.
Dr. Harris. You as the Director do not know if you assisted
the White House in preparing an estimate that was distributed
to every Member of Congress?
Dr. Frieden. On that specific number, I would have to give
you----
Dr. Harris. Okay. Let us forget the number. Let us forget
the idea of how vaccines for children are going to be affected
by the sequester. Is this the vaccine for children program?
Dr. Frieden. No, it is not, sir.
Dr. Harris. Which program is it? Is it 317?
Dr. Frieden. Yes, it is.
Dr. Harris. And what did the President's budget do to 317,
the President's prospective budget for 2013?
Dr. Frieden. The precise numbers I would have to get back--
--
Dr. Harris. Well, does a $58,000,000 cut sound familiar?
Dr. Frieden. Yes.
Dr. Harris. And what was the sequester cut?
Dr. Frieden. Again, the precise----
Dr. Harris. Does $30,000,000 sound familiar? Do you think
that is around the ball park, is it not?
So actually the President cut the program twice as much in
his budget. Can I assume that the President's proposed cut
would have reduced the funding to 4,100 children in Maryland?
Dr. Frieden. As per the justification that was published
with that, we have looked at ways that we can run the program
more efficiently by helping State and local health departments
recoup dollars, for example, for----
Dr. Harris. And you cannot do that under a sequester, but
you can do it under the President's budget? Is that my
understanding of your testimony today?
Dr. Frieden. I would have to get back to you on that.
Dr. Harris. So let me get it straight. Under the
President's cut of $58,000,000 to the 317 program, you think
you could get around that to avoid cutting vaccines to
children, but under a sequester that the President blames on
Republicans, you do not know if you can do that?
Dr. Frieden. We are going to do everything we can to limit
any damage that occurs because of the across-the-board cut, but
it reduces our flexibility significantly.
Dr. Harris. Is it your testimony that under the President's
proposed cut of $58,000,000 in his budget to the 317 program,
you could have avoided cuts to vaccines to children in
Maryland?
Dr. Frieden. We believe that we could have maintained
vaccination levels, yes.
Dr. Harris. Very interesting.
I yield back the balance of my time for now.
Mr. Kingston. Thank you.
Mr. Womack.
Mr. Womack. Thanks to all of the expert witnesses here
today for your testimony and for your service to your country.
DUPLICATION
I have really one fundamental question. In my 2-plus years
of serving in this capacity, not on this subcommittee, but as
an appropriator and as a Member of Congress, I notice that so
much of our Government is duplicative in nature. There is a lot
of turf protection that goes on in our business throughout the
Federal bureaucracy, but there is also a whole lot of--in the
military we called it ``mission creep.'' I will stop short of
that and just say there are a lot of things that we do from one
agency to another that can be looked at as duplicative in
nature. And I am going to ask this long question and then I
will just leave it to the panel. And then I will yield back my
time.
For example, all of your organizations fund activity or
some do related to health care-associated infections, on
prenatal care models, on issues involving biomedical research,
tobacco cessation programs, and other similar related programs
that come under a different title or a different theme from
organization to organization.
Are we being efficient? Is there proper collaboration, and
in your professional opinions, what are we doing to ensure that
the Federal outlays, in a constrained resource environment as
we operate today, are actually accomplishing the short-term and
long-term goals and not involving a waste of resources? So I
will just kind of throw that out on the table and let each one
of you have a stab at it. Thank you.
Dr. Clancy. Well, I will start with health care-associated
infections because I made a big focus on that in my opening
statement.
Our focus is on answering the question ``how do we do
that.'' We have known about these infections for decades. My
colleagues, Drs. Frieden and Collins, have done groundbreaking
science and so forth, but meanwhile, it was accepted as
disappointing but almost inevitable in health care settings
that a very unacceptably high rate of these infections
continued to occur. And we funded what turned out to be a
groundbreaking study in the State of Michigan in 2003, and that
led to dramatic improvements. And what was exciting about this
was the focus on making it work in small rural access hospitals
as well as ICU's and so forth. So that is our unique focus.
We use every piece of information we can use from the CDC
in doing this work. We do not reinvent definitions or anything
like that. Anytime there is new biomedical science, we are
there for it.
We play a minuscule or other role in the other areas that
you delineated, but I think it is fair to say that both through
a very short list of high priority goals for HHS, as well as
through multiple components of her leadership, the Secretary
herself insists on a great deal of collaboration so that we are
at all times making sure that we are getting the best value for
every dollar that the taxpayers have invested in this work. And
I will say that the return on investment for our investments in
reducing HAI's has been quite wonderful. I will have to turn to
my budget officer to get you the numbers, but we would be happy
to do that.
Dr. Frieden. Just health care-associated infections is a
good example where research from AHRQ, policies from CMS, and
monitoring support to States from CDC work really in close
coordination. And we have had terrific partnerships in this and
other areas.
Another area to think about is HIV where research at the
NIH developed the drugs. Funding through HRSA gives people
access to them, and support from CDC helps programs monitor
what is happening and prevent HIV. And of course, through the
Medicaid program as well, there is a lot of access to HIV care.
So there are many areas in which complex problems work. And
I will say that we work very closely together.
One additional example is CMMI has some new programs to try
things, and when they are in areas where CDC has expertise,
rather than hiring their own staff to monitor those programs,
they are paying us to make sure that we can put our staff on
the case and do that without duplication.
Dr. Conway. Just HAI's I do think is an excellent example.
We use the CDC measurement system and their expertise. We put
it in payment and delivery system programs at CMS, and we have
seen an over 40 percent reduction in central line infections. I
personally as an intern took care of a family whose neonate
passed away. So I think it is dramatic.
Mr. Womack. Thank you. I will yield back the balance of my
time.
Mr. Kingston. Well, that was generous of you. [Laughter.]
Mr. Fleischmann, you came late. Are you up to speed on what
we have been talking about?
Mr. Fleischmann. Well, yes, Mr. Chairman. Sorry. I was in
another subcommittee hearing.
Mr. Kingston. That is okay. You buy the coffee for
everybody. No. You buy Tennessee Italian pastry. I think that
is the penalty for coming late. [Laughter.]
Mr. Fleischmann. We can call them Little Debbie's.
[Laughter.]
Mr. Kingston. They do not have pastry but they have another
fine product they brew in the mountains. [Laughter.]
Mr. Fleischmann. Having said that with our good medical
personnel here, I am a teetotaler for the record.
Thank you, Mr. Chairman.
INTERAGENCY COORDINATION
I will address this to all witnesses. HHS has many
interagency coordinating committees and working groups. Could
you please tell us how many interagency coordinating committees
and working groups are in existence, and how are
recommendations from these advisory groups handled at HHS?
Dr. Collins. So this is, I think, very much a follow-up to
the question Mr. Womack was asking. You would want us to have a
lot of these interagency working groups, I believe, because the
ecosystem represented by the agencies at this table stretches
from very basic science trying to make discoveries about causes
of illness and the means to prevent and cure all the way
through understanding how that works in an epidemiological way
across the country in terms of health services and quality of
care in terms of issues that Medicare and Medicaid has to deal
with all the time. So we all are engaged in this.
Take diabetes, for instance, an enormous threat to the
health of our Nation. Each one of the agencies here has a
particular role to play in that kind of a circumstance, but we
need to be sure that we are together and we are not duplicating
efforts, but we are actually being synergistic and
complementary.
I could not tell you how many interagency working groups
there are, but I suspect if we tallied them all up, there would
be dozens. And that is a good thing. And we populate those with
people at a high level who have the ability to know what their
agencies are up to and have worked together quite closely.
And each of us at this table--we know each other really
well. We talk to each other a lot. We have senior staff
meetings shared between agencies in a bilateral sort of way. We
get it. This is a time where budgets are extremely tight. We
would not be happy about the idea of wasting a single dollar
right now either.
Mr. Fleischmann. All good? Okay, thank you.
DISSEMINATION OF HEALTH INFORMATION
A follow-up. In the area of health information, could you
each please take about 30 seconds to educate us on how your
organization spends on dissemination of health information?
Dr. Frieden. So CDC often is the lead for monitoring of the
health status of Americans and that information is provided to
individual researchers. It is provided through our website. It
is provided through grantees who get information to the public
in a wide variety of areas. We also coordinate across HHS on
issues like vaccine safety where we want to make sure that all
information is present so there is not a partial view.
Dr. Clancy. So I am going to make a quick statement. You
know, we all know, all of us, that it takes too long for
scientific information to benefit patient care. The statistic
is that it takes 17 years for 14 percent of funded research to
benefit patients. 14 percent. I do not know if that is good or
bad. Research can be risky business in terms of what is going
to pay off. We all think 17 years is too long. So I think it is
fair to say that each of us is trying to exploit and take
advantage of all kinds of new opportunities.
We have a particularly big role in getting health
information out to the public, both by virtue of how our
authorizing statute is written to get information out to the
public and to health professionals and also through a new
authority in the Affordable Care Act for getting information
about patient-centered outcomes research out there. We think we
are really cheap and efficient.
And we rely a lot on partners because particularly for
clinicians, many of them would much rather hear from the
College of Cardiology than even wonderful AHRQ in the Federal
Government, even NIH. They like hearing from their professional
organizations. So we utilize those partnerships very
effectively.
Ms. Wakefield. And I could just add, just to give you an
example, we would use from CDC their guidelines for screening
and treatment around heart disease, take those guidelines and
push them out to the community health centers across the United
States, of which there are about 9,000 sites. So that is a good
utilization of pulling it in very rapidly and pushing it out
through the infrastructure that we support across the country
in every State and territory.
Dr. Collins. NIH sees a major part of our role is
distributing information about the results of research,
clinicaltrials.gov, a place where anybody who is interested in
a clinical trial can find out what is going on anywhere in the
country, both publicly and privately supported. The PubMed
database, which is where people go to look at the public
literature, downloaded 40,000,000 pages on an average day by
people who are interested in that information, and MEDLINE,
which is perhaps one of the most trusted resources for the
public looking for medical information that is well-based on
evidence.
Dr. Conway. So we share our quality information, including
the private sector companies that utilize that information, to
build technology to support choice by Medicare beneficiaries
and their families.
Mr. Kingston. Okay. We are going to go to a second round,
and we will try to limit it to 4 minutes each, if everybody is
in agreement, and we will just keep going. We will try to talk
fast.
Dr. Frieden, we are probably looking at--I do not know--low
side 675, high side maybe 900 in IQ at the collective table
here at the moment. [Laughter.]
Ms. Lee. Your table. [Laughter.]
Mr. Kingston. I know I am not adding to the average.
COMMUNITY TRANSFORMATION GRANTS
But, Dr. Frieden, I want to talk to you about it
specifically. I am troubled and very unimpressed with community
transformation grants. I would ask you as a really smart
scientist who has earned his stripes, pseudo-science, public
relations, real serious stuff, good politics?
Dr. Frieden. The community transformation grants, which
were authorized and directed by Congress----
Mr. Kingston. That should tell you right there. [Laughter.]
Dr. Frieden [continuing]. Are an opportunity to allow
communities to work in specific areas with specific outcomes,
healthier school food, better control of blood pressure,
reduced exposure of children to tobacco and other cancer-
causing chemicals.
Mr. Kingston. I am going to kind of move along on a clip
here. It just strikes me that the only thing we are getting out
of them is a bunch ``me too'' stuff of kind of, oh, yeah, the
tobacco. Oh, well, that is an original thought. Sugary
beverages. Oh, that is an original thought. I mean, I do not
see much coming out of community transformation grants that
show, hey, you know what, this is a really good investment.
It disturbs me when tax dollars are used to fund government
to single out food rather than educate people on what you
should be doing for your exercise. It seems that there is a
real slant towards let's tax certain food items and make it
harder for people to get in as opposed to talking about the
broader picture of obesity. I do hope to have a hearing on
obesity.
But I am very concerned that what we are seeing now--for
example, CDC gets $825,000,000 in PPH funds, and $226,000,000
are used in community transformation grants. If we are talking
about not immunizing children so we can get a bunch of people
in Los Angeles to say, oh, we should have less tobacco, I do
not think that is a good investment of tax dollars.
LOBBYING
I just need assurances from you that these grants are not
going to be used to just continually lobby for more taxes, more
bans, and more restrictions on particular food.
Dr. Frieden. We take very seriously the restriction on
lobbying by grantees. We have a rigorous process in place to
monitor and oversee grantees and provide training, technical
assistance and guidance on this topic. And if we identify a
potential issue, we address it immediately.
Mr. Kingston. I am going to look forward to working with
you on that.
SODIUM
And I want to ask you about sodium because we get mixed
signals on sodium. You have said in the past that--and there
was a New York Post article that you said too much sodium
raises blood pressure which is a major risk factor for heart
disease and stroke. These diseases kill more than 800,000
Americans each year and contribute to the estimated
$273,000,000,000 in health care costs. But when pressed for
specifics, Karen Hunter of the CDC says that the CDC does not
have data on the number of heart attacks and strokes that are
caused by excess sodium.
So what specific data do you have on the number of deaths
caused by sodium? And this is a computer-generated number or
has it been peer-reviewed? Is it solid data or not? And does a
low-sodium diet lead to health problems in certain populations?
And I see you have 7 seconds. [Laughter.]
So I tell you what if we have a third round, I will let you
answer that. If not, let's do it for the record. Thank you.
Ms. DeLauro.
VACCINES FOR CHILDREN
Ms. DeLauro. Thank you. Just a quick comment on the
$58,000,000 in the immunization effort. I too would be opposed
to that cut. I think it is important to recognize as well,
though, that the administration made a presumption that the
Affordable Care Act would be implemented and that in fact would
accommodate immunization.
Let me move on and, Dr. Clancy, let me ask you a couple of
questions if I can. I will just tick them off very, very
quickly.
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
Last year, the subcommittee would have eliminated AHRQ.
What would we lose? And secondly, you began to mention one of
the arguments for eliminating AHRQ was that it is duplicative
of other agencies. You made a response. I do not know if you
would want to add to that response about whether there is
overlap with other agencies.
And last, AHRQ and the Patient-Centered Outcomes Research
Institute, which is set up by the Affordable Care Act. Some
have suggested that we should stop providing an appropriation
to AHRQ to do the patient-centered outcomes research because
that research can now be supported by PCORI. Is PCORI in a
position to take over the support of all of AHRQ's patient-
centered outcomes research?
Dr. Clancy. So thank you very much for your question. I
think that you probably got from my earlier statement my
passion for this work, and given the opportunities for
improving quality and safety and given what I think is sort of
a new day among health professionals in terms of their
excitement about improving health care, I think we would lose a
lot if AHRQ were to go away.
Quite specifically, the question I hear from health
professionals all the time is ``I want to be part of this
transformation. How do I do that? How do I get on board with a
variety of policy initiatives? How do I know what is right for
my practice? How do I do that?'' And we are the agency that
actually gives them evidence-based tools to make it easy for
them to do the right thing. And the excitement and enthusiasm
among health professionals--you cannot buy it. The payment
policies are really important, but the professional commitment
to providing the best possible patient care. So it is HAI's. It
is the work in team work. It is the work in communication. It
is information for the public. Dr. Frieden mentioned being a
disease detective. In our world, being a disease detective
often involves trying to find out precisely what medications
this patient is taking now and how can we make sure that we are
helping them to avoid potentially deadly interactions. So that
is the work in patient safety.
The second question was about duplication. I think the
unique area that we focus on is the ``How do I do that.'' Dr.
Conway referred to it as ``improvement science,'' which is a
slightly more glamorous sounding label. I do not care what you
call it. What I see is that we have got a health care system
that is not equipped to provide high quality, safe, affordable
care, and we have developed and generated practical solutions
for doctors, hospitals, nurses, pharmacists, and so forth to be
able to do that. And I cannot tell you how excited they are,
and we hear from them all the time. The words I hear are they
are ``game-changing.'' This approach to HAI's--that is what
really turned the corner for us, and we thought we were trying
really hard before.
In terms of patient-centered outcomes research, that is a
program we are phasing out. You probably know we think and are
very proud of the work we have done to date, particularly with
the Recovery Act funding as a foundation for the Patient-
Centered Outcomes Research Institute. Dr. Collins and I are
both on the board of that institute. So we have both, I am just
going to say, been quite generous both with our own time and
with sharing lessons learned. We have a unique and exciting
opportunity because 16 percent of the allocation from the PCORI
trust fund comes to AHRQ to support two vital areas. One is
dissemination of the findings to the patients, to families, to
health professionals, and so forth so that they have got good
information when they need it to shorten that 17-year time
frame. The other is building capacity, training future
researchers, training people who can understand how to use this
information.
Sorry for going over.
Ms. DeLauro. Thank you, Mr. Chairman.
Mr. Kingston. Dr. Harris.
Dr. Harris. Thank you very much.
Again, I want to thank you for all you do for protecting
and improving life and health.
VACCINES FOR CHILDREN
Dr. Frieden, I do look forward to your answer about who was
the source within the CDC for the information that I got
concerning Maryland. So I look forward to your answer.
[The information follows:]
Dr. Frieden: CDC provided data that was used in developing
the report.
Let me just follow up one more thing for you. A concern I
have is the ATSDR which apparently has issued reports on Dimock
and one other place where hydraulic fracturing was alleged to
have contaminated drinking water. And I read through the
reports. It is actually good that the ATSDR actually pointed
out that the EPA sampling was improper, you know, quality
control samples. I mean, I like that idea. But I would urge you
to keep it to science and leave the politics aside. That is the
one good thing I think we should insist upon, medicine, medical
research, public health research, is that we leave the politics
aside. Let's concentrate on science.
NIH RESEARCH FUNDING
Now, Dr. Collins, I have got to ask you a couple of things
here, and I did not think I was going to except that it popped
across one of my local, online--I guess you would call it a
blog--yesterday--2 days ago. It says, NIH study claims link
between the Tea Party and the tobacco industry. Are you aware
of this? I mean, again this popped across one of my local--let
me ask you. The only comment says--so it is a study. I guess it
was--was it University of California? Are you aware of it?
Dr. Collins. UC San Francisco.
Dr. Harris. UC San Francisco. So they allege that somehow
the Tea Party had its origin in the 1980's with tobacco
funding, which is pretty incredible because, I mean, I am a Tea
Party guy. I was there when it was established in 2009. I know
the origins. I find it incredible that NIH funding is funding
this because the one comment says, what may I ask does this
article have to do with Chestertown, which is the local
community. Of course, it has nothing to do with Chestertown and
everything to do with a partisan political agenda. I could not
agree more.
Dr. Collins, what methods does the NIH have when this kind
of research takes dollars from cancer research and other
important, vital research--what does the NIH do to universities
that waste Federal tax dollars this way?
Dr. Collins. Dr. Harris, I appreciate your question, and I
too am quite troubled about this particular circumstance. Dr.
Stanton Glantz, who is the author of that article, has been a
funded grantee of the National Institutes of Health, the Cancer
Institute, for 14 years and has done some very important work
in terms of tobacco control over those years and is considered
by peers to be among the best in the field.
Dr. Harris. If I might just interrupt, you do not consider
this among his most important work in tobacco research.
[Laughter.]
Dr. Collins. No, I would not.
Dr. Harris. Okay. Thank you.
Dr. Collins. If you look carefully at the acknowledgements
at the end of this particular paper, which came as a surprise
to us as well----
Dr. Harris. I am looking at them, but go on.
Dr. Collins [continuing]. It does cite two different grants
from the NCI. There is also wording there--and maybe you could
read it off to us--which says that this particular work and
this particular paper was not suggested or encouraged by the
NIH. He did this on his own.
Dr. Harris. Correct. And that drills down exactly to my
question. This was the use of Federal dollars on a clearly
partisan political agenda. I mean, look, we are going to come
to agree--clearly partisan political agenda. What is the NIH
going to do to make sure that we do not fund this research, we
fund the real medical research as we go forward in a time of
constrained resources?
Dr. Collins. Of course, we thought we were funding a
different kind of research when those grants were awarded.
Dr. Harris. So what is within the NIH's abilities to, shall
we say, make sure that this researcher of this institution does
not play fast and loose with taxpayer money in this kind of
research?
Dr. Collins. So it is a very appropriate question and I am
struggling with it, to be honest.
Dr. Harris. Could you get back to me about what plans the
NIH is going to have to be certain that this kind of research
is not funded?
Dr. Collins. The tension here is both to recognize that
this is an unfortunate outcome but also not to put NIH in the
position of basically playing a nanny over top of everything
that our grantees do because a lot of what they do, which is
more appropriate, ends up being quite innovative.
Dr. Harris. Thank you very much.
Thank you, Mr. Chairman.
Mr. Kingston. This is a very good discussion, but we are
out of time.
Ms. Lowey.
Mrs. Lowey. Thank you very much, Mr. Chairman.
And I just want to say to Dr. Collins and my colleagues,
since I got on this committee, which I love, many years ago I
have always tried to figure out how you can legislate
excellence consistently. And that is the challenge that we all
have because we are so committed to the important work that you
are all doing. So I thank you for your comments and maybe you
can come back with some good advice.
DIABETES PREVENTION PROGRAM
I would like to focus for a moment on the diabetes
prevention program because we know that between 1980 and 2010,
the number of Americans diagnosed with diabetes more than
tripled. I understand that some of you are involved with an
effort to alter that trend called the Diabetes Prevention
Program which helps people at risk make the kinds of modest
life changes that can substantially reduce their chances of
developing diabetes. The program originated with a large study
by the NIH that demonstrated the potential of modest lifestyle
changes in reducing risk of type 2 diabetes, and CDC is now
leading the implementation of these findings in partnership
with organizations throughout the country using funding from
the Prevention and Public Health Fund.
Now, before I ask the question, I just want to associate
myself with the chairman's comments before about sodium because
there have been recent reports on the Mediterranean diet and
another report, no salt, no sugar, no fat. And at some point
maybe we can have a hearing or a discussion of all these diets
because it is so important, Dr. Frieden, to your work and to
everyone's work. I would be interested in that.
But my question today to Dr. Collins and Dr. Frieden, can
you tell us how the Diabetes Prevention Program works, about
the respective role of your agencies in developing and carrying
out this effort, and are we seeing some results?
Dr. Frieden. So the Diabetes Prevention Program is a great
example of partnerships where the NIH funded research that
shows that for people with pre-diabetes, if they participate in
this program, their risk of developing diabetes falls by 58
percent. We then took that and worked with the YMCA, now called
the Y, to come up with a lower cost way of doing that, and now
we are working with providers throughout the country and
insurers throughout the country to identify ways to get
patients access to these programs. What we have done is to
essentially verify that a provider is doing the program with
fidelity to the model and require them to provide aggregate
reporting periodically to us, and then United Health Care and
other insurers are going to pay those providers because there
is a great return on investment here. A single person with
diabetes costs on average $6,600 more to care for per year than
someone without diabetes. So if we can prevent a few of these
cases, we can save a lot of money for the health care system.
One of the areas that this is addressing is how do you get
the health care system to pay for lower cost, high value
preventative services. And that is something that I think all
of us are learning and understanding more of.
Dr. Collins. Yes. I think this is a great example of our
agencies working together in terms of conducting the original
study, which has now been extended out over 10 years, a follow-
up, showing that the benefits of this lifestyle change, which
is diet and exercise, are sustained over long periods of time,
especially for people over 60, which is also an interesting
part of the discovery, and then CDC picking this up in terms of
implementation in the real world to see how this works out.
We have been talking now a lot with CMS about how we could
see a path forward here for a proven, successful enterprise
here to prevent diabetes to be more broadly available to people
who have Medicare and Medicaid coverage.
It was a challenge because a lot of the delivery of the
health care depends upon non-traditional providers, coaches,
lifestyle coaches who are successful in being able to maintain
people's exercise and diet abilities.
Mrs. Lowey. Well, thank you, Mr. Chairman. My time is up.
I would like to add this discussion to the one that we are
going to have because we have known a lot of this for a long
time. Whether it is Weight Watchers or Over-Eaters Anonymous
how do you really get people to change behavior with all the
advertisement for sugar, starches, etc.? But this is a longer
discussion. Thank you very much.
Mr. Kingston. It is a great discussion, and I do hope to
have some hearings on it.
Ms. Roybal-Allard.
TB OUTBREAK IN LOS ANGELES
Ms. Roybal-Allard. Dr. Frieden, before he went into
politics, my father was a public health educator responsible
primarily for educating the Latin communities in California
about the spread and prevention of TB. So I grew up with a
healthy respect for the dangers of that disease.
I have been closely following the rising number of TB cases
among L.A.'s skid row homeless population which has been called
the largest TB outbreak in a decade. Equally concerning are
other communicable disease outbreaks such as last year's TB
outbreak in Florida and last year's whooping cough outbreak in
the State of Washington.
Given that CDC's budget has been significantly cut over the
past several years and sequester is expected to take an
additional $300,000,000 from CDC's budget, will the CDC have
adequate funding and resources to control and prevent the
spread of communicable diseases in all States? And if not, will
some communities be hit harder than others? And what risks, if
any, will this pose to the rest of the population at large?
Dr. Frieden. We will do the best we can to mitigate the
damage that sequestration cuts will do, but the reality is that
about two-thirds of our budget goes out to State and local
entities. Those entities have already absorbed about 45,000
fewer staff because of State and local reductions in funding.
And so this comes at a very difficult time for State and local
governments, and there is always the risk that an outbreak will
be undetected or detected more slowly or controlled more slowly
with fewer resources.
With respect to the Los Angeles tuberculosis outbreak, we
have a team that arrived yesterday at the request of the State.
We only go places where we are requested. They requested
assistance and we have sent a team there. But some aspects of
the investigation will be difficult to do in this budgetary
climate.
For example, we are increasingly using what is called whole
genome sequencing of bacteria and viruses to understand the
transmission, where they spread and how they spread. It is a
costly and difficult study to do. They are getting cheaper, but
the bioinformatics needs are great. And this is an area where
we need to continue to grow our capacity.
Just to give you an example a couple of years ago when
cholera hit Haiti, we were able to do sequencing of the genome
of that bacteria, but we were not able to interpret the results
because we did not have the bioinformatics capacity. And I am
ashamed to say we had to send the information to Canada for
them to interpret it for us. I never want to have that happen
again on my watch at CDC. So we will do everything we can to
respond as effectively as we can to outbreaks that occur.
On average, we start an investigation about every day. So
which of those we may be able to address less well I cannot
predict.
Ms. Roybal-Allard. And if you are not able to address them,
what communities do you think will be hit the hardest and how
will that impact the population at large?
Dr. Frieden. I think the spread of infectious diseases
knows no boundaries around the world and also can spread in
hospitals from food. There are populations at higher risk,
people who chose not to get vaccinated, for example, or
communities that have low vaccination rates. But ultimately
because we are all connected by the air we breathe, the spread
of communicable disease is a potential risk to everyone.
Ms. Roybal-Allard. It will affect all of us. Thank you.
VIOLATIONS OF ANIMAL WELFARE REGULATIONS
Dr. Collins, in January I sent a letter asking about
violations of Federal animal welfare regulations in NIH-funded
research laboratories. Since I have not received a response to
date, I want to follow up on that issue.
It is my understanding that NIH requires federally funded
animal research laboratories that violate animal welfare
regulations to return the funds used for the noncompliant
activities. There was a well publicized case several years that
a noncompliant lab was ordered more than $65,000.
My questions are, are the FDA and USDA notifying NIH about
noncompliant projects funded by NIH, and what is NIH doing in
response to these reports? For example, over the last 5 years,
how many incidents requiring grant repayment have been reported
to NIH? What actions have been taken, and how much in taxpayer
money has been returned to the NIH?
Mr. Kingston. And, Dr. Collins, you will have to answer on
the record.
Dr. Collins. Okay. I will be glad to answer on the record.
I am sorry you did not get a response to your letter, and I
will be sure you get one.
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Ms. Roybal-Allard. Okay. Thank you.
Mr. Kingston. Ms. Lee.
Ms. Lee. Thank you very much.
DIABETES IN INDIVIDUALS WITH SICKLE CELL TRAIT
Dr. Collins, let me ask you if you could give us--and you
may not have it here--an update on an effort that actually was
through this committee we mounted as it relates to the whole
issue of diabetes with individuals who have the sickle cell
trait and the A1C test. Several years ago, I just happened to
stumble upon the fact that the A1C test is not valid if in fact
one has the sickle cell trait, which primarily are in
population of African American and Southeast Asian populations.
We raised this with the National Institute of Diabetes and
Digestive and Kidney Disease and also worked with NIH to
develop a public awareness campaign.
I want to know how that is going. Do physicians now and
labs know that--because there were many, many people who were
being treated for diabetes who did not have the disease because
they had the sickle cell trait, and they were never tested for
the sickle cell trait. And so it was a real problem throughout
many communities. And so I am wondering if you could give us an
update on that, if we know what has happened. Are labs and
physicians fully aware now that they need to be very careful in
administering that test?
Dr. Collins. So, Congresswoman Lee, you were right to raise
this. This is an important issue because it was leading to
confusion and misdiagnosis. And there has been attention paid
to this by the National Institute of Diabetes, Digestive, and
Kidney Diseases with Dr. Griff Rodgers as the director of that
effort. And there has been, although I do not have the details
on the tip of my tongue, a recent workshop looking at this
trying to figure out how best to distribute the information
that you refer to.
All of this I think is being assisted--and it is an
important thing to bring up at this hearing--by a much closer
relationship across the Department in terms of sickle cell
disease and other things that need to be looked at more
closely. The CDC is now engaged in a surveillance effort so
that we have much better record availability in terms of sickle
cell disease across many States, which has been something we
have not previously had access to, and Tom and his team have
taken that on.
Susan Shurin, who is the former acting director and now
deputy director of NHLBI, has made it a personal priority to
bring together various parts of HHS in the sickle cell agenda.
We have two new, very exciting approaches therapeutically
to sickle cell disease, one of which has already gone into
phase I trials at our clinical center, the sort of first really
new ideas about drugs since hydroxyurea, which has been almost
20 years.
So there is an increased focus on this first molecular
disease, this disease that very much deserves attention and
advances all across the board, from basic science to clinical
issues such as the one you raised. I could give you a more
thorough report on that for the record.
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Ms. Lee. I would appreciate that because I hope this
committee realizes the importance of this and the seriousness
of this because there are many people who are being treated and
mistreated because they were not properly diagnosed. And I
think it is a really important issue that I am going to stay on
until no one is being mistreated.
Dr. Collins. You have been very effective in drawing
attention to that. Thank you.
Ms. Lee. Thank you.
IMPACT OF SEQUESTRATION ON MEDICARE & MEDICAID
And finally, if I have a couple more minutes, you probably
will not have to answer this on the record, Dr. Conway. The
budget cuts, as it relates to the sequestration, the impact on
administering Medicare and Medicaid services because of the
fact that these payments are going to be cut to doctors and
hospitals and health plans and providers who provide services
to Medicaid and Medicare patients--what is going to happen to
the patients and the doctors?
Dr. Conway. So as the agency has said publicly, on April
1st there will be a 2 percent cut to all doctors, hospitals, as
well as health plans in terms of the sequestration cut. So as
you alluded to, that is a major cut in terms of payments.
Administratively we also will need to look at our operations
and prioritize work to try to deal with the cuts as best as
possible.
Mr. Kingston. Mr. Honda.
Mr. Honda. Thank you, Mr. Chair.
HEPATITIS B AND C
My question will be around hep B and C. It is directed to
Dr. Frieden. We have seen hep B and C rise to alarming levels
to a point where the new prevalence rates for hep C now
overshadow those of other major diseases. This is not a problem
that is going to go away. And yet, we find that we continue to
fund CDC's division on viral hepatitis at a very meager level.
So in an ideal world, what is an appropriate funding level that
the CDC should have, and then what kind of sacrifices have you
had to make due to the insufficient funding put towards
combating hepatitis B and C?
Dr. Frieden. As you point out, Congressman, hepatitis B and
C are a major problem. And we do have new treatments available
through work that NIH and others have funded which are
effective at achieving long-term viral suppression, essentially
a cure.
Last year, CDC published guidance on encouraging doctors to
test everyone born in a certain cohort, I believe 1945 to 1965,
at least once for hepatitis C and to get people into treatment
because we know that many people who are infected are not aware
that they are infected and therefore cannot get the treatment
that they would benefit from. And we work closely with CMS,
with AHRQ, with HRSA to increase access to testing.
In terms of the exact funding level of the program, I would
have to get back to you. But as with every program, it would
face roughly a 5 percent budget cut. It is funded at a very low
level currently relevant to other programs. Our major effort
here, in addition to trying to come up with better ways to
diagnosis the acuteness of hepatitis C infection, is to scale
up the treatment throughout the country by supporting State and
local governments and health providers to do that.
Mr. Honda. In the area of public and private funding, that
cooperation, what kinds of partnerships have you been able to
leverage and what kind of leverage has been realized through
this relationship?
Dr. Frieden. We have had an excellent relationship with
many of the professional societies and nongovernmental
organizations that have been advocating for better prevention
and treatment of people living with hepatitis B and hepatitis
C. We have also worked closely with many of the providers in
thinking about how to scale things up and with State and local
governments in terms of how to affect the practice of care in
their communities and identify parts of their community that
may be at highest risk and ensure that they get the services
they need.
Mr. Honda. What kind of attention is being focused towards
screening of hep B and C in the public? Is that a question for
yourself?
Dr. Frieden. We have released a public education campaign
called No More Hepatitis, encouraging people to know more about
their status. We have reached out to health care--
Mr. Honda. Oh, know, k-n-o-w. Okay.
Dr. Frieden. And also no. [Laughter.]
Dr. Frieden. And so this is one of the efforts that we have
had. We also find that working closely with health care
providers, people are seeing a doctor. So through electronic
health records, through CMS, HRSA, and others, we are looking
at how to ensure that people get the test, and then if they are
positive, follow up in care. And we are seeing many gaps in
that cascade. We are working with different groups to try to
close them.
FUTURE IMPACTS OF SEQUESTRATION
Mr. Honda. Through the chair, if I may ask, the members
here, the panelists, we are looking at sequestration. We are
looking at cutbacks. You said 2 percent in your arena. If we
look at the cutbacks and we get a funding level that has been
cut, is there a way you could project what it is that we are
going to suffer in the future? What are the future impacts on
our society? What is the cost of that? If you can come up with
something like that, I would like to be able to share that so
that we can let people know how short-sighted some of our
actions are right in this country. And so if that information
can be shared, I would be very appreciative of it.
Mr. Kingston. Mr. Alexander.
Mr. Alexander. Mr. Chairman, if you will, just three short
questions to read into the record, if you would allow me.
FOOD-BORNE ILLNESS
The CDC has a key role in investigating food-borne illness
and helping identify suspect foods. The outbreak of listeria in
cantaloupes was the example. How can you assure us that we are
able to detect such outbreaks quickly?
CDC FUNDING AT STATE AND LOCAL LEVEL
And why is CDC's funding so focused on supporting public
health agencies at the State and local level?
CDC'S UNIQUE ROLE
And number three, in an era of reductions, we cannot afford
to have agencies tripping over themselves. What makes CDC
unique and deserving of our support?
Thank you, sir.
FOOD-BORNE ILLNESS
Dr. Frieden. Thank you very much. CDC's role in terms of
food-borne infections is to identify outbreaks when they occur
and then work with State and local governments to stop them.
We coordinate very closely with both the Food and Drug
Administration and the USDA. Our top scientists meet weekly.
There are 30 to 40 clusters of infections that we are
investigating at any one time, and with that interagency
coordination, we are able to prioritize those and take rapid
action.
CDC FUNDING AT STATE AND LOCAL LEVEL
It is State and local governments that monitor whether
infections are spreading. They track the laboratory results. We
coordinate a network called PulseNet. PulseNet takes the
infections that occur and subjects them to a DNA test to see if
they are related. It is an old technology, and actually we need
to replace it in the coming years with something that works
even better based on whole genome sequencing. That is going to
take a while, but that will allow us to find outbreaks sooner
and stop them quicker.
CDC'S UNIQUE ROLE
But CDC's role is fundamentally to identify and stop
outbreaks. We handle the illness part of it. FDA and USDA
handle the food part of it. And often it is our investigations
that will identify a new way that food became contaminated so
that the manufacturers can reduce the risk. And we emphasize
the entire food chain from farm to table. At every step, there
are responsibilities and things that can be done to make our
food safer.
Mr. Kingston. Thank you, Mr. Alexander.
And that is the end of the second round, and what we are
going to do is ask members to submit the rest of their
questions for the record. There will be a lot of questions like
that.
Mr. Kingston. I do want to say this and I think Ms. DeLauro
is just going to make a statement or two right now.
NIH LOGO
About every other campaign, somebody comes to me and says
you have to change your logo because you have had it the same.
And I always say, you know, I understand there is always
somebody new who wants to tell you why something that is tried
and true does not work. And I have said, you know, if you guys
want to change the logo, fine, but I am not paying for it
because this logo was designed by my wife and good friend on my
kitchen table.
But I heard you guys are looking at a new logo. And so my
question is to you for the record, you know, whose idea is
that? Why is it necessary? Is this a good time for it? And how
much are we talking about? And I see you are prepared to answer
this question. [Laughter.]
All new logos take a while to get used to.
Dr. Collins. This is one old, ugly logo. So this is
basically what we have had for the NIH logo for the last 34
years.
When I came to the NIH----
Mr. Kingston. Well, let me do this in fairness and
consistency. Could I get that for the record?
Dr. Collins. Sure. If I could just say, the point of this
was actually to save money. We have proliferation of way too
many logos. We are going to focus on just one.
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Mr. Kingston. Okay. And I do want you to know--well, let me
yield to my friend, Ms. DeLauro, and then I will conclude.
Ms. DeLauro. I do not have any closing statements, but I
want to very quickly get three answers.
NATIONAL CENTER FOR ADVANCING TRANSLATED SCIENCES
Dr. Collins, we gave you money for NCATS. What has been
accomplished? There was a question about duplication there. How
are we preventing that?
MATERNAL AND CHILD HEALTH BLOCK GRANT
Dr. Wakefield, return on child health block grant. It has
been cut back in appropriations. What is its role? What kind of
efforts does it deal with in terms of prenatal care and infant
health?
FOOD-BORNE ILLNESS
And Dr. Frieden, just to piggyback on Mr. Alexander's
comment on food-borne illness, how do we modernize your
capability to implement the Food and Safety Modernization Act?
What is your concern about sequestration and food safety?
Mr. Kingston. Those are for the record?
Ms. DeLauro. No. Quick answers.
NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCES
Dr. Collins. So NCATS, the National Center for Advancing
Translational Sciences, has been I think in its course of its
just 1 year and 3 months actually embraced by virtually all the
sectors that are touched upon, academics, universities, and
industry.
I would like to maybe send for the record an editorial
written by Bernie Munos who is sort of seen as a really
authoritative view about the intersection between public and
private who has ringingly endorsed the way in which NCATS has
provided an opportunity to tackle bottlenecks in the pipeline
that were otherwise not being attended to for the benefit of
industry as well as academia. This is turning out to be a
really wonderful enterprise.
MATERNAL AND CHILD HEALTH BLOCK GRANT
Ms. Wakefield. So in terms of the Maternal and Child Health
Block Grant, a couple of comments I think could be made. First
of all, the money that we receive is distributed based on a
formula using the number of children that are in poverty in a
State compared to national poverty rates. It is a matching
program, so it is really important in that respect too. So the
States match. We match 4 Federal dollars for every $3 that are
invested by the States. The resources of that program go to
care for Nation quality improvement, State infrastructure,
special attention to children with special needs, for example.
In terms of infant mortality, it is an extremely important
investment to help drive down rates of infant mortality, and we
have actually been fairly successful on that front over the
last few years. But we have very large disparities between
African American infants and white children, and that is an
area where we need to continue to do our work.
FOOD-BORNE ILLNESS
Dr. Frieden. And we do need to modernize our laboratory
testing so that we can go to methods that are quicker and more
sensitive for detecting outbreaks.
I would also like to mention that as we understand how our
health departments work to collect money from insurers, we are
realizing it is much harder than we had anticipated. And that
is one of the things that we are dealing with with many of our
programs, including the immunization program, and the reason
why we are less optimistic now about the ability to modulate
the impact of cuts than we were a year ago.
Ms. DeLauro. Can you let me know just what sequestration
would do to the food safety area?
Dr. Frieden. It would reduce our funding by about 5 percent
which would limit our ability to develop new tools as well as
better use the existing tools that we have now to find and stop
outbreaks.
Ms. DeLauro. And PulseNet will not be able to be upgraded.
Dr. Frieden. We will do everything we can to manage through
it.
Ms. DeLauro. Thank you.
COMMUNITY TRANSFORMATION GRANTS
Mr. Kingston. You know, there is $226,000,000 in these
pseudo-science community transformation grants that we could
probably get you. I am just thinking that that is going to be a
source of discussion.
I want to say this, Dr. Collins. While you and I have
talked about that Tea Party tobacco study privately, I did not
know that other committee members were monitoring it as well.
And I think that is where we can find some common ground as we
grapple with this issues, is just the straight allocation of
resources to what makes sense and what does not.
And I do, Dr. Frieden, have a lot of questions on BARDA. We
had a bill on the floor yesterday. It is very important to all
of us in terms of stockpiling and chemical, biological attacks
and everything else that are of national security. I am going
to submit those to you for the record.
Mr. Kingston. So there is so much here and I know that Rosa
and I could probably sit here till 5 o'clock, but at some point
we may need to vote and eat. [Laughter.]
But with that, this hearing is adjourned. We meet again
tomorrow at 10 o'clock.
[The following questions were submitted for the record.]
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Thursday, March 14, 2013.
ADDRESSING SOCIAL SECURITY ADMINISTRATION'S MANAGEMENT CHALLENGES IN A
FISCALLY CONSTRAINED ENVIRONMENT
WITNESS
CAROLYN COLVIN, ACTING COMMISSIONER, SOCIAL SECURITY ADMINISTRATION
Mr. Kingston. Well, welcome. This is actually the way Ms.
DeLauro and I like it. [Laughter.]
We get to ask all the questions.
It is great to have you here. I welcome Commissioner Colvin
here. I know you will be managing the Social Security
Administration I guess until further notice, and we are
delighted to be working with you.
A couple things that we are concerned about is 2 years ago
we directed the Social Security Administration in the fiscal
year 2012 omnibus develop, with assistance of the National
Academy of Public Administration, a strategic plan to direct
how the agency's service delivery approach should evolve in
response to a number of pressures. Like any other multi-billion
dollar operation, a large service delivery organization needs
to understand where it is headed and how it plans to tackle the
well-known and unknown challenges ahead. It is, therefore,
extremely difficult for me to understand why the Social
Security Administration has refused to follow the direction of
Congress and develop a truly long-range strategic plan in
consultation with the well-respected NAPA.
Social Security needs to long-term plan more than ever. A
large number of employees are retiring. We actually had some
incredible testimony yesterday from some of the folks involved
in the aging advocacy forum, and something like--I cannot
remember the number--10,000 people a day will start retiring
and that by 2050, 19,000,000 of the population will be over 65
years old. And it is just staggering when we look at the
graying of America, although I know I think people prefer the
word ``silvering'' of America. ``The silver tide,'' or what is
the name for it?
So I understand the needs and the pressures on funding, but
what we really do not have as clearly as I think the committee
would like is a vision in terms of where the agency is going
and how it is going to deal with this. And we all know Social
Security is extremely difficult to reform, otherwise we would
have done it. It is enormously popular. It is a universal
program, and making changes--there is always a constituency
group that says too far, too fast, not me, not in that
direction. But the reality is we do need to have a thoughtful
focus on where Social Security is going to be in 10 years, 15,
20, 30 years.
So I am looking forward to this hearing.
And with that, I will yield to Ms. DeLauro.
Ms. DeLauro. Thanks very much, Mr. Chairman.
I want to say thank you to our witness for joining us and
thank you for everything that you are doing at the Social
Security Administration.
Social Security is the ultimate legislative expression of
the shared values of this Nation. For over 75 years, it has
tied generation to generation. It ensures that seniors have a
secure retirement after decades of service to their community.
And it provides a safety net for those who can no longer work
due to an accident or to disability.
As soon as the first Social Security check was issued,
poverty amongst the elderly began to drop. There were 30
percent of elderly Americans in the 1950's who were in poverty.
Today it is about 10 percent. Two out of three seniors today
rely on Social Security as the prime source of monthly income,
including three-quarters of all elderly women. Women live
longer than men. Sorry, Jack. That is a fact of life. We live
longer.
Mr. Kingston. If you would yield to me. If you want to live
longer in a world without men, that is your business. That will
be your loss. It will not be as fun or as confusing.
[Laughter.]
We have had this technical mike problem. It is because of
sequestration, let the record show. [Laughter.]
Ms. DeLauro. Without doubt.
Speaking of sequestration, the decision to let that go
through in my view puts the basic functions of Social Security
at risk. These are cuts that come at a time when agencies have
been dealing with funding that has not kept up with inflation
or demand over the years. In the case of Social Security,
funding over the past 2 fiscal years for routine operations has
been essentially flat. In each of these years, the funding
level provided was below the President's request by
$924,000,000, or about 8 percent. The cuts have an impact on
our ability to serve seniors, to ensure that they get the
proper benefits they have earned. Efforts to prevent waste,
fraud, and abuse to ensure that benefits only go to eligible
individuals have not been fully funded. The Budget Control Act
permits additional funding to be provided above the spending
caps for continuing disability reviews and SSI
redeterminations. If we had fully funded this in 2012, it would
have provided an additional $140,000,000 for program integrity.
The 2013 House subcommittee provided none of the funding,
cut this work by about $483,000,000, and while the claims are
that we want to save money by cutting out program waste and
inefficiencies, rhetoric is not matched by action. Rather, it
suggests that people would prefer to see Social Security falter
in its basic responsibilities to America.
We need to be clear. The only thing SSA uses its funding
for is to get Social Security benefits to the seniors and
others who deserve them in a timely fashion. We are talking
about retirees that have worked their entire lives for
retirement benefits, individuals with disabilities, and seniors
who live in poverty. Right now, people are waiting desperately
for resources they deserve, earned, or they need to get by.
With these deep cuts, fewer applications will be processed,
backlogs will grow, more erroneous payments will be made, and
people will have to wait even longer in offices to have their
phone calls answered. The Social Security Administration is
already understaffed, and these cuts will only make things
worse.
Due to limited resources, the Social Security
Administration has already taken measures such as curbing
hiring and closing offices.
Meanwhile, a record number of individuals filed retirement
claims in 2012, and while the Social Security agency should be
applauded for completing 820,000 disability appeals this last
year, the backlog grew by 29,000. It still grew by 29,000.
Despite the recent progress, the average wait for a disability
appeals hearing is nearly 1 year.
I also understand that the agency has taken advantage of
technology to curb and cushion some of the effects of these
deep cuts. We want to hear about those efforts. In fact,
though, technology can only go so far since much of the work is
lengthy, it is complicated, and it requires individual
attention, the kind of work that demands a trained,
knowledgeable employee, a real person, if you will, working
with the beneficiary to assist him.
So a combination of more work, fewer staff has really
stretched the agency, and unfortunately, the future looks
bleak. In less than 10 years, the cuts made through existing
BCA caps will take non-defense discretionary spending to the
lowest level on record as a share of GDP.
Some people are demanding further reductions in caps, which
would mean that the shortfalls will just get worse. My view is
that we simply cannot do that and properly provide our seniors
and others with the benefits they deserve.
Let me just say a quick thank you to you for what you are
working to do to make the SSA more modern, efficient, the use
of technology to become more advanced to ensure that people get
the benefits that they have earned. I welcome you today and
hope that you can help the subcommittee to understand the
impact of these budget policies on our seniors and families.
Thank you so much for being here.
Ms. Colvin. Chairman Kingston, Ranking Member DeLauro, I
want to thank you for inviting me to discuss our service
delivery challenges and what we must do to successfully manage
them.
I am Social Security's Acting Commissioner.
At Social Security, we are responsible for administering
some of the Nation's largest and most successful programs. We
also administer programs providing an economic lifeline for the
most vulnerable among us. Last year, we paid over
$800,000,000,000 to almost 65,000,000 beneficiaries. We take
great pride in helping the American people by providing some
peace of mind during important transitions in their lives.
These transitions may include retirement, surviving the loss of
a family member, or coping with severe disabilities. While the
faces and circumstances of our customers vary, our commitment
to serve them never changes.
Over the years, Congress has asked us to take on more
responsibilities and challenges. Time and again, we have
succeeded when given adequate, predictable funding. Most
recently when Congress asked us to reduce the time it takes for
an individual to get a hearing decision and gave us the funding
to meet that objective, we delivered. In addition, when
Congress gave us funding to ramp up program integrity, we
dedicated those resources to tools that deliver an excellent
rate of return for the American taxpayer. In fact, recent
estimates suggest that continuing disability reviews save $9
for every dollar invested, and Supplemental Security Income
(SSI) redeterminations save about $6 for every dollar invested.
But in this difficult fiscal climate, our ability to serve
the public has suffered. Over the past 2 years, we have
operated at funding levels nearly $1,000,000,000 below the
President's budget. Sequestration further threatens our ability
to serve the public. At this time, we cannot adequately invest
in the information technology that would help us reach more of
our customers. Further, we have lost many of our Federal and
State employees through attrition.
To get by, we have consolidated 41 field offices and closed
490 contact stations. We have also abandoned plans to open new
hearing offices and a new teleservice center. The result is
deteriorating service nationwide. Wait times are going up in
our field offices and hearing offices, and those who call our
800 number have to wait longer.
Predictably, the American people are frustrated. Longer
waits can lead to dangerous behavior. More and more we receive
reports of receive frustrated customers threatening and
assaulting our employees and other members of the public. Just
last month, in Representative Simpson's district, a visitor to
the Boise office told one of our employees, ``If I get denied,
I am pretty sure I am going to lose it and hurt people or even
shoot someone.'' In Casa Grande, Arizona, someone even set off
an explosive device in one of our offices.
Still, we focus on what we have always focused on,
conscientiously and compassionately serving our customers. They
are, after all, to us people, not numbers. They are a
grandmother seeking a replacement Medicare card, a worker of 30
years applying for hard-earned retirement benefits, and a
wounded warrior in need of disability benefits because of
severe Posttraumatic Stress Disorder. We will never lose sight
of our customers. We remain committed to serving them with
care, diligence, and skill.
However, without sufficient, predictable funding, we can
only do so much. In this day and age, Americans increasingly
want to do more business with us online, and doing more
business online makes sense for the taxpayer. Our online
services are the highest rated in the public and private
sectors, but with limited funding, we cannot do much more than
maintain the information technology that we have.
Moreover, without sufficient, predictable funding, we
cannot invest in our best asset, the employees of Social
Security. If we do not have enough staff to keep up with the
work, the public can expect to wait longer in our offices, on
the phone, and for disability decisions. The quality of
decisions will also suffer without resources to invest in
training.
Of course, we recognize that fiscal belt-tightening means
making tough choices. We may need to further reduce office
hours, close offices, defer workloads, and take other cost-
saving measures that will sadly delay services to the public
even more. We will do what we can to manage these cuts fairly.
However, if Congress makes a greater investment in our
agency and the millions of people we serve, we will do what we
have always done. We will deliver. We will invest in
information technology and in our employees. We will continue
to streamline our business processes and our rules. We will
maintain Social Security as one of the most efficient and
effective agencies in the Federal Government, one with an
administrative overhead that is a mere 1.5 percent of all the
payments that it makes.
Thank you for the opportunity to appear before you today. I
will be happy to answer any questions you have.
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Mr. Kingston. Thank you very much, Ms. Colvin.
I wanted to get something clear in my mind. You have
something like $100,000,000 to $200,000,000 in IT carryover
funds that are accessible to you. Correct?
Ms. Colvin. Yes, we do have carryover funds available.
Mr. Kingston. But I think you just said--and I actually was
having trouble finding--because I think your testimony was not
quite tracking the complete written testimony. But I think you
said something like without sufficient funds to implement some
of the high-tech----
Ms. Colvin. Yes.
Mr. Kingston. But you have $100,000,000 to $200,000,000
sitting there.
Ms. Colvin. Well, that certainly is nowhere near the
dollars that we need to be able to do both maintenance of our
systems, as well as additional online services and improvements
in applications.
Mr. Kingston. How much will that take?
Ms. Colvin. I would have to get back to you with a specific
number. But right now at the sequestration level, we----
Mr. Kingston. Well, let me interrupt you a minute.
Shouldn't you know how much you need? And the reason why I
asked is----
Ms. Colvin. I have it. I do not have it right here.
Mr. Kingston. But somebody here would know. Right?
Ms. Colvin. I do not think so. It depends upon what we are
going to do. When we get an allocation, we lay out what our
plan for the year is going to be, what new applications we
expect to do, what modernization, what our maintenance costs
will be. So we always submit a budget that indicates the amount
that we are going to--I mean, if we were to submit to you
everything that we would like to do, the funding would be just
not possible. So what we do is try to, each year, look at what
we think is reasonable and make a request. So if you want to
know what we submitted in our 2013 request, I can provide you
with that figure.
Mr. Kingston. That would be helpful to me.
[The information follows:]
The fiscal year (FY) 2013 President's Budget assumed $857
million for our Information Technology Systems budget.
Mr. Kingston. And it gets back to my opening statement on
the centralized plan.
Ms. Colvin. Let me speak to that, if you would like.
Mr. Kingston. Please.
Ms. Colvin. We were advised by our attorneys, when we
received our appropriation, that we could not do a single
source contract, that it would be in violation of the
procurement law.
So based on that, what we did was develop a service
delivery plan with in-house staff. We consulted with the staff
of this committee to get their input. We have used that input
and the input of various other stakeholders--the advisory
board, and advocacy groups, et cetera--and we have developed a
draft plan. It is still in the works, but it will be posted on
the Federal Register hopefully this week and it will ask for
comments. We expect that the staff will probably offer further
comments, and then we would expect to finalize it.
Certainly strategic planning is something that we need to
focus on more in the agency. That is certainly something that I
am very much interested in as the Acting Commissioner. So this
plan was developed under Commissioner Astrue. I expect, once
that is submitted, that I will begin a further planning process
in the agency during the interim that I am there.
Mr. Kingston. And are you dealing with the National Academy
of Public Administration?
Ms. Colvin. No, we are not. As I indicated, our attorneys
said we could not do sole source, that there were many other
organizations out there that had the capacity to do this. And
so unless I get a different legal opinion, I do not think that
I would feel comfortable doing anything differently.
Mr. Kingston. I need a clarification. Maybe staff can help
me on it on your side of the table or mine.
But if it was stipulated in the fiscal year 2012 law to
work with them, why would that be a violation of the law?
Ms. Colvin. I have been informed that the Competition and
Contracting Act of 1984 requires us to obtain full and open
competition through the use of competitive procedures when we
contract for goods and services. And we do not believe that the
language expressly authorized us to do that.
Now, this is very technical. I would be very happy----
Mr. Kingston. No, no.
Ms. Colvin [continuing]. To provide you a more complete
response for the record, if you would like.
But I know we have had a lot of discussions with the
committee staff, and I think the conclusion was that the
language was not sufficient to allow us to do a sole source
competition--I mean, non-competition contract.
Mr. Kingston. All right.
Ms. Colvin. Would you like something further?
Mr. Kingston. Yes. I think that would be helpful.
Ms. Colvin. All right. We will do that.
[The information follows:]
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Mr. Kingston. And I will yield to Ms. DeLauro.
Ms. DeLauro. You have mentioned some of these facts, if you
will, in your testimony.
But Commissioner, let me ask you about the number of closed
field offices. The closures, as I understand it, will respond
to the pressure of dealing with flat funding you pointed out,
which has been eroded by inflation. Again, now we see
sequestration, new cuts, stagnant funding levels. Just in a
couple of areas, tell us a little bit more about what you have
already done in terms of office closures. Is closing additional
offices something that the Social Security Administration is
looking at to achieve the cuts required by sequestration? Let
me start there.
And I do not know. I think we ought to make a list
available probably to all Members about the Social Security
offices that have been closed in their communities and what is
pending as it regards this effort. I think they ought to have
that information.
So tell me about the office closures. I want to also ask
you about recent staffing trends, and will you have to
terminate any employees or implement furloughs under
sequestration? But let's start with the office closures.
Ms. Colvin. Thank you, Ms. DeLauro.
I would like to first say that we have had to make some
really tough and undesirable decisions over the last 2 years.
In 1989, we received the President's budget. For 2010 and 2011,
we received $1,000,000,000 less. And so that meant we had to
make some very difficult decisions.
One of those was that because we had such high attrition,
many of our offices were viable because we did not have
sufficient staff to be able to staff them. And in those areas
where we had offices that were nearby, we consolidated offices
and moved those staffs together. And we did work with the
community. We did notify individual members whose districts
would be impacted. We have closed 41 since then. We closed 490
contact stations.
Ms. DeLauro. What is a contact station?
Ms. Colvin. That is where we would have one individual who
staffed that facility and would go there maybe 1 day a week or
2 days a week or on a schedule so that people would know when
someone would be there and they could, in fact, go there.
With the use of videoconferencing and some of the Internet
usage, we felt that we could no longer keep contact stations
open. It did not make good business sense.
We have closed 490. We probably have another 40 or so that
we expect to close, and there will probably be a small number
that will remain open. We can give you the specifics on that,
if you would like.
This was not something that we did lightly, but we have
continued to try to serve our customers in those areas. We
realize that everyone is not going to use the Internet. They
are not going to have access to it. They are not going to feel
comfortable using it. So we are going to always have to have
field offices. But we have lost significant numbers of staff
over the last 2 years both at the State and local level. So we
just cannot do that.
In the testimony, you should have pictures of long lines at
some of our offices. People wait from 30 minutes to 2 hours.
That is not the type of service that we are proud of, nor is it
the type of service that someone who has paid for an earned
benefit deserves. But we do not have the ability to do anything
differently.
Ms. DeLauro. Will you have to close additional offices,
additional contact stations, if the sequester continues?
Ms. Colvin. We may. That is an option. My absolute last
alternative is to furlough staff because we have lost so many
already. We have to have staff to do the work. We also expect
another 3,000-plus persons who will attrit out of the system
this year, and we had hoped to be able to fill some of those
critical positions. But we are not certain yet what we will be
able to do there. So, yes, there is a possibility that we may
have to close offices.
As you know, we have also reduced our office hours that we
serve the public. We have reduced it by a full hour, Monday,
Tuesday, Thursdays, and Fridays, and a half day on Wednesdays
because we do not have overtime. And staff have to have time to
adjudicate the cases. Even though we do work online, it still
requires a human being to review the application, make sure it
is accurate, and then to adjudicate the case. And we have other
post-entitlement work.
But more importantly, we have program integrity work that
we have to do. If we do not do that, we keep people on the
rolls who should not be there.
Ms. DeLauro. My time has run out. But I am going to ask you
later about some of the limitations of technology in terms of a
personal commitment.
Thank you, Mr. Chairman.
Mr. Kingston. Mr. Joyce.
Mr. Joyce. Good morning, Commissioner Colvin.
Ms. Colvin. Good morning, sir.
Mr. Joyce. Thank you for your testimony here today.
I was wondering if a disability claim is denied, someone
has a right to appeal, and the appellate process can take more
than a year. What, if anything, has your agency been doing to
try to speed that process up?
Ms. Colvin. Thank you for that question.
Congress was very generous in funding us to reduce the
hearings backlog, and as I say, we deliver when you fund us.
And as a result, we started with a processing time in the
hearing offices of over 500 days. I think it was 555. We were
down to about 350, 357. I will give you the exact numbers in
writing.
[The information follows:]
At the height of the backing in August 2008 our hearing
offices had an average processing time of 532 days. We reduced
the average processing time down to 340 days by October 2011.
Ms. Colvin. And our goal was 270. But as a result now of
the cuts, that number is going back up. But we made tremendous
progress in reducing that number. As I said, it was over 500
when we received the funding from you, and now it is down to
less than a year. That is still too long, but I mean, we did do
what we said we would do based on the funding that you made
available to us.
Mr. Joyce. Thank you.
I yield back.
Mr. Kingston. Ms. Lee.
Ms. Lee. Thank you very much.
Good morning. Good to see you.
Ms. Colvin. Good morning.
Ms. Lee. Let me first say thank you for being here and
thank you for doing a tremendous job under very dire
circumstances really.
My mother actually is a retired Social Security employee.
She worked for Social Security 20 years. She is 88 years old
now.
Ms. Colvin. And we certainly thank her for her services.
The strength of our organization is our employees.
Ms. Lee. Yes, I tell you. And I come from Oakland,
California, and we have some wonderful employees and it is just
a great operation. And I just hate to see and to hear all of
the, I say, assaults that you are under and attacks.
First, you have had to downgrade the service in terms of
staff hours. You just laid out the day's hours. Now you have
got on top of that sequestration.
Let me ask you. What demographic is this going to hit the
worst?
And secondly, what is the morale like with your employees
at this point? I mean, this seems like a heavy-duty burden that
you all are carrying. And it really concerns me because the
Social Security offices are the offices of last resort for so
many people just to be able to live their daily lives. And now
with the kinds of cuts and trauma that the agency is facing,
you know, I am really worried about what is taking place.
Ms. Colvin. Thank you, Congresswoman Lee.
We are very concerned. We are an agency under stress. And
as I mentioned before, the employees are heroic in their
performance. Caseloads have increased. We cannot give them
overtime. We have not given them training. There is no travel.
And yet, they still serve in a compassionate and caring way. We
serve those people who are most at risk. Congress recognized
the need for a safety net, and we have the Social Security
program.
But we also provide other services. In addition to our core
services, we provide the Medicare cards. We process those. We
process Medicare Part D and because so many of the local and
State benefits require verification of benefits, many, many of
our customers come to get verification of benefits. So we
really are a basic safety net service in the community.
I would say that there is no one demographic that is
impacted. All of the seniors of this country are impacted, all
of the disabled, survivors. People who come to us come when
there is some transition in their life, normally not a good
transition.
And we have tried to stem the tide. We have had great
efficiencies with our IT investments. We continue to improve
those. And by the way, our Internet applications are rated the
best in Government and best in the private sector. But you
still need a human being. You have to be able to review these
applications to make sure they are accurate, and you also have
to go back and contact people, and you have to adjudicate. So
there is a tremendous need for staff. We are way down below
where we were 2 years ago, and yet we are at a time when the
baby boomers are aging out and people are reaching their
disability-prone years. And so our workloads are going up
tremendously.
So we have proven time and time again that when you give us
adequate, sustained, and predictable resources, we deliver. I
remember back when I was here in the 1990's, 1994 to 2001.
Congress gave us 7 years, multiple years, of funding for the
CDRs. We did every CDR and had no backlog. We knew what we had
to do. We knew what our timeframe was. We knew what our funding
was going to be, and we delivered. You asked us to reduce the
disability backlog. You gave us the funding. We delivered.
So we are an agency that when you invest in us, you get
your money's worth plus more. When you invest $1 in a CDR, you
get $9 back. When you invest $1 in a redetermination, you get
$6 back. And I do not think there is any Federal agency or
private agency that has an overhead of 1.5 percent of its
expenditures.
Ms. Lee. But even when we do not invest where we should,
you still deliver under dire circumstances.
Ms. Colvin. Yes, but we cannot anymore. We cannot anymore.
We are a ``can do'' agency, and it hurts an employee to have to
close the door and people have to come back a second day.
Ms. Lee. So what is their morale like?
Ms. Colvin. It is very low. It is very low. Fortunately,
because they are committed to public service, they still try to
do what they can do, but you see higher stresses as a result of
more illness. We have an older workforce. We have major
challenges.
Mr. Kingston. Thank you. The gentlewoman's time has
expired.
You know, I have to say, though, while I understand and I
am hearing you, you have 17 employees who are full-time union
representatives, paid by the taxpayers to do nothing but union
activities--17. And then you have 1,463 who do part-time union
activities, paid for by the taxpayers. It is $14,000,000. It is
such a disturbing thing to taxpayers.
I am hearing you say, well, we cannot pay claims. But I
would suspect--I am not sure, but I would suspect if you asked
those people standing in line, Democrat, Republican, liberal,
conservative, do you know that 17 employees at Social Security
are full-time union and that it costs about $14,000,000 a year
that you are paying for, do you feel good about that, or would
they say why don't they do that on their own time. And you
know, I know there is a statute on that, but I do not ever hear
administrators like you saying, you know, I want you to know
this is a problem.
Now, that is nothing--nothing--compared to what the GAO
said the overpayments were on SSI, $3,300,000,000. Let me
repeat that to my friends. $3,300,000,000 in overpayments. How
much of that money has been recovered? And that is a GAO report
which you have seen.
Ms. Colvin. And it is an accurate report.
Let me, first of all, say that we take, first of all,
preventing overpayments and then collecting them very
seriously. In fact, as the deputy during the time that I was a
deputy and certainly now as Acting Commissioner, I have been
personally involved in improper payments. Our accuracy rate for
improper payments in our title II program, which is less
complex--you have the age, you have the quarters, you get a
benefit--is 99.8 percent. You cannot get better than that. In
SSI, it is 92.7 percent.
So we have been making tremendous strides in our accuracy
rate. The problem is just one-tenth of a percent can result in
$50,000,000. So we are taking major steps to increase the
accuracy rate.
Mr. Kingston. It sounds a little bit like, well, you know,
the reductions, if you look at those as percentages, those
would be small too, and yet we have spent a lot of time this
morning talking about those. But $3,300,000,000 is big money,
and that is only 1 year, by the way, as you know.
Ms. Colvin. Absolutely.
Mr. Kingston. Only 1 year. So if it is 8 percent and 8
percent is a small amount, that is still huge money,
$3,300,000,000 in a 1-year period of time.
Ms. Colvin. The SSI program is very complex--very complex.
Some of our biggest challenges are individuals reporting their
changes in assets and wages. We have instituted a program
called--well, it is Access to Financial Institutions--where now
we are able to work with the banks and go out and identify any
assets that individuals have not reported. And that has been
very effective. As our budget allows, I will continue to reduce
the threshold so that we can do more and more of that. And we
are removing individuals because they have, in fact, not
reported all of their resources.
We also have instituted a telephone wage reporting system
where individuals can report their wages so that we can learn
early because, as you know, we do not get the wage reports but
once a year, although there has been a proposal in the
President's budget to get it quarterly because the earlier we
get it, the quicker we can check. So the agency is very
aggressive, in preventing overpayments.
We have the CDI units, which are our Cooperative Disability
Units, where we work with our Office of Inspector General to
identify any potential fraudulent cases so that we can prevent
anything from happening before it happens. We focus on
aggressively going after any dollars that are overpaid.
I will say we also focus on under payments. We have
individuals who should have been paid more, but because of the
complexity of the program, we have not been able to do that.
But that is a high priority.
Mr. Kingston. How much of the $3,300,000,000 in 1 year
overpayment for SSI has been recovered?
Ms. Colvin. I can provide you that for the record, but you
will see that our numbers have increased each year.
[The information follows:]
Below is our SSI overpayment collections for the last five
fiscal years:
FY 2008--$1,059,600,000
FY 2009--$1,102,600,000
FY 2010--$1,168,900,000
FY 2011--$1,171,400,000
FY 2012--$1,202,200,000.
Mr. Kingston. Thank you. My time has expired.
Ms. DeLauro. It is not the question I was going to ask, but
I cannot stay out of this discussion because I just find it
very interesting.
Mr. Kingston. I had a feeling.
Ms. DeLauro. Oh, yes. I just find it so, so interesting
that my majority counterpart has--we are always eager to bring
up waste, fraud, and abuse. Quite frankly, we are not
interested when it comes to other areas of the budget like crop
insurance or any other way, but that is a fact of life.
However, when we come to funding the efforts that would
allow for this redetermination or for the continuing disability
reviews, the subcommittee has a very dismal record.
Example. 2012, Budget Control Act explicitly provided an
exemption in the caps for program integrity at SSA at
$623,000,000. The enacted level was $140,000,000 less than was
permitted.
The 2013 House bill that barely made it to the
subcommittee, provided no additional BCA-permitted funding.
Zero. Zero for program integrity. $751,000,000 less than was
permitted.
According to the chief actuary at the SSA, the lack of
funding in the House subcommittee bill would have cost
approximately $5,000,000,000 to $6,000,000,000 over the long
run. Each dollar spent, as the Commissioner has pointed out,
for the program integrity saves between $6 and $9 on average.
I would encourage my colleagues to provide the funding for
program integrity so that in fact we can see what those
redeterminations cough up or the reviews cough up so that we
can save money and cut out whether it is an overpayment,
whether it is an underpayment, or whatever it is. You cannot
have it both ways. You cannot make a determination that you do
not want to provide the money and then say, my God, you are
losing money. And that has been the case over and over and over
again. And if this subcommittee wants to do its job, it would
provide this agency with that money for program integrity--it
is what it is all about--instead of complaining about program
waste.
I just will mention this. I will bring it up in another
context. And that is I hope my colleagues on the other side of
the aisle will help us to uncover the 26 people who get at
least $1,000,000 in a premium subsidy from crop insurance, and
in fact, they have no asset test, no threshold levels in income
or anything else. We cannot even find out who they are. Nobody
will make it public. So I am going to enlist my colleagues when
we are talking about this issue and trying to find those folks
who are getting this money which we cannot account for.
You do not have to comment on that. I have got about a
minute or so left here.
Mr. Kingston. Let the record show your microphone is
working fine now. [Laughter.]
Ms. DeLauro. Yes, indeedy. Yes, indeedy.
I just want to ask you this question, and then I am going
to have to dash to the Ag Committee, but I will come back.
In terms of what you talked about, a skilled labor force at
Social Security over the long term, how long does it take to
train an employee? What are the limitations of the technology
in terms of the complex nature of some of the cases that we are
talking about here?
Ms. Colvin. We have determined that it takes well over a
year for a new claims examiner to be qualified to adjudicate a
case. And we provide very intensive training. In addition, they
are assigned to a mentor. These are very, very complex cases.
The cases that are less complex have been automated. SSI is
certainly our most difficult program to administer, and we do
have a long-range plan to try to automate that also, but that
is very complex. But you are talking about looking at all of
the information that has been provided and then other medical
information in adjudicating a case.
As you know, the disability process starts at the State
level with the disability examiners, and we are very concerned
because we have not hired anyone in those positions over the
last 2 years. And so as we are losing the more seasoned
examiners. We know that even if we hire today, it is going to
take us about a year to have a proficient staff person there.
Mr. Kingston. Mr. Joyce.
Mr. Joyce. Thank you, Chairman Kingston.
Commissioner, I would like to follow up on something the
chairman brought up with you, and maybe I missed it in your
answer. But what is the threshold amount at which you start to
look for overpayments?
Ms. Colvin. What is the threshold amount?
Mr. Joyce. Yes. You said there was a threshold, but I did
not hear a number.
Ms. Colvin. No, I do not recall saying there is a
threshold. We go after any overpayment. We do not have a
minimum number that we would look for. What we do is review a
case to see if the information that we received is accurate,
and then if it is not, it means that we have overpaid that
individual. It could be a month's over-payment, 2 months
overpayment. We would pursue that.
Now, I do not know if you are referencing the fact that
there could be a waiver under extenuating circumstances, but we
generally pursue all overpayments.
Mr. Joyce. Well, I am sorry. I just heard you say the word
``threshold,'' but I did not hear the amount.
Ms. Colvin. Are you talking about overpayments
specifically?
Mr. Joyce. Yes. That is what you are looking for is people
that you have overpaid.
Ms. Colvin. Yes. Well, we would pursue all of those.
Mr. Joyce. And I also wanted to follow up. In an NPR
testimony, former Commissioner Astrue mentioned that the
program needs to adapt to the times. Do you agree?
Ms. Colvin. I am not certain what his reference was when he
said ``adapt to the times.'' Do you know what he was
referencing?
Mr. Joyce. Well, that the program is maybe running a 1980's
program when we are in 2013. That is the way I took the
comment. I was wondering if you had any ideas about that.
Ms. Colvin. Well, if he was speaking of the disability
program, we are always looking at medical advancements. We are
looking at policy changes that need to occur. We are in the
midst right now of updating our medical listings. In some
instances, those medical listings had not been updated for
many, many years. We now have updated, I believe, 10 of the 14,
and we are on a cycle where we will update those every 3 years
so that as medical advances occur, the listings would reflect
those medical advances. I think you certainly have to
constantly be attentive to the changes both in technology and
in the medical community. And I know that is happening on an
ongoing basis.
I would suggest that the program is not the same as when it
was originally implemented. Even Congress has made many changes
over the years to try to keep up with the changes that they
believed were necessary.
Mr. Joyce. So you agree that something needs to be done
then to continue working forward and make it this----
Ms. Colvin. We have research that is going on internally
and externally. So we are always looking for ways to improve
the program to make it more appropriate and relevant to today's
needs. I would say that is something that is ongoing. Yes.
Mr. Joyce. And efficient?
Ms. Colvin. I think it is efficient. I think that clearly
there are always pros and cons. Sometimes Congress agrees and
sometimes it does not. But you know, you all make the laws and
we try to implement them at Social Security.
Mr. Joyce. Thank you.
I yield back my time.
Mr. Kingston. Thank you, Mr. Joyce.
Ms. Lee.
Ms. Lee. Thank you.
I wanted to go back to this whole issue of online activity.
The digital divide is still very real in many parts of the
country in many of our communities, and while we have to move
toward technology--I understand that and you all are doing a
really great job--I wanted to find out if you have certain
online requirements. For instance, oftentimes employers will
not accept a resume unless that resume is submitted online.
Well, a lot of people in my district cannot submit resumes
because they do not have a computer. They go to the library.
There is a long wait. Then they have to leave and do other
things. Do you have any requirements for online-specific
response?
And then the other issue is how are you addressing--given
your cutbacks and given the stresses that your employees are
dealing with now, how are you calibrating that so that people
who do not have access to computers are still able to receive
the services that they deserve?
Ms. Colvin. Thank you, Ms. Lee.
We recognize that we are going to always have customers who
will not choose to work with us online. We are almost at 50
percent of our claimants using online services. So that is
about 50 percent who are not. And so we expect that some people
will always want to call in by phone or walk into the office to
have face-to-face services. We do not expect that we will ever
have a system where we will not have that.
What online services allow us to do is two things. One, it
allows us to meet customer expectations because some customers
really want to be served in the privacy of their home, and they
do not want to come to the office. Two, because we get certain
efficiencies with online services, it allows us to be more
efficient, to be able to process cases faster, and to keep up
with the increasing workloads. So there is always going to be a
balance.
But we do not require anyone to use online services. We
make them aware of it. We encourage them to use it. And
certainly as the populations get younger and younger, they
will, in fact, want to use online services.
Ms. Lee. Okay. Thank you very much. So there is no
requirement for any service to be accessed online.
Ms. Colvin. You are thinking of direct deposit, which is a
Treasury requirement. We do not require that you do online
services.
Ms. Lee. Are you still mailing checks?
Ms. Colvin. The Treasury Department requires that you have
the direct deposit. There are a number of individuals who still
have not signed up for direct deposit. Treasury has assured us
that they will still get their paper check, but they are out of
compliance. So they will still encourage them to move to direct
deposit. They do have a waiver for individuals who do not want
to do direct deposit, particularly those who are older, 90 and
older.
Ms. Lee. I know a lot of people who do not want direct
deposit.
Ms. Colvin. Right. But Treasury at this point has said that
they will still get their paper checks. I do not know how long.
Ms. Lee. They will get their----
Ms. Colvin. Yes. Treasury has said that they will.
Ms. Lee. Once Treasury says that is it, direct deposit,
then we have to go to Treasury----
Ms. Colvin. Yes.
Ms. Lee. Because that is a big issue. That is a big issue.
Ms. Colvin. It is. And we are working with Treasury. We are
letting them know the issues that develop from our perspective.
But it is a statute, and it is a Treasury requirement.
Ms. Lee. Thank you.
Mr. Kingston. Mr. Womack.
Mr. Womack. Thank you, Mr. Chairman. Sorry I am late. I had
a previous hearing that I was attending.
If I go back over some material that has already been
covered, I certainly apologize up front.
I am going to confine my line of questions toward
automation because this is an agency that I think has
benefitted from and can continue to benefit from our capacity
to utilize the automated technology that is out there and maybe
that we have yet to see. So I am kind of asking at a 30,000-
foot level. Are we continuing to do the things necessary to
ensure that we are maximizing our technological capability
without sacrificing privacy and matters of privacy that can be
compromised? And then I will follow up on that.
Ms. Colvin. Thank you, Mr. Womack.
We believe that technology is the one thing that has
allowed us to consistently see a 4 percent production increase
each year for the last 5 years. Certainly with the loss of
staff that we have had and the increasing workloads, we would
not have been able to keep up without automation.
About 50 percent of our applications now for disability and
retirement are filed online, and that number continues to go
up. It is probably about 48 percent, but it continues to go up.
And we are constantly bringing on new applications. People can
file for retirement and disability online. With My Social
Security now they can get their earnings statement online. They
can do a change of address, direct deposit, and other things of
that nature. And we are constantly developing additional
applications.
A great part of our workload is individuals coming into the
offices for benefit verification because they need that to get
local and State benefits, and we work with those local and
State entities. We now have the ability to provide the benefit
verification online. We have just started that. So now we need
to make sure that the providers and local governments will, in
fact, go online rather than send their individuals into the
office.
We have an IT plan relative to how we would roll out
increased online services, but right now, we are operating
within the agency, at what we call, it's ``lights on,'' minimum
that is necessary to keep us running. We do not have an
allocation in this existing budget to do new applications. I
think the number that--we have about $850,000,000 in the IT
budget now. We would need money above and beyond that amount to
do additional applications.
My desire is to try to at least keep the things that we
have in place going. For instance, we are bringing up a major
system, Disability Case Processing System, where instead of
having 54 separate State Disability Determination Services
(DDS) systems, we will have one system that is Federal. That
will speed things up. It will make it consistent. That is going
to cost money.
Now, we have budgeted that each year. We would certainly
expect that would be there each year because we developed a
long-term plan. And that is what we do when we are looking at
systems that we can bring up.
But again, unless we have sustained and predictable
funding, it is very difficult to plan because, you know, IT is
not something you can do overnight. And so you have got to have
some sense of what your budget is going to be from year to
year. So it is difficult, but we certainly are trying to do the
very thing that you have asked are we doing.
Mr. Womack. This year my wife received a--and I am not real
sure how she got this, whether it was the paper statement that
came in the mail, the calculation that shows your Social
Security. I cannot remember what you call that. We used to get
those. But this year, all of a sudden, another name showed up--
I guess it was called an alias that she might have gone by--
showed up with a different income stream, and it was a very
complicated thing. But it just appeared out of nowhere. And I
am not asking for any help in deconflicting that because we
have already taken steps to do that. There is a basis for my
question.
Now, there were some coincidental things about it. The name
was the same. General location, geographic location of the
State was the same, where they were from, and both of their
parents--two different people--by the same name had a father
that had an initial H and D. And so all of a sudden, boom, it
gets plugged in as part of her earnings record. It benefitted
the other person greatly, not so good for my wife.
That said, how does that happen? And do we have enough
defense in depth of our automated systems so that we are able
to discern something that is about to go plugged in on
somebody's earnings record that should not be there? And is
there a way that those things can be flagged? Because her
earnings record was pretty consistent for years and years and
years and years and years, and then all of a sudden, something
appears out of the blue. It threw us for a loop.
And I know there are a lot of people out there that
probably are caught up particularly with stolen identities and
what have you. There are a lot of people caught up in this kind
of a scenario, and it bothers me that they may not know what to
do.
Ms. Colvin. This scenario we are very concerned about. We
know that people are always trying to hack into the systems. We
certainly take security measures. We right now are reviewing
our authentication process. As you know, My Social Security has
not been up that long. We have had tremendous response, but we
are looking at the authentication process to see if we need to
make it more vigorous and more robust. So we are always looking
at that.
We work with our Office of Inspector General if they
identify any cases that are the kinds of cases that you are
talking about to do an analysis to determine what happened, how
it happened, and how to prevent it from happening again.
We realize that we have an awful lot of data Personally
Identifiable Information (PII) and we do everything that we can
to protect that data. To say we have never had a breach, I do
not think I could say that. But I will tell you that protecting
PII has the highest priority in the agency. We have reviews
that are done by an outside auditor each year. We have inside
reviews that are done by our own staff, and then we have the
OIG reviews. But this is an area we focus on.
Mr. Womack. Thank you very much.
I yield back.
Mr. Kingston. The gentleman's time has expired.
I wanted to, number one, make sure that on this fraud
thing, that we are taking it very, very seriously--a fraud or
overpayment. You know, I am outraged about 26 people who I am
not even sure what Ms. DeLauro meant on the crop insurance. But
frankly, we should pursue them. The school lunch program has a
16 percent error rate. The school breakfast program has a 26
percent error rate. Lord knows the Pentagon procurement system
is broken and needs lots of attention. I think the military can
play the game as well as anybody when it comes to moving funds
around and making things very confusing.
But we as Democrats and Republicans and Independents are
charged with the job that I do not think we are taking as
seriously as we should be. There is a lot more common ground
than we want to give ourselves credit for. If we cannot agree
on overpayments and error rates and fraud, then this country
has no hope, and if this country has no hope, the world has no
hope. I just feel very strongly about it. When I go home and I
talk about this, this is just unbelievable that we cannot
sincerely have a shared outrage about this.
You know, as a Republican conservative, certainly I
understand these 14 union employees. None of them would
probably vote Republican. We understand that this is a
political deal. And it is a statute. You cannot do anything
about it and I cannot get anything about it but get frustrated.
$14,000,000 for union activities on the taxpayer dime. But you
know, maybe we cannot change that immediately for partisan
reasons.
But why can we not really go after the overpayment with a
great zeal and just a great fervor? I mean, why can we just not
say--you know the old expression, partisanship ends at the
water's edge. The President is about to go to Israel. He met
with us yesterday. I am glad he is going. But why can
partisanship not end when it comes to over payment and fraud
and abuse and inefficiencies? And to me, it seems like there
should be a culture.
I will ask you this, and I know I am lecturing. I do not
mean to lecture, but I am getting it off my chest, which I hope
we all feel some common ground with.
SSI claims, according to your testimony, have gone up 38
percent since 2007. Do you really believe in your heart of
hearts that that many people have become disabled? Or is it, as
folks tell me on the street, their unemployment ran out and
that gives them an opportunity for a more permanent income
stream. And I am not saying they are not desperate. But do we
really believe--and I will ask you. Do you share any of my
outrage on that 38 percent increase since 2007 in SSI? Is that
merely coincidence?
Ms. Colvin. Well, Mr. Kingston, the SSA actuaries indicate
that the increase is due to the changing demographics, that it
is due to the aging of the baby boomers. It is due to the
people reaching their disability-prone years, and that some of
it is due to unemployment, but that that is due to the fact
that individuals who normally would qualify for disability
under our listings try to stay in the workforce and they do as
long as they can, and they reach a point where they just are no
longer able to because of their disability.
So I am not seeing anything to suggest that--I mean, we
certainly try to apply the disability law according to the
standards. We have quality reviews. The accuracy rate in the
DDSs still remains high.
Mr. Kingston. I mean, you are not on trial here.
Ms. Colvin. No, but I am telling you what I understand.
Mr. Kingston. I mean, you are not on trial and this is not
your fault.
Ms. Colvin. I understand.
Mr. Kingston. But do you really believe this is because of
changing demographics? I mean, I know you can get an actuary,
just like a lawyer, to give you a lot of answers, and I am not
saying you did that at all.
Ms. Colvin. Well, if you ask me do I believe as an
individual, I would say yes. I worked with the disability
population at the local and State level. When I was in
Maryland, I was responsible for that population, when I was in
Montgomery County, at the local level. If you look at the
disabilities under which they come, it is no different than the
Social Security Disability Insurance (SSDI) population except
that they come based on income as opposed to the fact that they
paid into the system. I did not see a difference.
Mr. Kingston. Well, then you probably have the breakdown of
that 38 percent, how many, say, are over 50 years old, how many
are under.
Ms. Colvin. We would have that.
Mr. Kingston. And what is that?
Ms. Colvin. Oh, I do not know it in my head. I will be
happy to give it to you for the record.
[The information follows:]
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Mr. Kingston. But you would know in your head that it is
consistent because you are saying that it is a demographic
change. So you had to have something more than a gut instinct.
Ms. Colvin. No. I am saying that as people get older, they
become more prone to disabilities. So if you look at the
population, you can see that.
Now, for children or younger people who are on the
disability rolls, some research would suggest that it is due to
the fact that as you get larger numbers and you see more coming
on because of mental health issues, et cetera, that can be
because it is more readily identified. I would be happy to
share with you the research studies that have been done in that
area. But I am not seeing anything that----
Mr. Kingston. Okay. I would like to see it because it is so
interesting to me.
Ms. Colvin. We would be happy to do that.
[The information follows:]
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Mr. Kingston. You know, I always say to people back home
you can say what you want about Members of Congress, but we do
get lots of information and lots of opinions. And certainly,
you know, when I am back home, this is one of the opinions that
I have gotten consistently that people have moved towards as a
pot of money or a stream of money and, again, just because of
the unemployment situation. So it is interesting to me that
your conclusion is completely different, and your conclusion is
presumably backed up by facts. So I would like to see the
demographic breakdown that this is just the aging of America
rather than this is the gaming of America, you might say. I
think it would be very interesting to know. Well, I get a
different opinion on the street I got to tell you.
Let me ask you this, though. If I am right, are we in the
same boat that you would share my outrage if I am right? And if
I am wrong, I will say, golly, I am wrong and I would tell you.
Ms. Colvin. As I mentioned before, we take fraud very
seriously within the agency. In fact, our employees that I
commend for the work that they do are usually our first line of
defense. When someone comes in and based on the information
that they are provided or information that they have obtained,
that they are attempting to get a benefit that they are not
entitled to, we are very aggressive in referring that case to
the Inspector General.
I will say also that SSA has always been very focused on
fraud detection and prevention. When I was here in 1998 as the
Deputy Commissioner for Operations, I instituted the existing
CDI units, which is a partnership between SSA and OIG because
we wanted to be very aggressive in going after any individual
who might be trying to commit fraud. And that was 12 years ago,
and now it has even been intensified.
So this is an agency that believes if a person is entitled
to a benefit, they should get it, but if they are not entitled
to a benefit, that we should do everything under the law to see
that they do not get it. And if they got one fraudulently, we
should aggressively go after them for fraud. So we do that.
Mr. Kingston. So as founder of this--what did you call it?
I know my time is way over, Mr. Joyce. I appreciate your
patience.
Ms. Colvin. Cooperative Disability Unit, CDI.
Mr. Kingston. I am reaching out.
Ms. Colvin. I understand.
Mr. Kingston. We are on the same page then. We would be on
the same page on the outrage of somebody who is----
Ms. Colvin. Yes, absolutely.
Mr. Kingston. If there is any hope between some of the
division in this town, I think we should be able to come
together over somebody who is taking advantage of a benefit
that should be going to somebody else who, as you pointed out,
might be getting underpaid.
Ms. Colvin. Absolutely.
Mr. Kingston. Or one of your employees who has been in the
system for 20-25 years and just is frustrated to death right
now.
Mr. Joyce.
Mr. Joyce. Thank you, Chairman.
I would like to follow up on your questions. One of the
things that you were talking about with this designation of the
disability--if someone is under 50, does that continue on for
the rest of their lifetime--that payment?
Ms. Colvin. That is a good question. No, sir. That is why
the CDR is so important. Based on the disability, we diary a
case and we determine when that case should be reviewed again,
and that is what triggers our continuing disability review. So
we would then review that case at an appropriate time to
determine if there has been any medical improvement that would
now disqualify that individual. Or if it is an SSI case, and
they are on the rolls, we would look at the medical piece, but
we also look at the asset piece to see if they are still
financially eligible based on income. So we do that on a
regular basis. And that is why the continuing disability
reviews and the redeterminations are so important.
Mr. Joyce. How long into the future do you look then? A
year, 2 years out after they----
Ms. Colvin. It depends upon the type of disability if
medical improvement is expected. We do CDR's every 3, 5, or 7
years depending upon the type of disability.
Mr. Joyce. And what, if any, investigation is taken to see
if they have mislead your agency to the disability?
Ms. Colvin. Well, that would be where you would be
verifying the medical information, or you would be verifying
the asset information. So we would verify that.
Mr. Joyce. With the ones with the disability that might be
coming because they have run out of unemployment, can you tell
whether or not their unemployment ran out and now they are
applying for the disability?
Ms. Colvin. I do not know the answer to that question.
Mr. Joyce. So there is nothing that would indicate or
trigger for you that perhaps this person was gaming the system?
Ms. Colvin. You mean because they previously received
unemployment?
Mr. Joyce. Right and that expired. Now, all of a sudden,
they come over----
Ms. Colvin. We are not looking at whether or not they
previously got unemployment. We are looking at whether or not
they meet the standard, the definition of disability. So there
is a very extensive review process to make that adjudication
determination.
Mr. Kingston. Will the gentleman yield?
Mr. Joyce. Yes.
Mr. Kingston. A question on that. When 43 percent of them
do it online, how do you know--do you get a doctor
verification?
Ms. Colvin. Oh, that is just the initial application. They
still have to be physically seen.
[Clerk's note.--Later corrected to ``They have to get an
extra medical review by a physician or a consultant.'']
Mr. Kingston. Okay.
Ms. Colvin. Yes. We were saying that it happens to save
time.
Mr. Kingston. Yes, but it is just the initial.
Ms. Colvin. Yes.
Mr. Kingston. Okay. I yield back.
Ms. Colvin. They still have to be seen. Yes.
[Clerk's note.--Later corrected to delete ``They still have
to be seen, yes.'']
They cannot get a determination just by something that is
written. They have got to have an entire medical review by a
physician or a consultant.
Mr. Joyce. So that would be an independent review by your
agency after they bring in their documentation from their
primary care physician.
Ms. Colvin. Yes. All of that information is given to the
disability examiner at the DDS level who then has to review
that. In some instances, they may require an additional medical
consultant. They may require the individuals to see a physician
of our choice, but you have all of that. There is a whole
series of steps that one must go through in order to receive a
medical determination.
Mr. Joyce. If you know, what percentage of those are denied
and what percentage of those who apply are accepted?
Ms. Colvin. I can get that information for you. I do not
know the percentage of denials and acceptance.
I understand that at the initial allowance rate, it is 30
percent that are allowed.
Mr. Joyce. And 70 percent denied.
Ms. Colvin. Yes.
Mr. Joyce. Thank you.
I yield back.
Mr. Kingston. Thank you.
While you were gone, Ms. DeLauro, I pledged to locate those
26 farmers. [Laughter.]
Mr. Kingston. Even if they are all from the great State of
Georgia or Connecticut.
Ms. DeLauro. And I hope--and I know you hope as well--that
they are all farmers.
Mr. Kingston. They are probably not. They are probably
doctors. [Laughter.]
Ms. DeLauro. I am sorry I was not here for the beginning of
the discussion, but I would like to have you walk us through
the disability claims process, if you would not mind, to give
us a better idea of how intense, or labor-intensive it may be.
Ms. Colvin. I do not think I can do that sitting here. That
is a very technical process. As I mentioned earlier, it takes
well over a year for a disability examiner to become
proficient. Can I give you that for the record?
Ms. DeLauro. Yes. I would appreciate that. I think it would
be useful for us to have a better basic understanding of what
you are faced with.
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Ms. DeLauro. I will go back to where I left off. What can
be done with technology and what cannot be done with
technology?
Ms. Colvin. In the disability process?
Mr. Kingston. I promise the majority had nothing to do with
your microphones.
Ms. DeLauro. I will give you the benefit of the doubt,
Jack.
Because sometimes we over-think the technology side and
there is a lack of understanding of the person-to-person
interview, the kind of effort required because this is not
cookie cutter. This is based on individuals.
Tell us a little bit about the 1-800 number, what is
happening with that, what is the backlog, response time. And
obviously, given the nature of our current budget situation and
the sequestration, what will happen with that? That has got to
be one of the most frustrating things, when you put in a call
and it goes nowhere. It is like a hole. So tell me a little bit
about what is happening there.
Ms. Colvin. As I mentioned earlier, we have seen a
deterioration in all of our metrics. The numbers are going in
the wrong direction. But just now we are looking at 15 percent
or 3,300,000 of our calls where when people dial, they get a
busy signal. That is 15 percent, or 3,300,000 of the calls that
we get a year. Those individuals get a busy signal.
Ms. DeLauro. 3,300,000 calls?
Ms. Colvin. Yes. 15 percent of our calls.
And then once they get through, we have what we call
average speed of answer, how quickly we answer once you get
through. We are now at 7.5 minutes, which means it is doubled
since fiscal year 2010. So not only do you have trouble getting
in, once you get in, you still wait another 7.5 minutes before
you get a live operator. So our metrics are going in the wrong
direction, and that is because, again, we have not hired since
2010. More people are calling because of the waiting. They
would prefer not to stand in line for 2 hours. So they go home
and they try to call, and they cannot get through.
Ms. DeLauro. I cannot see the clock, so I do not know if I
have any time left.
Mr. Kingston. You are good.
Ms. DeLauro. You may have answered this, and if that is the
case, I apologize.
The reasons disability claims are going up?
Ms. Colvin. Well, I answered that question. I think Mr.
Chairman and I sort of had different views, but I indicated
that our actuary has indicated that those increases are due to
demographic changes, the result of the baby boomers aging out,
the individuals reaching the disability-prone years, and some
of it to unemployment, individuals who meet our listings, tried
to work but have not been able to sustain work and now with the
job market have just decided that they are eligible, they
think, and they apply. Now, in some instances when people are
unemployed, they apply. So our application rates go up, but
they are denied. So we still believe that we have a high
accuracy rate relative to approving people who are, in fact,
disabled.
Ms. DeLauro. And then just finally, I would love to see if
you have the data on gender breakdown, on what is happening to
women.
Ms. Colvin. I am glad you brought that up because I missed
that important variable. The actuary also indicates that
because more women have entered the labor force, they are on
parity now, and they also contribute to the incident rate of
allowances. So that is a variable. Yes. Thank you for
mentioning that.
Ms. DeLauro. Thank you, Mr. Chairman.
Mr. Kingston. Mr. Alexander.
Mr. Alexander. Thank you, Mr. Chairman.
Ms. Colvin. Good morning, sir.
Mr. Alexander. Good morning. I believe in your testimony
you mentioned closing of some of the field offices, 41. One was
in Louisiana in my congressional district. Look, I commend you
for taking the often difficult step of reducing cost, savings,
but my concern is that there is a lack of a long-term strategic
plan. So can you outline how field offices are closed and how
you decide on which ones and tell us how they fit into the
administration's long-term plan for dealing with----
Ms. Colvin. Let me answer that in two ways. We are in the
process of developing a long-term plan. I know this committee
has been concerned that a plan did not exist. There is a plan
that is coming in that was developed under the previous
Commissioner. We are going to let that move forward. But I am
also going to be starting a planning process during the interim
period that I am there as Acting Commissioner.
With the closing of offices, I have asked to look at the
criteria that we use. A lot of it is based on the viability of
an office as we lose staff, whether or not there are other
offices that are in close proximity. So there is a whole host
of criteria that goes into making a decision about whether or
not it is going to close. I think it would be better if I
provided you with something for the record that indicates the
existing criteria, but I am looking at that again also.
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Mr. Alexander. Okay. Thank you.
Mr. Kingston. I wanted to ask. You are in a position to see
up close what works and what does not work. And you might not
want to answer this, but just to venture into policy a little
bit, do you have some suggestions that could be helpful for us
as we discuss Social Security?
For example, yesterday the President met with the
Republican Conference and said that he does support changing
CPI. And his point to us was that is not necessarily a
comfortable position for a Democrat. What he was saying to us
is you have to move from comfortable positions too, and if we
are going to save these universally popular programs, we have
to do something.
He did not say this statistic, but I think this is
generally accurate. My dad retired at age 65 in 1980, and all
the money he put in Social Security he received back in 3
years. He lived 25 years. So it was a great deal for him. Today
if you retire, I believe it takes 17 years to recoup what you
put in it. But for our children, they will probably get 70
cents on the dollar. I think those are roughly correct, don't
you think?
And so as we sit here, we know we have to change things. I
do not know changing CPI does the trick. I do not know that
means testing does. I do not know that raising the age. And by
the way, what is the age today? Because I know it is moving up?
Ms. Colvin. It is around 67.
Mr. Kingston. It is not quite to 67, though, is it? It is
66?
Ms. Colvin. It is between 66 and 67.
Mr. Kingston. It is going up 3 months a year.
Ms. Colvin. It is going up depending upon date of birth.
Mr. Kingston. And you know, when that decision was made in
1982, I think 40 Members of Congress got an invitation back to
the private sector showing how difficult it was even then.
I mean, do you want to say anything about policy? You
certainly do not need to.
Ms. Colvin. Well, I think, you know, Mr. Kingston, that the
Treasury Department is really the agency that deals with the
solvency debate. Our role at Social Security is to provide
data, to provide analysis, to indicate what the impacts will be
of various proposals that go forth. We provide technical
assistance to the committees here, the congressional
committees, and we provide technical assistance to the White
House, to the Office of Management and Budget. My role is to
implement the law as you have passed it and to run the agency.
So fortunately or unfortunately, I do not have to----
Mr. Kingston. I am not trying to debate you in a policy
discussion. Trust me. I just was wondering.
Ms. DeLauro.
Ms. DeLauro. Just in terms of notifying offices on closure,
how much advance warning do they get?
Ms. Colvin. 60 days.
[Clerk's note. Later corrected to ``90 days'']
Ms. DeLauro. The coordination of workloads between offices.
You know, what we have heard--the impacts of erosion of funding
due to inflation, that it is creating a problem to work between
agencies. Is that accurate?
Ms. Colvin. Between agencies?
Ms. DeLauro. Field offices and coordinating workloads. I am
sorry. Field offices.
Ms. Colvin. What we do is we have our field offices that
are stressed, and they are not able to get to the workload. We
have the ability to transfer work among offices because we have
virtual offices, and a lot of our work now is electronic. What
we are trying to do is ensure that you are not disadvantaged
because you live in a particular geographic area of the country
and trying to provide the same level of services as we can. So
we do constantly look at what is happening and see where we can
share work across offices where it is electronic.
Ms. DeLauro. And what will be your continued ability to do
that with further cuts?
Ms. Colvin. I do not know the answer to that. It depends
upon my level of funding. As I said, we continue to lose staff.
So I really do not know the answer to that.
Ms. DeLauro. I think it is important--and I know Mr.
Alexander asked about the facility in his district. I really do
believe it is going to be important for Members to know where
notices are going out, if that occurs, if we proceed forward
here with this, and it appears that sequestration is moving
forward. And I know you said you do advise them and so forth.
Ms. Colvin. We do.
Ms. DeLauro. But I think it does not hurt to let people
know that whether it is your contact station or your field
offices or even where offices have shortened hours--that always
generates complaints to our district offices, the lack of
service. So I just think that Members have to continually be
aware of what is at stake in these efforts.
I think it is also interesting that your budget is almost
entirely staff or support for staff, unlike some of the
agencies that come before us. At the Social Security
Administration you do not administer grants or loans or do any
of that. What is a unique challenge because of the nature of
your agency with regard to a flat budget or sequestration?
Ms. Colvin. Well, you know, we have fixed costs that go up,
rental facilities and other costs that are fixed, and they go
up each year. So we do not have a lot of flexibility.
Unlike other agencies, none of our work is discretionary.
It is all required by statute. And we do not control the number
of applicants that come in the door. And so if we do not have a
sufficient budget, which means we do not have sufficient staff
and we are not able to invest technology, that means we are
going to continue to see a deterioration of services. And the
American public has to accept the fact that they are not going
to get the kind of service that they got in past years.
We do not have other places to cut. All of our budget
supports our staff. Training. We are going to see some quality
issues because if you do not train people, they are not going
to know how to do the job correctly, and once they learn
incorrectly, they continue to do it incorrectly. Or if they are
trying to serve too many people in a span of time, they are
going to make mistakes. And so every time you have to redo a
case because it is not correct, the information is older, and
it is more expensive.
Ms. DeLauro. That leads me to my last comment, if you will.
If SSA saves money with program integrity work, those funds are
simply kept in the trust fund for future years. These are not
funds----
Ms. Colvin. It does not help us with our administrative
needs.
Ms. DeLauro. With your administrative needs.
Ms. Colvin. No, it does not.
Ms. DeLauro. So I would just say once again, as I said
earlier, that I think that we should not be penny wise and
pound foolish when it comes to program integrity, that we
should allow you to deal with those redeterminations and other
efforts in order to be able to safeguard overall the program
and the beneficiaries.
Ms. Colvin. I would really just urge the committee to look
at giving us adequate, sustained, and predictable funding. I
think if you look at how we spend the dollars, you can see them
easily accounted for. Our metrics are very clear. The number of
benefits we give out, the number of program integrity
initiatives that we handle are spelled out so there is no lack
of clarity relative to how we use the money and where it goes.
But we need sustained funding. We need predictable funding, and
of course, we need adequate funding. Our funding for the last 2
years has been $1,000,000,000 less than the President's
request. It is just not going to allow us to do the work. It is
not going to allow us to serve the public.
Ms. DeLauro. Thank you.
Thank you, Mr. Chairman.
Mr. Kingston. I just have three closing comments.
Number one, I want to join--and I want to speak on behalf
of all the members of this committee. We do feel that your
field employees, who are a very important part of our field
offices as well are doing a great job.
Ms. Colvin. Thank you.
Mr. Kingston. They are responsive to us. And I believe that
they have the customer's best interest in mind.
Ms. Colvin. They do.
Mr. Kingston. And they are sympathetic and empathetic.
Number two, I do want to pledge to work with you on this
SSI issue.
Ms. Colvin. Thank you.
Mr. Kingston. If I am wrong, I am going to be the first to
admit it. If I am right, though, let's join together and find
out.
Ms. Colvin. Absolutely.
Mr. Kingston. And then number three and something very
important, I wanted to have the pleasure of ending a hearing on
Social Security with my good friend, Rosa DeLauro, on the far
right of me. [Laughter.]
Ms. DeLauro. Touche.
Mr. Kingston. Thank you very much.
[The following questions were submitted for the record.]
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Wednesday, March 20, 2013.
CHILDREN'S MENTAL HEALTH
WITNESSES
PAMELA HYDE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES
ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES
DEB DELISLE, ASSISTANT SECRETARY, OFFICE OF ELEMENTARY AND SECONDARY
EDUCATION, DEPARTMENT OF EDUCATION
Introductions
Mr. Alexander. Good morning. The chairman will be here in a
few minutes, we understand. But he wants to go ahead and get
started so we won't mess up everybody's day.
Good morning. Today, we will hear from the Department of
Education and the Substance Abuse and Mental Health Services
Administration of the Department of Health and Human Services
about the state of the mental health system for children in the
U.S.
The tragic massacre of 20 children and 6 adults at Sandy
Hook Elementary School on December the 14th of last year has
led to a national discussion about whether the mental health
care system in the U.S. is designed to effectively identify and
treat youth with mental health diseases and disorders before
they lead to, in the most extreme cases, tragedies like the one
I just mentioned.
The administration is already talking about creating new
programs. But today, we are going to take a step back and look
at the current system as it exists today. We will hear about
what has and hasn't been effective at improving the mental
health of children and reducing violent and disruptive behavior
in schools, focusing on the role of Federal programs.
I am interested in learning how we can better target
current resources to address this issue. On an issue as
important as this, we can't afford to waste a single dollar on
programs that are duplicative or ineffective.
And I will yield now to Ms. Lee for an opening statement.
Ms. Lee. Thank you very much.
First, let me thank both of you for being here today and
take a moment to just mention that our subcommittee ranking
member, Congresswoman Rosa DeLauro, was asked to join the
official House delegation to the inauguration of Pope Francis.
So she won't be with us today.
But I am very pleased to take the lead for the Democratic
side today, as she requested me to do. My background, of
course, is in clinical social work and mental health, community
mental health, and I am really pleased to be here today with
you.
The recent mass shootings, including those in Connecticut,
Colorado, and Arizona, have launched a real national discussion
about mental health issues, especially as they affect our
youth. This is certainly a discussion we should be having, one
that really should have started a long time ago. These horrific
events really serve as a reminder of the possible consequences
of untreated mental illness.
But we should also remember that the vast majority of
people living with mental illness are not violent and also that
the vast majority of violence is not caused by people with
mental illness. The fact is that those suffering from a mental
illness are far more likely to become victims of violence than
the perpetrators.
Also, the reality is that for far too long, too many of our
young people, their experience with violence is not the
devastating mass shootings, but the everyday violence that is
all too common in communities like Chicago and my district in
Oakland and right here in Washington, D.C. So when we fail to
address mental illness, when people cannot access services and
there is nowhere for them to go, the outcomes are not positive.
Children with undiagnosed, untreated mental illness become
adults who often end up in prison, experience homelessness, and
are victims of violence and have many health concerns that are
harder to treat due to their mental state. As a clinical social
worker, I opened a community mental health center in Berkeley,
California, that served low-income clients, and I saw firsthand
the effects of the lack of services on the mental health of
individuals, on their families, and on their communities.
There was an overwhelming need then, and that was in the
'70s. And there is an overwhelming need now. It is the
resources that, inexcusably, are lacking.
In recent years, we have seen a dramatic decrease in
resources for mental health at all levels. SAMHSA mental health
programs were cut by 5 percent between 2010 and 2012, and
sequestration has almost doubled that cut. Adjusted for
inflation and population, 2013 now is about one-fifth lower
than 2002 level.
As for the States, the Association of State Mental Health
Directors estimates that in the last 4 years, States have cut
$4,350,000,000 in mental health services while, at the same
time, an additional 1 million people sought help at public
mental health facilities.
So I hope that today we can hear more about the
consequences of these cuts. I hope that we are able to discuss
what can be done to reach more children with undiagnosed and
untreated mental health challenges. Since we know that in most
cases treatment does work, and early treatment and prevention
is absolutely necessary.
Finally, I hope to discuss how to make our schools a safer
learning environment without turning them into armed camps, the
impact of mental health treatments on the pipeline to prison,
which is really devastating low-income communities and
communities of color. So I thank our witnesses for being here
and look forward to today's discussion.
Thank you, Mr. Chairman.
Mr. Kingston [presiding]. Well, thank you very much, Ms.
Lee and Mr. Alexander.
Ms. Hyde, we will go ahead and start with you, and then Ms.
Delisle, you will do the same.
Opening Statement of Pamela Hyde
Ms. Hyde. Thank you, Chairman Kingston and Vice Chairman
Alexander and Ranking Member DeLauro and Congresswoman Lee, for
your holding this hearing.
And I do want to acknowledge Assistant Secretary Deb
Delisle, whom you are going to hear from in a moment. Our
agency works very closely with the Department of Education. You
will see that as we talk through today.
I think you are aware that SAMHSA's mission is, in fact, to
reduce the impact of mental illness and substance abuse on
America's communities, and we do that in a number of ways. We
do it by being a voice for behavioral health, but also by
substance abuse and mental health surveillance and data, by
setting standards and regulating programs, by doing practice
improvement efforts, by funding States, tribes, territories,
and communities, and by providing information to the public.
I wanted to start with just some of that public information
that we try to get people to be aware of, and that is that
three-quarters of adult mental health issues start before the
age of 24, about half before the age of 14. So investing in the
mental health of our children and youth is critical not only to
them, but to adults.
Less than half of adults and less than one in five children
and adolescents receive treatment for diagnosable mental health
and substance use disorders. And even less, about 11 percent of
adults with substance use disorders, receive treatment.
The reasons for this lack of treatment include cost, not
knowing whether and where to get help, and not knowing whether
treatment will work. Generally, people wait much longer to get
treatment for a mental health or substance abuse disorder than
for physical symptoms for themselves or their children.
And science tells us that we can prevent mental and
behavioral health disorders among young people, and the sooner
we intervene, the better the outcome. So the longer we can keep
a young person from drinking or taking drugs such as marijuana
or abusing prescription drugs, the more likely we can keep that
young person from developing a serious problem in adulthood.
Persons with behavioral health problems have higher rates
of heart disease, hypertension, disease, and smoking than those
without those conditions. And people with mental and substance
use disorders are nearly two times as likely as the general
population to die prematurely. About half the deaths from
tobacco use in our country are among people with mental and
substance use disorders.
Today, suicide is, unfortunately, the third-leading cause
of death among young people. However, it doesn't have to be
this way. We know that behavioral health, mental illness, and
substance abuse prevention, treatment, and recovery is, in
fact, a public health issue, and it can be tackled and solved
in that way. Positive emotional, mental, and behavioral health
increases a young person's chance of social, academic, and
developmental success, and that benefits us all.
As you know, in January, the President announced some
initiatives to ensure that students and young adults receive
treatment for mental health issues. To ensure adequate coverage
of mental health and addiction services, the administration
issued a letter to State health officials about Medicaid plans
being subject to MHPAEA, or Mental Health Parity and Addiction
Equity Act. And in addition, the administration will issue
final regs about MHPAEA this year.
The President also proposed initiatives to increase mental
health access for the Nation's young people. And SAMHSA has a
specific role in three of those.
The first is Project AWARE, Advancing Wellness and
Resilience in Education. This project would provide States with
resources to help schools and communities address mental health
issues, identify mental illness early, and refer young people
to treatment. Project AWARE would also provide Mental Health
First Aid training.
Second program is Healthy Transitions. It is a proposed new
grant program for innovative State-based strategies supporting
young people ages 16 to 25.
And a third program is a workforce program to be operated
jointly with HRSA that would train more than 5,000 additional
mental health professionals to serve students and young adults.
And finally, HHS and Education, along with the White House,
will soon launch a national dialogue on mental health.
So we have come a long way in the prevention, treatment,
and recovery supports for mental and addictive disorders, but
we have a long way to go. And we can do better, which is why
the administration is taking steps to increase awareness of the
importance of mental health to our Nation's health and increase
access to mental health services, especially for young people.
Thank you again for this opportunity to discuss SAMHSA's
role in this, and I would be pleased to answer any questions
you may have.
[The prepared statement of Administrator Pamela Hyde
follows:]
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Opening Statement of Deb Delisle
Ms. Delisle. Thank you very much.
Chairman Kingston, Congresswoman Lee, and members of the
subcommittee, thank you so much for holding this very important
hearing on children's mental health.
I appreciate the opportunity to share the Department's
efforts, as well as the President's plan for improving mental
health supports for students. And obviously, I am very pleased
to be here with my colleague Pam Hyde because we have done a
lot of work together, and our partnership is deepening every
single day.
As you are very well aware and has been expressed earlier,
our students today face a whole host of challenges to their
mental, behavioral, and emotional well-being in their schools,
in their homes, and in their communities. There are many
complexities of life that impact children's overall well-being
and, in turn, influence their academic achievement and their
feelings of inclusiveness and safety in school settings.
There is a growing awareness among Federal policymakers of
the linkages between children's exposure to violence and mental
and emotional wellness. The groundbreaking National Survey of
Children Exposed to Violence found that 10 percent of children
in this country have been exposed to multiple forms of
violence, such as community violence, sexual abuse, and
domestic violence. And secondly, the risk and severity of
health and mental disorders increases for children who have
been victimized multiple times by up to tenfold.
To ensure that our students can focus on learning, our
educators must have both school-based resources and effective
partnerships with community health professionals to identify
risk factors, recognize students displaying signs of emotional
and mental distress, and connect students and their families to
a continuum of supports to help them cope, to recover, and to
continue successfully in their academic careers as well as in
life.
Further, under applicable Federal law, schools have an
obligation to identify, evaluate, and provide special education
and related services to students with disabilities, including
mental health-related disabilities. School-based mental health
supports are particularly critical to helping educators respond
effectively to the myriad of incidents affecting students on
campus and in school buildings, from teen dating violence to
the emotional distress that students bring to school and to
tragic events, such as that which occurred in Newtown,
Connecticut.
Last December, I testified before the Senate Judiciary
Committee about our efforts to stem the use of suspensions and
expulsions, which disproportionately impact students with
disabilities and students of color. Schools must recognize
behavioral incidents as opportunities to help students cope
with trauma and to support, rather than to exclude, students
with emotional and behavioral difficulties.
In recent years, the Department has worked to improve
educator and student access to mental health resources and
supports through financial support to school districts,
technical assistance, and interagency partnerships with Federal
partners, such as SAMHSA. For example, since 1999, the
Department has partnered with DOJ and SAMHSA to address youth
violence prevention and support the social, emotional, and
behavioral needs of students through the Safe Schools/Healthy
Students initiative.
Far too often, the resources directly available within a
school building are limited. For example, while the American
School Counselors Association recommends a ratio of 250
students to every counselor, the national student-to-counselor
ratio is approximately 450 to 1, as of 2010. One counselor to
attend to the needs of 450 students, is an overwhelming ratio
for sure.
Our Office of Safe and Healthy Students administers a grant
program to establish or expand school counseling in elementary
and secondary schools. In 2012, we awarded $21,200,000 to 60
recipients in 24 States to hire and train qualified mental
health professionals, with the goal of expanding the range,
availability, quantity, and quality of counseling services.
The Department's Office of Special Education and
Rehabilitative Services has invested in behavioral research,
demonstration, and technical assistance activities for more
than 20 years, including through the positive behavioral
interventions and support centers, which provide States,
schools, and communities with a clear, evidence-based roadmap
to safer school climates that support students through
evidence-based behavioral frameworks.
Further, we are working closely with DOJ and HHS to
strengthen the use of behavioral frameworks in the 10 cities
that comprise the National Forum for Youth Violence Prevention,
which have all pledged to strengthen local capacity to prevent
youth violence and gang violence.
On January 16th, as Pam mentioned, the President announced
a comprehensive plan ``Now is the Time,'' which outlines a
multifaceted approach to reducing gun violence and is based on
the recommendations of the Vice President's task force that was
established in the wake of the school shooting in Newtown,
Connecticut.
Mr. Kingston. Your time has expired.
Ms. Delisle. Okay.
Mr. Kingston. But Members have looked at your testimony,
and it is very good, very meaty, and so don't think we
haven't----
Ms. Delisle. Thank you. I appreciate that. Thank you for
the opportunity to be here.
[The prepared statement of Assistant Secretary Deb Delisle
follows:]
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Mr. Kingston [continuing]. Time because I think you will
find a lot of bipartisan support for the direction we all want
to move on this committee, and I want to give Members plenty of
time for questions.
So, not being rude, but want to move on to the dialogue.
Ms. Delisle. Thank you.
Mr. Kingston. Sorry, my mike wasn't on. I hope you heard
what I said.
IDENTIFYING CHILDREN WHO NEED MENTAL HEALTH SERVICES
Ms. Hyde, and I want to say one of just the most
heartbreaking statistic that I have just heard is that the
number-three cause of death in teenagers is suicide. I don't
know that America knows that statistic, but I think all of us,
as parents and family members, are just heartbroken to ponder
what that means. And we have all seen it, and so certainly, we
want to do everything we can.
A friend of mine, Dr. Chris Tillitski in Macon, Georgia,
told me that--and he is a child psychologist--said after
Columbine, there was just a tremendous growth in his industry
because, he said, any time a child drew a weird picture, the
mom would bring him in and say, ``Is he the next Dylan
Klebold?'' the perpetrator of--and he said, you know, for some
of his colleagues, it was a great opportunity for successions.
And he said, but there is also, if you know what you are
doing, you could say, ``No, this is a kid being a kid.'' It is
so difficult to identify when there is a mental illness, and
one of the things that your testimony has said is that schools
would identify. But I don't think schools or school counselors,
whether it is 1 to 5 or 1 to 500 have that ability to truly
identify the kids.
So can you comment on that? Because you sure don't want to
misdiagnose it and plant some seed that, well, you drew a weird
picture. Therefore, you have got a problem.
Ms. Hyde. Thank you, Mr. Chairman.
That is true. We don't want to identify children that don't
need help. What we know, though, is that there are a number of
children who do need help who don't get identified.
And I think part of what these proposals would do is help
people have more information--school officials, families,
community intervention folks, other sort of folks who are
interfacing with young people--know what the signs and symptoms
are, what they should be looking for, what is appropriate to
look for. And then the referral process is to refer to an
individual who is capable of doing the appropriate assessments
to determine what is going on.
So we know that sometimes behaviors are part of young
people's growing up. But we also know that sometimes those
behaviors do identify young people with needs that are not
getting attended to.
Mr. Kingston. Well, who would have the power--you know,
coming at it for a minute from a Libertarian standpoint, how
would the State be given that power that you don't like a
child. The child is belligerent or whatever. And so, you say
you need testing and counseling.
Because I know that teachers aren't perfect, and teachers
often may have their own ax to grind on a child. And it would
appear to me to have some concerns about the State having the
power to be able to send somebody off.
Ms. Hyde. I don't think the State would take that power. I
think Assistant Secretary Delisle may want to comment about how
the schools would do this. We're not asking anyone who is not--
or not suggesting that anyone who is not trained, licensed, and
able to make those assessments do that.
What we are trying to do is raise awareness. For example,
suicidality and other kinds of things that may indicate a need
for professional help rather than trying to get teachers to be
diagnosticians. That is not what we are trying to accomplish.
Mr. Kingston. But the teacher would be closest to the
child, observe the behavior, refer the child to somebody, and
that could lead to mandatory assessment. And that is empowering
the State. Is that not the case?
Ms. Hyde. I don't know----
Mr. Kingston. I am just saying there is a real fine line
there.
Ms. Hyde. I don't think we are looking at mandatory
assessments. Parents and others are involved in these
decisions. It is not the State that makes those decisions. It
is rather a teacher or a parent who is identifying behavior----
Mr. Kingston. Well, the teacher is the State, though. I
mean, the teacher is a State employee. So if the teacher is
empowered to do it. I am just saying a little concern on that.
Let me ask you this, in terms of the exposure to violence,
and you had mentioned exposure to violence very close to being
a victim of violence. But what about the cultural exposure to
violence, whether it is from violent lyrics in a song or
Hollywood movies or whatever? Do you feel like there is any
influence on behavior because of the barrage that children are
exposed to?
Ms. Hyde. We have done a lot of work about child exposure
to violence. CDC has also done a significant amount of work.
But frankly, we don't have good evidence about what those
impacts are. We do know that witnessing violent behavior or
witnessing violence in the community can have a traumatic
impact on a child.
For some children, they have the resilience and capacity to
take that in and deal with it and bounce back. For others, it
has a profound and lasting impact on their health and mental
health.
So it depends, and we don't have the complete data that we
need to make those decisions at this point.
Mr. Kingston. Is that something that we should study?
Ms. Hyde. I would commend you to the CDC to talk about
those issues. They and others are looking at whether or not
those issues can be studied.
Mr. Kingston. You look very, very young. However, I would
have to ask you this. Do you think children are exposed to more
violence today than they were when, say, you were 10 years old?
Ms. Hyde. Mr. Chairman, I am not as young as you seem to
think I am. I wish I were. [Laughter.]
Ms. Hyde. I don't know that I can answer that. My children
are in their 30s. I know what they did and what they saw when
they were young people. I don't have grandchildren. So I don't
know what children so much are exposed to today.
There is no question that there is a culture in our
communities about violent behavior, and the issue is how do we
make sure, from SAMHSA's point of view, that anything that is a
traumatic event, what is the impact on that child's behavioral
health. And again, we have a number of years, about 10 years'
worth of work in child trauma issues and identifying what kinds
of things will have an impact on a child's behavioral health.
Mr. Kingston. I am just wondering if gratuitous violence
and blood splattering in Hollywood is more than it used to be,
which I think it would be, and if that has any influence? And
would you think that would be something we should examine, or
should that not be examined?
Ms. Hyde. Mr. Chairman, again, this is not my area. So we
could probably try to get back to you with some information
about that.
Mr. Kingston. Okay. Ms. Lee.
Ms. Lee. Thank you very much, Mr. Chairman.
Before you arrived, I mentioned that I am a trained
clinical social worker by profession. My background is mental
health. And I wanted to follow up with regard to your question
in terms of the signs and symptoms and just say a couple of
things, why it is important, I think, to follow up with that.
Because you are absolutely correct. There is a fine line.
But trained mental health professionals really know how to make
those diagnoses, and they know what the signs and symptoms are.
And that is why it is so important to--and you mentioned the
ratio of 1 to 450.
In my own State of California, when I was in the California
legislature, we had one mental health counselor to about 1,200
students. And of course, I have legislation that would really
authorize a full mental health school counselor national
program. But I think it is extremely important that we know
that we have to have trained mental health counselors, whether
it is psychiatrists, psychologists, clinical social workers, on
campuses to really begin to address that in a big way.
I don't know what the ratio is now in some States, but I
know California is even more than 1 to 1,200 counselors. And on
the other hand, when you look at what is happening with
students of color, young African-American and Latino boys, they
are being suspended and kicked out of school for a variety of
reasons. Where a mental health counselor could identify what
some of the behavioral issues are and really help reduce the
drop-out rate tremendously if we had a larger number of mental
health counselors on campus.
So let me just ask you, in terms of the violence that the
chairman referred to, because I think there is--since I was a
teenager, there is an increase in violence throughout the
country. I am concerned about the impact of this trauma on a
child's mental health, whether they are a direct victim of
violence or witnessing or living in areas.
Because in my community, some of these young people I would
diagnose as having post traumatic stress syndrome. They live in
war zones, and that is how they function, as if they are living
in a war zone because of the trauma around the violence.
Could you comment on that and how you see, how this
administration sees the results of violence in terms of the
trauma to the mental health of young people throughout the
country?
Ms. Delisle. If I could comment----
Mr. Kingston. If the gentlewoman would yield a second? You
know one thing that I don't know if you can touch on it now,
but among the young men of color that you referred to, they
have not been the perpetrators of these slayings. Is that
correct?
Ms. Lee. That is correct. You look at the statistic----
Mr. Kingston. And that is interesting. You know, I don't
know if----
Ms. Lee. But what you would see, though, with young men of
color, this becomes a pipeline from the cradle to the prison
because majority of them never come back to school, and they
end up in behavior that sends them into juvenile hall and then
into prison.
Mr. Kingston. Yes, and there are other losses.
Ms. Lee. That is right.
Mr. Kingston. Yes, thanks.
Ms. Hyde. Mr. Chairman and Congresswoman Lee, the issue
about young men of color, if I could just touch on that? I
think that we tend to galvanize and get our interest up when a
mass casualty shooting occurs. But as you said, Congresswoman
Lee, there are young people who die every day on the streets of
our cities who are disproportionately, in many cases, people of
color because of the everyday violence that we experience.
And I think that is part of what your question is about
this trauma that we deal with. As I said earlier, we have a
long history of working in the trauma arena in SAMHSA. We have
a National Child Traumatic Stress Network and program, and they
have done significant work in coming up with appropriate
evidence-based practices to address those issues and to be able
to identify those young people who have mental health problems
because of it.
There is a whole set of issues about risk and resilience
factors, but there is some point at which resilience is not
enough if you are exposed to violence constantly. And there is
pretty good evidence that that exposure to violence, especially
cumulative, has implications for both health and behavioral
health issues.
Ms. Lee. What are the implications, though?
Ms. Hyde. The implications are more substance use, more
suicidality, more mental health issues, more depression,
anxiety, more issues in school in performance, and just the
developmental growing up process.
Mr. Kingston. Thank you.
STUDENT SAFETY TO AND FROM AND AT SCHOOL
Ms. Delisle. Chairman Kingston and Congresswoman Lee, I
just want to add one piece to that. That is one of the
difficulties we have, particularly on the way to school and on
the way home from school, as you indicated, with neighborhoods.
So we still know that schools are still one of the safest
places to be.
However, having been in education for 38 years, I have seen
the numbers of students who have passed through my own career
who have been afraid to come to school. And we know that they
are walking through gang-infested neighborhoods. They have
experience--so even as young as 5 years old, student
absenteeism becomes very high when they are living in
neighborhoods, when we keep kids out of school for whatever
reason, through suspensions, expulsions, or when they are self-
selecting out because of walking to and from school in unsafe
neighborhoods. They are missing school.
DISPROPORTIONATE IMPACT OF STUDENT DISCIPLINARY ACTIONS
Your emphasis on the school-to-prison pipeline is very
real. Obviously, we have a lot of reports out about the range
of students who--especially students of color and students with
disabilities--who are disproportionately impacted by
suspensions and expulsions.
So, at the Department, we are working really hard to put
out guidance and to be sure that people are very familiar with
the data, particularly with some recent data that has been
released. We have been supportive of schools having a response
to intervention and restorative justice programs. And we need
counselors and mental health workers who are able to work with
students as well as with teachers to ensure that there are
behavioral supports, that they know what are the strategies to
use with certain students to be sure that they are focused on
learning.
Ms. Lee. Thank you very much.
Thank you, Mr. Chairman.
Mr. Kingston. Mr. Alexander.
STIGMA OF MENTAL ILLNESS
Mr. Alexander. I used to be on the Health and Welfare
Committee in the State legislature, and it was always a puzzle
to me, as I made visits to sites around the State of Louisiana
that took care of the mentally ill, it was always a puzzle why
everyone was reluctant to talk about the problem.
Parents, every day, today we will hear somebody say,
``Well, my brother has got cancer,'' or ``My sister has got
cancer. You all pray for them,'' or whatever. But we never hear
anybody ask someone to be concerned about a family member that
has a mental problem.
Do we find it easier today for individuals to talk about
the massive problem that we have in mental health? Is it easier
to talk about it today than 20 years ago?
Ms. Hyde. Mr. Vice Chairman, it is a great question, and I
think short answer is, yes, it is easier today than it was
years ago, but we are a long way from where we need to be.
There are still a number of negative attitudes about mental
health. There are misperceptions, misinformation.
There is an assumption that addiction is just a matter of
will. There is an assumption that these things are moral issues
and social issues rather than public health issues.
There was a time, and I am sure you recall, when cancer was
not something we wanted to talk about, and we are much more
willing to do that today. I think one of the positive outcomes
of things like this hearing and our opportunities to talk about
it is people are more willing, I think, than ever, as it is
discussed, to come out, if you will, about being in recovery,
having a family member who has a mental health or addiction
issue and being willing to address it.
So to the extent that those concerns about how people will
be treated, either in school or for adults their employment or
other kinds of social relationships, if you look at the public
attitudes, they do suggest that people have misperceptions
about not wanting to have such individuals live in their
community.
There is a public attitude that doesn't really match
reality about people thinking people with mental health issues
are dangerous to each other or to other people in the
community. So there is a lot of misinformation still out there
and a lot of concerns about having those disorders. And
therefore, it makes it difficult for people to be willing to
talk about it.
It is part of the reason we are going to announce a
national dialogue on mental health soon is to try to be able to
get the volume up on talking about mental health and addiction
disorders.
Mr. Alexander [presiding]. Okay. Thank you.
Ms. Roybal-Allard.
Ms. Roybal-Allard. Good morning.
Ms. Hyde. Good morning.
Ms. Roybal-Allard. Administrator Hyde, I have been very
concerned about the use of psychotropic drugs to treat children
with behavioral problems. And I, along with Representative
DeLauro and Senator Tom Harkin, asked GAO to look into this
issue. And what GAO found was that children on Medicaid are
prescribed these medications at twice the rate of privately
insured children and that an alarming 18 percent of foster
children were taking psychotropic medications.
GAO also reported that these drugs represent the single
largest expenditure in Medicaid. It was over $2,800,000,000 in
2007. Given your mission to reduce the impact of substance
abuse, what is your agency doing to address this pervasive and
costly substance abuse problem? And are you building
partnerships with Medicaid, the foster care program, medical
specialty societies, and treatment centers to work on ways to
better treat these children and avoid turning them into drug-
addicted individuals?
Ms. Hyde. Thank you, Congresswoman. Thank you for the
question because we are doing a lot.
We have a strong relationship with the Administration on
Children and Families. They have taken this issue on very
strongly, looking at psychotropic drug use among foster
children.
And I am sure you know that foster children are sort of
disproportionately on Medicaid. So sometimes those numbers
coincide to make it also look that way for Medicaid-eligible
children.
SAMHSA focuses on the right treatment at the right time. We
are focusing heavily on psychosocial interventions, wraparound
interventions, where ACF is very much interested in having
foster parents aware of how they can get those kinds of
interventions.
We are trying to monitor with them more the use of
medications to see what is happening with that and trying to
make sure that medication is only one part of a treatment plan.
And frankly, if psychosocial interventions can happen first,
that is the preference.
So we also have been sponsoring a child and adolescent
psychiatric fellow from Johns Hopkins. He comes to SAMHSA once
a week, and he is currently working on an issue brief regarding
engaging Asian-American youth in psychiatric treatment and
trying to look at ways to do this without starting with
medication.
So we also have a lot of work with State systems in our
NCTSI, or National Child Traumatic Stress Initiative. Also
looks at ways to intervene with young people who have traumatic
experiences, and frankly, most foster children come to the
system with some sort of traumatic experience.
So we are doing a lot, and it is our goal jointly with both
the private sector professional groups as well as with our
Federal partners. CMS has also been very heavily involved in
this effort to try to look at both the trauma aspects, how to
get more funding into Medicaid for services that are not
starting with medication for children.
Ms. Roybal-Allard. Okay. One of the concerns is that there
is no consistent Federal policy guidance on prescribing these
drugs to children in the Medicaid and CHIP programs. So as the
lead mental health agency for our country, what can SAMHSA do
to encourage that alternative treatment options, such as
counseling and psychotherapy, find their way into practice for
these children that are in Medicaid and CHIP?
Ms. Hyde. Congresswoman, one of the things that we are
doing with the association for adolescent--child and adolescent
psychiatry professionals is try to develop guidance on the use
of psychotropic medications. So it is frequently the
professional groups that will set this guidance. We are trying
to provide support in doing that, and we are also supporting a
youth advisory group working with the AACAP is the acronym.
That group is providing feedback about Web site resources
for youth, including the creation of youth videos. So youth by
youth. Youth listen to other youth, and trying to get them more
educated about psychotropic medication issues as well.
Ms. Roybal-Allard. Do I have time for another question, or
is it----
Mr. Alexander. I believe you have 36 seconds.
Ms. Roybal-Allard. Okay. I will just wait.
Mr. Alexander. I won't be quite as strict as the chairman.
But thank you.
And Members will ask questions in the order in which they
came into the room. So, Mr. Joyce, Dr. Harris beat you over
here. So, Dr. Harris.
Mr. Joyce. I am leaving then. [Laughter.]
Mr. Harris. You chased him out. No, thank you very much.
And Ms. Hyde, I have a question for you, and I am glad we
are going to open a dialogue on mental health because it is
important. But part of my concerns are that as we discuss
serious mental health issues in youth that could lead to
problems and then link that to solutions to gun violence
issues.
And for instance, in our State, they are attempting to link
this by requiring that anyone who is involuntarily committed
loses their right to obtain a firearm for the rest of their
life. I mean, this is not--and the reason why this is
significant is because part of your testimony was we have to
dispel this perception that people with mental health issues
are dangerous. But in Maryland, they are about to pass a law
that says someone with a mental health issue is dangerous.
We are going to add stigma instead of removing stigma. We
are going to add--I think we add impediments to obtaining help
rather than removing them.
Interestingly, one of the Vice President's recommendations
was is that we address unnecessary barriers, including HIPAA,
that prevent sharing of data. But HIPAA, the purpose of HIPAA
is actually to prevent sharing of data, the--some of the most
private data you have, which is your medical data.
So the quandary is how do we--and one of the reasons why we
need a dialogue and haven't it because this is a tough issue. I
mean, how do we address and how is your administration thinking
about addressing the issue of identifying people who need help,
who may be dangerous to themselves and others, but not
stigmatizing those people? Because I think that is a key to
getting people into the system in many circumstances.
So my first question would be how do you--how do you do
that? And specifically because, again in your testimony, I will
read word-for-word your testimony. ``For most of these
conditions,'' you are talking about mental health conditions,
``prevention works, treatment is effective, and people do
recover.''
So how do we avoid a lifelong stigma attached to treatment
of some of these serious issues?
Ms. Hyde. Mr. Chairman, Congressman Harris, thank you for
the question. It is a great question because we share your
concern.
And part of the reason we want to launch a national
dialogue, and we are going to do that with Education, is to try
to get at these tough issues, as you said. There is already in
the Brady bill language about prohibition of individuals who
have experienced involuntary commitment being prohibited from
getting a gun. It is left to the States to determine whether or
not there is a way out of that for the individual, and only
part of the States have passed those laws to allow that.
Part of what we want to do with the national dialogue is,
in fact, have fact-based conversations and make sure that we
don't tie mental illness and dangerousness or violence. There
is no evidence that people with mental illness who do commit
acts of violence do it with guns any more than anybody else who
commit acts of violence.
So people with mental health problems are not that
different in that sense. What they have is a public health
issue and a diagnosable illness that can be treated, in many
cases prevented, and people do recover.
So that is the kind of conversation we want to have and
foster. And then we want to have in each community who takes on
this kind of a dialogue an opportunity to have facts to support
that and also to have an opportunity to think about in their
local community how will they address this issue and how will
they take that on?
We want to make sure that local residents who are ordinary
citizens have that part of that conversation because a lot of
times, people come to that with media views of what people with
mental health are, and those are not always accurate. We are
also working on some media guidelines and trying to help people
get accurate facts in order to begin the conversation.
Mr. Harris. Thank you very much.
I appreciate that because these are--again, these are very
difficult issues that we are going to have to work our way
through, always being mindful that individual rights and
liberties are--that is a cornerstone of America. And I share
some of the chairman, before he had to leave, some of his
comments that as we--in our zeal to identify people who need
treatment, we have to be careful because we are empowering
people to be agents of I will say agents of the State, really.
As he suggested, a teacher who refers someone for mental
health is the government doing it, and we have to be sensitive
to that, that that kind of perception will--I think in my mind
will actually impair access at some point. Some people will be
reticent to have the government involved, and we should be
thinking of ways to guide some of this more into--more into
mainstream medical treatment. Because most medical treatment in
the United States is not delivered by the Government, and that
is why I think people seek it.
Ms. Hyde. Congressman, we agree. And one of the reasons
that we want to do things like Mental Health First Aid is we
don't want to have someone like me treat cardiac problems, but
we may want somebody like me to know when a person has the
signs and symptoms of a heart attack so that we can get the
right help at the right time.
So Mental Health First Aid and that whole approach to
awareness and raising consciousness about this is not at all
meant to have agents of the State or even the public treat
people. It is to help them know when to help someone seek help
and get the help they need.
Mr. Harris. Great. That is an important distinction.
Thank you very much, Mr. Chairman.
Mr. Alexander. Ms. Lee.
Ms. Lee. Thank you, Mr. Chairman.
And I think, following up on that question, I think that is
part of the reason why I am so pleased to see in the
President's initiative funding to train mental health
professionals. I mean, that is extremely important. And I hope
this committee would support that effort because early
identification of possible mental health issues is extremely
important.
And teachers are hired to teach. They are not hired to be
mental health counselors or psychotherapists. But teachers can
know the signs and learn the signs. And if we had the mental
health counselors right there on campus, the early assessment
could be made, and determinations with the family could be made
in terms of the course of action.
BULLYING PREVENTION
Let me ask you, Congressman Honda is chair of our bullying
caucus, and I wanted to ask you about bullying because we know
that there has been an increased rate of suicide as a result of
bullying. And how are you--I mean, what is going on now in the
country?
Are there strategies and programs to address bullying?
Because this is a very serious problem that young people are
faced with in all of our districts.
Ms. Delisle. Sure. I will start there. Congresswoman Lee, I
think that this is an issue which is certainly a priority for
the Department as well as for schools across the country
because of the issues of bullying, as you mentioned, that
result in some pretty horrific events for students and for
children in their lifetime.
We have a number of initiatives, including through
proposals in Now is the Time, to increase programs, evidence-
based programs in schools for teachers and for students and for
families to engage in around the issues of bullying and school
climate. And I want to emphasize school climate is so critical
because when many of us have walked into school districts or
schools, when we have had an opportunity to kind of just walk
in the school, within 5 minutes you know whether or not you
want your own child in that school.
And if the school climate is such that there is an answer
of no to that question, ``Do I want my own child in this
school,'' we should not wish it for any other child in any
other family.
Part of the culture of that school is creating a safe haven
for students, is creating a climate in which students and
teachers feel respected, and they also learn the art, if you
will, of communicating with one another. And they also provide
opportunities for students to learn behaviors other than
bullying, and they respond to that.
So programs such as Positive Behavior Intervention Support,
which is included in the proposal in Now is the Time, is one
such example of increasing funds and technical support to
schools to do that.
We also have been working closely with SAMHSA throughout
the proposals through Now is the Time, in addition, in other
kinds of ways in making sure that our kids feel safe and secure
in schools emotionally as well as physically.
Ms. Hyde. And Congresswoman Lee, I would add to that that
one of the things that this administration has done, from the
President and First Lady, is to call on all of us to
collaborate around the issue of bullying because it is such a
pervasive issue. We have created a common Web site,
stopbullying.gov. We had multiple Web sites and multiple places
for people to get information, schools to get information, kids
to get information about bullying.
We have created some cyber-bullying prevention efforts, and
that common Web site is actually jointly funded and managed
between HHS and Education. And within HHS, there is three
operating divisions and offices that are collaborating on the
editorial board about making sure that we all contribute, and
then Education is providing a lot of the guidance and
leadership on that.
So we are working a lot on that, and CDC and others have
been doing research around what happens to kids when they are
bullied and what kinds of impacts that has. You see kids with
increased behaviors that are like inappropriate sexual
behaviors, inappropriate eating behaviors, inappropriate
substance use behaviors, in many cases tied back to bullying
behavior.
So we are doing research. We are doing public information.
We are doing information for teachers and parents and for youth
themselves, and calling on youth also to get engaged to just
say this is not okay. It is not an okay behavior that we, as
youth, want to put up with in our schools.
Ms. Lee. I will hold my next question until the next go-
around, Mr. Chairman.
DUPLICATIVE VS. COLLABORATIVE PROGRAMS
Mr. Alexander. Thank you.
I guess I offended Mr. Joyce.
You both mentioned and the President has mentioned new
initiatives to deal with mental health. The Government
Accountability Office tells us that today we have 82 teacher
training programs, and it is hard for us to believe that within
the programs that exist today that there is not a program that
would adequately deal with the problem that lies before us.
So my question is if these new programs are authorized and
financed, what current programs would they likely take the
place of?
Ms. Hyde. Vice Chairman Alexander, we carefully crafted
these proposals with the White House, OMB, and each other to
make sure they were not duplicative and were actually
collaborative. They, in many cases, build on successes that we
have done at a pilot level, and we are now proposing to try to
take some things statewide, to move things into a statewide
approach.
In other cases, like Healthy Transitions, for example, it
is a pilot to try to see if we can specifically address that
very difficult transition age or what is now being called the
emerging adults population because they have very specific and
difficult issues. And some of them are in schools, and some of
them are not.
So bringing communities and schools, parents, law
enforcement, and others together is really critical. So we want
to support the in-school programs, and we also want to support
the community-based mental health and first responders and
parents programs. So we are working very carefully to
collaborate, rather than to duplicate.
Ms. Delisle. Yes, I would just add to that, I think the
strength of the proposals are really deepening our partnership,
which is already existing and working really hard for schools
to see that they have an ability to really deepen their
partnerships in the local community.
So as I mentioned previously, I have been in education for
a long time, and it has been more common practice to have
schools sort of isolate themselves around the community
services that are available. So part of our partnering and the
proposals in Now is the Time really lift that up and cause
communities to think about how do they strategize across the
support structures that are needed for students in the Pre-K
through 12 setting.
And in mentioning the teacher training programs, we also
have to be very aware that in the teacher training programs, as
Congresswoman Lee mentioned, teachers are learning to teach our
youth. They are not learning all the trades and the tools that
mental health workers have available to them. That is a
specialty area in and of itself.
So our proposals are also linking those so that while
teachers may have access to resources or to become better, I
guess, identifiers of students who may potentially have issues,
the real crux here is--in the proposals--is the partnership and
those community relationships. And some of them are a little
bit new and deeper.
So, for example, in Now is the Time, we also are going to
be providing $25,000,000 to address the post traumatic stress
disorders that Congresswoman Lee actually mentioned. That is a
deeper program than has been issued before.
We are very careful that our programs are not just
replicating themselves just in quantity, but also in quality.
Mr. Alexander. Okay. Ms. Roybal-Allard.
PREVENTING UNDERAGE DRINKING AND VIOLENCE
Ms. Roybal-Allard. While we have had some success, underage
drinking remains a serious public health and safety concern.
Just yesterday, an article in the L.A. Times highlighted the
severity of the problem, telling the heartbreak story of a
young woman who was raped while she was intoxicated.
For years, members of this committee, including Rosa
DeLauro, Frank Wolf, and myself, have worked to provide SAMHSA
with resources to prevent underage drinking through the STOP
Act, and we have watched with disappointment and with a great
deal of concern as much of the school substance abuse
prevention money has been reduced or eliminated.
Administrator Hyde, can you speak more to the relationship
between youth alcohol abuse and violence, where you have seen
the most success in preventing youth alcohol abuse and why, and
what else needs to be done?
Ms. Hyde. Thank you, Congresswoman Roybal-Allard, and thank
you for your support of the STOP Act and for these issues.
As you know, we have reinstituted this year, or last year,
the ICCPUD. It is sort of the worst acronym in the Federal
Government. But it is the Interagency Coordinating Committee on
the Prevention of Underage Drinking. It comes out of the STOP
Act, and we reinstituted it at the principal level. It had been
working at the staff level, but really to try to raise these
issues.
The connection between youth and students who are drinking
and causing violent behavior, it is usually one-on-one or
individual violence, but nevertheless, about 696,000 students
between the ages of 18 and 24 are assaulted by another student
who has been drinking each year. These are 2009 data. About
97,000 students between the ages of 18 and 24 are victims of
alcohol-related sexual assault or date rape.
So this is a huge issue. We have seen major gains about the
reduction of underage drinking in certain age groups. So the
12- to 17-year-old age group, binge drinking is actually
quite--is down quite a bit, about 30 percent over the last few
years. The 18- to 24-year-old age group, not so much. We
haven't seen those kinds of reductions. We also see continuing
deaths from alcohol-related injuries by car, by vehicle or by
accident when a young person is intoxicated.
So the STOP Act is an important part of our portfolio. Part
of it is this interagency working effort we have. We have
launched this year a webinar series that has gotten incredible
reaction to try to get information out about underage drinking
and how the data that we put into the congressional report,
which is funded by the STOP Act, has become a really important
tool to the field and to communities and to organizations like
our drug-free communities, prevention programs that are
focusing on substance abuse among young people, including
alcohol.
So the STOP Act itself has funded about 180 communities,
and last year, we did an additional 81 grants, and we expect
about 15 new ones this year. You can see that the numbers are
lower in part because of the reduction in dollars that have
occurred over the last couple of years. I think Congresswoman
Lee read those numbers.
So we provide as much funding and as much support, and the
webinar series is a way to try to get word and information out
short of calling people together in conferences and other ways
that we might have done that in the past, but to try to
continue to get our efforts around underage drinking dealt
with.
We also know, frankly, that young people who don't drink
until they are older, until they are 21 or older, are much less
likely to have problem drinking as an adult. So it is a
critical issue not only for our young people, but for adults as
well.
SCHOOL-BASED ALCOHOL PREVENTION STRATEGIES
Ms. Roybal-Allard. Okay. Assistant Secretary Delisle, can
you talk about what is being done in the schools to address
underage drinking with I understand your limited resources as
well? And what more could be done if you did have adequate
resources?
Ms. Delisle. Thank you, Congresswoman, for that question.
I think one of the issues in schools is always providing
information to students and to their families. Not just about
the data around the inappropriateness and the legal
ramifications of underage drinking, but certainly the health-
related risks as well.
In my experience in viewing schools across the country,
they rely heavily on school counselors to help with that
information gathering, providing support structures for teens.
We have seen some examples of schools that actually have
created student support groups and also have created community
events so that students have a place to go that are non-alcohol
related.
So even in the high school years, they may have a prom or
after prom activities that are totally devoted and are ensuring
that the students who come there are committed to an alcohol-
free life.
So the proposals that we put forth to increase counselors
in the schools would certainly help to provide that
information, as well as to help bridge the gap with communities
that are facing the 18 and up group to which Ms. Hyde referred.
BUDGET REQUEST FOR HEALTHY TRANSITION GRANTS
Mr. Alexander. Mr. Joyce.
Mr. Joyce. Thank you.
Administrator Hyde, I would like to thank you for coming
today and ask you about when you were speaking about
individuals 16 to 25 being at high risk for mental illness,
substance abuse, and suicide, at the same time, these are the
least likely group to actually go out and seek help.
I see that the administration arrived at a $25,000,000
funding level for State-based strategies to support these young
people. How did you arrive at that number?
Ms. Hyde. What we were trying to recognize is that this age
group has special issues--system issues, legal issues, and just
coming of age issues. We have other programs in about that age
or about that cost range that will allow us to pilot and do a
pretty good demonstration to determine what is the best way to
approach those kinds of issues.
We have some programs here and there that do transition age
youth, but it's not been a focus. So what we are trying to do
is use these dollars to pilot in a few States what would be the
best approaches. So anytime we start a new program like this,
we do an extensive evaluation and then try to make sure that we
have got the best programs and the best practices before we try
to take it to scale.
Mr. Joyce. With the other things that you have been doing,
do you have any idea what your success rate is as far as
getting kids to attend and be involved in these type of things?
Ms. Hyde. Our programs, whether it is our Drug-Free
communities program or whether it is the Safe Schools/Healthy
Students program or any of them, show incredible success. When
you engage young people, you can reduce the perceptions of
violence as well as the actual violent behaviors. You can
reduce the drug use, and you can reduce the violence associated
with that drug use or that alcohol use.
So, on any particular program that we have in place now, we
do have data, and we can share that with you if you have a
particular interest in a particular program. Or if you would
like some information just in general about what we are seeing
in those programs, we can let you know.
Mr. Joyce. Thank you.
IDENTIFYING STUDENTS WHO HAVE MENTAL HEALTH ISSUES
Assistant Secretary Delisle, thank you also for being here
today. It is easy for teachers to be able to tell when somebody
has a fever. What are we doing to assist teachers in trying to
pick out those who might be having mental issues?
Ms. Delisle. Congressman Joyce, it is actually nice to
become reacquainted with you. I actually worked in the West
Geauga local school districts, and we had some interactions
with your office. So it is nice to become reacquainted with
you.
Mr. Joyce. I recall.
Ms. Delisle. Yes. [Laughter.]
I was going to say it wasn't always under the best of
circumstances. Not on your condition, it was because of some of
our folks.
Anyway, I think one of the things we discussed a little bit
earlier and was provided in my testimony is that it isn't easy
for a teacher to do because they are not naturally trained in
that. And as Congresswoman Lee has mentioned, that is not their
area of expertise.
So the more that we can provide knowledge and resources to
teachers, the better. So what are these indicators? And then
have them be able to connect with a mental health provider who
can follow up on that and just suggest whether or not that is
something that we ought to look at a little bit closer, or it
is developmentally appropriate for that student to be behaving
in that kind of way.
What is even more important, though, is not just that
diagnosis or that recognition of that mental health disorder,
but also how the strategies that a teacher may use within the
classroom to more certainly engage that child in a productive
kind of way. That is what is really necessary.
So we look to mental health providers to provide that
information, that knowledge, and resources to students as well
as to their families because sometimes families don't know how
to cope with a child who may have a mental health disorder.
Mr. Joyce. And you know why this is of special interest to
me after what took place in Chardon?
Ms. Delisle. Yes.
EFFECTS OF VIOLENCE IN VIDEO GAMES
Mr. Joyce. And that is why I want to know what--also you
had, Ms. Hyde, you had talked before with the chairman about
violence in programming. What about has there been any studies
done on violence in video games and its effect on teenage?
Ms. Hyde. Congressman Joyce, that was the question the
Chairman asked me, and it is not my area of expertise. So I
actually don't have the information here about that. I know
that there are other parts of the department that are looking
at those issues. So I would--we can get back to you about who
might be the right individual to have talk to you about that.
Mr. Joyce. Do you have any input on that, Ms. Delisle?
Ms. Delisle. I would say the same. [Laughter.]
Mr. Joyce. Well, it is of special interest to me,
obviously, because there is a combination. Obviously, there are
some mental health issues, and there is also some issues with
the violence that you will notice that between the video games,
the fact that--and Hollywood. But in video games, the fact that
they re-spawn, and all of a sudden, 60 seconds later, 30
seconds later, I don't know what that is, but then all of a
sudden, these kids come back.
And in that case particularly where this young man shot the
people in the high school, the first thing he asked was ``Why
did you do it?'' ``I don't know why.'' And wanted to have that
moment back in time.
Well, because I really think that it is on top of having
some mental issues that there is also a play of how much
violence these kids are getting used to, and it is not right.
So any help you could give us in that area, I would really
appreciate it because it is something I am very interested in.
Thank you.
Mr. Alexander. Thank you.
AMOUNT OF FEDERAL FUNDING ON MENTAL HEALTH IN EDUCATION
What percent or what is the total amount spent by the
Federal Government on mental health in education? Do we know?
Ms. Delisle. Congressman, I do not have that number. We
could certainly get that back to you and combine all of our
programs out of Ed, but a starting estimate would be $50
million.
Mr. Alexander. Thank you.
Ms. Lee.
Ms. Lee. Thank you very much.
MENTAL HEALTH TREATMENT MODALITIES USED IN SCHOOLS
There are a couple questions I would like to ask, and you
probably would have to send this to the committee, the answer
to this one. But I am interested in knowing what the treatment
modalities now that are being used in schools in terms of
mental health treatment.
I mean, I was trained way back in the day in psychoanalytic
psychotherapy, play therapy, behavioral therapy. Is there any--
and I know it depends on the diagnosis or the kind of plan, the
treatment plan. But I am curious now to know what the primary
mode of treatment is for young people.
Ms. Delisle. Congresswoman Lee, actually, within schools,
what we see is that the treatment occurs outside of schools
with mental health professionals in a specific setting. What we
see happening in schools is sort of what I would view as the
secondary approach, and that is so everything from play
therapy, et cetera, that is being used to support what occurs
with that provider on the outside of the school.
Ms. Lee. I see.
Ms. Delisle. So that interaction and that information
sharing is really critical.
Ms. Hyde. Congresswoman Lee, there is a program that was
initially researched by NIMH, the National Institute of Mental
Health, with very good results, and we have with Education
implemented it in many school settings. And that is something
called the ``Good Behavior Game.'' It is a program that is a
preventive program. It trains teachers how to deal with
behaviors in the classroom.
And there are incredible results for both the teachers and
the young people. That is more of a preventive intervention,
but it is--and it is child specific. So that is an example of
something----
Ms. Lee. I would like to learn more about this.
Ms. Hyde. Okay.
IMPACT OF FUNDING CUTS ON PROGRAMS
Ms. Lee. Let me ask you about going to the funding. I
mentioned in my opening statement funds have been cut between
2010 to 2012 for SAMHSA, what, 5 percent? Now, on top of that,
we have got sequestration. Funding now is about a fifth lower
than 2002.
Tell me what is going on with regard to funding, and how
you are going to--what the impact of sequestration is on
children's mental health programs and services? Knowing that we
are nowhere near where we need to be, does this mean we go
backwards again, or what do we do at this point?
Ms. Hyde. Congresswoman Lee, obviously, all of our programs
are programs that are showing good results in what they do. And
if they don't show good results, we don't continue them. So any
program that sees a reduction means it is less that we can do
for the communities in America.
In some cases, sequester will result in fewer new grants. I
gave you an example of that with the STOP Act grants that we
anticipate this year. In other cases, it is literally fewer
people who will be able to get substance abuse treatment or
other kinds of services that support people getting those
treatments.
For the last 3 years, we have taken the responsibility to
consolidate, make sure that programs that are able to be more
efficient and more effective can be done in a different way. So
we have done everything we can to reduce expenditures without
reducing impact on programs.
We are at the point where that is no longer possible. So
additional reductions are going to mean reductions in grants
and programs and our public efforts, our public education
efforts, and our efforts at outreach and our efforts at data
collection, et cetera.
Ms. Delisle. So, Congresswoman Lee, I would add to that
that in the President's 2013 budget, it actually included
$196,000,000 for a Successful, Safe, and Healthy Students
program that was part of the ESEA reauthorization proposal. And
much of that was really focused in on supporting students in
schools both with mental health issues as well as creating
these positive support structures that I place.
So, like SAMHSA, we are very concerned with sequestration
about the possibilities of grants being reduced and funding
available to schools. So, for example, in our Project SERV
program, we actually provide dollars to the local school
district. So when there is an incident that occurs, a shooting
such as in Chardon, Ohio, when learning is interrupted, we
provide dollars for mental health workers to support the
students and the educators.
But the other concern that I have is almost a secondary
one, which is, for example, in Title I, which serves our
poorest children, particularly in the areas of reading and
mathematics, while that is focused on an academic venue, what
my concern is that with that lowered, lessened services to
students in the academic field may, in fact, yield more
behavioral incidents in schools when students become frustrated
because they can't read or they can't catch up with their
academics.
So there is also a secondary component that is really
critical.
Ms. Lee. Thank you very much.
Mr. Alexander. Dr. Harris.
Mr. Harris. Thank you very much.
ALARMING TREND IN YOUTH SUICIDE STATISTICS
Ms. Hyde, let me just talk about another topic that people
don't like to talk about. We need to talk about it because a
lot of people are concerned, and that is teenage suicide.
It is of concern to me that the CDC report last year
indicated that if you look at children who either attempt or
complete suicide, that the incidence over the past few years
from they looked at data from 2009 to 2011, actually increased
about 20 percent, where just under 8 percent of teenagers say
they either considered or attempted suicide.
And interestingly enough, the highest incidence are
Hispanic girls, which is interesting, and I am not sure what
the explanation is. But it actually gets to the point, two
points and two questions.
One is whatever we are doing, it is not working because the
incidence is going up. As we continue to spend billions of
dollars, I mean, the incidence is going up. And I guess the
questions are related. In your opinion, what is the cause of
the increased incidence, and why haven't our strategies worked
for that particular topic, teenage suicide?
Ms. Hyde. Congressman Harris, thanks again for that
question.
You may be aware that over the last couple of years, there
has been a public-private partnership called the National
Action Alliance for Suicide Prevention that was kicked off a
couple of years ago by Secretary Sebelius and Secretary Gates
because we are also concerned about this issue, obviously,
among military personnel and veterans and their families.
That effort has spent 2 years with the Surgeon General
updating something the Surgeon General just released last fall
called the ``National Strategy for Suicide Prevention.'' And in
that strategy, we looked at young people. We looked
specifically at Native Americans. We looked specifically at
military personnel, and we looked a number of other groups.
We also brought together the different players in the
Federal Government who do the data about this. So CDC tends to
do the mortality data, and SAMHSA, frankly, does a lot of the
data around thoughts, plans, and acts to commit suicide, but
may not result in actual death.
So we have been able now to combine those data to get a
better picture of young people who have higher rates of
attempts and thoughts of suicide. Frankly, older people, older
men have attempts that result in death.
So we are sort of looking at the whole range. There is a
different approach when you are looking at the distress of
young people that results in the kinds of attempts and acts and
thoughts versus the actual result in death.
We also have done an increasing amount of work, at least in
SAMHSA, to address the Latina, young women of Hispanic
background. About 25 percent of our Garrett Lee Smith grantees
are specifically focused on this community. So I think there is
looking at the data, that is a community that has a higher
incidence of those kinds of thoughts and actions, and we are
trying to look at it from young people before college, but also
on college campuses and that age group that is specifically
addressed appropriate there.
Why has it not worked? I think that is part of what we have
learned through the interagency and public-private partnership
from the Strategy and the Alliance. And I think what we know is
intervening early. I think we know that there are a lot of
individuals who don't know the signs and symptoms. So right in
front of you can be a young person who is exhibiting signs and
symptoms, but either a parent or teacher or a faith leader
doesn't know what kind of outreach to do.
There are youth who don't know how to reach to other youth,
and they are some of our best early interveners to get help for
young people. And then, frankly, young people as well as older
people who attempt and enter hospitals or enter emergency rooms
after an attempt are at high, high risk of repeat attempts and
death from suicide.
So we are also looking at hospital emergency rooms,
readmission rates, connections, and care coordination once they
leave there. Those are the kinds of issues we are also trying
to look at.
The National Action Alliance set a goal of a reduction in
over 5 years of a specific set of numbers, which is not in my
head at the moment. But so we are really trying to look at the
metric and trying to get those numbers down.
Mr. Harris. And what--are there any proposals--has this
alliance actually come forth with their proposals yet? I mean,
because this trend is not a new trend. My understanding is this
trend started around the middle of the last decade, and after
gradually dropping off, it started to increase.
And you know, the CDC data is not just mortality. CDC data
is attempt or complete. So this is not new data. I mean, how
long is it going to take for us to actually be able to do
something?
We spend a lot of money on this. We spend millions and
millions of dollars on some of the grants you suggest. Is there
a realistic possibility that we can actually reverse this
trend?
Ms. Hyde. Congressman Harris, again, we collaborate with
CDC and use each other's data. So they do use some of our data
on the acts and completions--I mean the acts and the thoughts.
And what we are trying to look at there is what is the trend
compared to what is going on in the environment?
So, frankly, as the economic issues have been more dire, we
have seen some of the rates go up. We are also trying to look
at what that data, the mortality data comes a little later than
the data about thoughts and actions. So, yes, the Action
Alliance has actually put out some recommendations and the
strategy has very explicit things.
It just came out last fall, and we are now in the process
of implementing. And as I said, there is a commitment at the
public-private level as a metric to reduce those numbers in a
certain period of time. We can get you that metric. I just
can't pull it out of my head.
Mr. Harris. I would appreciate that. Again, and the report,
any reports you have from the alliance. I would appreciate
that.
Ms. Hyde. Okay.
Mr. Harris. Thank you very much, Mr. Chairman.
Mr. Alexander. Fiscal year 2012, $117,000,000 was devoted
to mental health. The fiscal year 2013 request from the
President was $88,000,000. That is quite a bit less, and the
President now is proposing after a response or in response to
the Sandy Hook tragedy to train an additional 5,000 mental
health providers.
And another aspect of the President's proposal includes
devoting $25,000,000 to State-based strategies on young people
between the ages of 18 and 25. So the question is for those 17
or 18 to 25 that are no longer in school, how do we propose
reaching them?
Ms. Hyde. Congressman Alexander, there are actually two
parts to your question. The first part, I think, refers to our
program, which is called the Children's Mental Health
Initiative. It is a program that has been in existence for a
number of years. We have done a lot of evaluation, and it is a
great program. We have developed models that help us know now
that we need to push those out across the country.
So in the same President's budget, there was actually a
proposed increase in the Mental Health Block Grant, and what we
were trying to do was say, okay, we have proved the process and
let us begin to move it to scale by moving it throughout all
the States, not just in the communities that we could fund. So
there was a rationale to the way that set of proposals was
proposed.
You asked a second question, and I have just lost it. Was
the second part of your question was?
Mr. Alexander. How do we reach those that are no longer in
school?
Ms. Hyde. Ah, okay. The Healthy Transitions project then is
proposed as what we call our ``theory of change,'' actually. It
is once we prove a program works for a specific set of kids,
and the Children's Mental Health Initiative was for young
people with serious emotional disturbances. We now see a set of
young people who are moving from the child-serving system to
the adult-serving system, moving out of school, sometimes into
community colleges or colleges, but not always, and have a very
different set of structures to deal with.
So what we want to do now is do some pilot work to see what
is the best approach for serving those young people and do the
evaluation that we have done on some of the other programs that
have been in place for a while.
Mr. Alexander. Ms. Lee.
Ms. Lee. Let me ask you, going back to the funding and the
impacts, your response in terms of the sequester really is very
scary because we are talking about what we need to do in the
future. So I don't know what is going to happen to these kids.
I just don't know.
So I want to hear from you what you think could happen and
what we need to be prepared for in all of our communities. And
then, secondly, the President's plan that he is putting
forward, it has, of course, funding requirements. Is this going
to be in his budget? I mean, he is going to request it in his
budget, right, and this will come before this committee?
I mean, well, we are going to have to appropriate some
funding for the President's plan, right? Okay. Now can you make
the case for that?
Ms. Hyde. Congresswoman Lee, I can speak to the proposals
on the mental health side, and Assistant Secretary Delisle can
speak to the education programs.
The case for it I think we have been talking about in this
hearing, and you have offered us an opportunity to do that,
which is to try to take a program called Safe Schools and
Healthy Students that we did a lot of good work on together
over the last several years. We are taking that program, along
with a new concept, the Mental Health First Aid, and packaging
those together to try to take to scale in a few States a
program called Project AWARE.
And what that will do is bring what we learned from the
Safe Schools/Healthy Students program and put it together with
Mental Health First Aid to get awareness up, to get communities
and schools working together across a State, and to take it to
scale in the State. See if we can do that. See if we can go
from the projects to the scale.
The second project we just got through talking about is the
Healthy Transitions Program, which is really trying to address
that transition age youth. If you look at a number of the mass
incidents or mass casualty incidents, it is this age group that
is involved. Not always, but some of them are.
We are not suggesting that we are trying to prevent those
issues, but we do know that that age group has particular
issues. It is when some of the first psychosis tends to happen.
It is when, we have already talked about, there is more
incidence of issues and less help seeking.
We know that parents are less involved as kids become
adults. They are less able to influence children's behavior
sometimes. So we are trying to look at all those issues and see
what that can mean.
And then the third program is the workforce program, and we
just produced a report that was requested by Congress, gave it
to Congress last week, that sort of delineates the need for a
health workforce of all sorts everywhere. It is not just in one
place, but it is really a workforce that needs to be produced
more.
Ms. Lee. Okay. So what happens, though, to the damage done
by sequester? You know, I mean, I want to support and make sure
all of the President's initiatives are fully funded.
But now we have a problem with the lack of funding for
those who have been just sort of left outside of the service
realm because the cuts have taken place. So what happens to
them?
I mean, do you double down on the new programs? Do you
increase it by 50 percent? Do we look at how to make up for
lost time and lost services and lost children? I mean, how do
we deal with it?
Ms. Hyde. Congresswoman Lee, we do the best we can with the
dollars that Congress appropriates to us. And to the extent
that the sequester has reduced programs, we are going to see
fewer people treated. We are going to see fewer professionals
trained. We are going to see fewer individuals informed about
their ability to make a difference in this.
We are going to see less ability to train teachers. All of
those things are going to happen across the board for the
programs under the sequester reductions.
Ms. Lee. Yes, so it seems to me that the dollar amount that
the President is requesting is not enough, quite frankly.
COLLABORATION BETWEEN SCHOOLS AND MENTAL HEALTH PROVIDERS
Mr. Alexander. Mr. Joyce.
Mr. Joyce. Thank you, Mr. Chairman.
Again, Assistant Secretary Delisle, if you would, could you
explain what has been taking place, what outreach has been made
in trying to encourage collaboration between school systems and
local mental health facilities? And you may have answered that,
and I may have been missing. And I apologize.
Ms. Delisle. Thank you, Congressman Joyce.
I think we have had a lot of impact in modeling, first of
all, at the Federal level about our own initiatives across not
just with SAMHSA, but also with the Department of Justice. We
have cosponsored some learning sessions. We have cosponsored
some webinars. We have cosponsored some summits.
For example, we had a bullying summit last summer, which
was highly effective in getting people to really discuss a very
critical issue. So, first of all, we are modeling that at the
Federal level.
At the local level, many of our grant programs actually
have a requirement in them that communities and schools partner
over a variety of issues, such as mental health issues, such as
counseling, such as family support structure, such as family
engagement.
So we have made that a priority in the Ddepartment for
schools to actually reach out into the community to support the
programs and to support the learning needs of all students.
Mr. Joyce. That is fantastic. Is there any way to measure
the outcomes of whether or not we are actually getting
something accomplished?
Ms. Delisle. Well, to the extent possible, Congressman,
that we could measure the numbers of meetings and interactions,
we will be looking at that. So even through our ESEA
flexibility waiver packages, the States even had to arrive at
ways in which they would reach out to schools, et cetera, and
engage community members in those plans.
So we will be looking at that. I don't know if we will be
able to actually collect data on the effectiveness of them
because it is a pretty hard variable to isolate. But certainly,
the numbers of interactions would be one that we could measure.
Mr. Joyce. Great. Thank you.
I would yield back, Mr. Chairman.
HIGHER RATES OF ATTEMPTED SUICIDE BY LATINA YOUTH
Mr. Alexander. Ms. Roybal-Allard.
Ms. Roybal-Allard. I want to go back to the previous issue
that was raised by Dr. Harris with regards to adolescent
suicides and add to the previous discussion with regards to
Latina youth suicide. Because for the past 20 years, adolescent
Latinas have had significantly higher rates of attempted
suicide, and in 1995, it was reported that 1 in 5 reported a
suicide attempt.
And recently, rates among adolescent girls have decreased.
However, the Latina population has continued to have higher
rates even than their African-American or white counterparts.
More staggering is that for every 1 suicide death, there are
reports of 8 to 15 attempts. And some of these cases are being
seen in girls as young as 12 years of age.
So I just wanted to make the point that there is a real
need for specific programming and extensive research focused on
why Latinas are at a higher risk for attempted suicide. I
really don't have--I have a question, but I just wanted to get
that on the record.
Also, Administrator Hyde, for all of these issues that we
have been discussing today, it is critical that we have a
culturally and linguistically competent mental health
workforce. In its Gun Violence Task Force recommendations, the
administration has proposed $50,000,000 to train more than
5,000 additional mental health professionals to serve students
and adults.
And the proposal seems specifically designed to train more
social workers, counselors, and psychologists. Can you give me
a sense of how these resources will be allocated? For example,
will money be going to the National Health Service Corps? Is
the administration proposing any new funding at all for the
SAMHSA Minority Fellowship Program?
How is all this money going to be distributed and where?
Ms. Hyde. Congresswoman Roybal-Allard, yes. We are--a
portion of the workforce proposal is specifically to double the
Minority Fellowship Program that we do. It is currently a very
small program, about $5,000,000, but it gives us a lot of
special efforts at increasing those professionals that are from
those populations that are least well served.
We want to double it and focus the Minority Fellowship
Program on a youth-serving population, not always under 18, but
that young adult population. We want to try to get at that and
encourage that. So that is another--that is a $10,000,000
program.
Then $35,000,000 of the program will be collaboration with
HRSA, which is using its authority, it has a mental and
behavioral health authority, to put specific grants out to
develop new professionals in the groups that you said. We are
focusing with them on those professionals that will be
clinically trained. We can produce Ph.D.s as well, but
sometimes the Ph.D.s are teachers or trainers.
And while we need those as well, this particular project is
trying to focus on master's level individuals who will be
clinically trained and work directly with young people and
their families.
Then there is another part of the project that is for
peers. So paraprofessionals and peers we know have a great
capacity to engage, to do recovery supports, and to do some of
the other really critical services that, frankly, especially
for young people, a peer can do much better in many ways than
the licensed professional, clinically trained folks.
So it is a combination, and we packaged this program with
HRSA carefully to try to produce as many as we could with the
dollars we had available in a 2-year period. So it is all of
those things.
Ms. Roybal-Allard. Okay. I have just a few seconds left. So
I didn't know if you wanted to comment on my previous comment
on the Latina issue?
Ms. Hyde. On the Latina issue? Oh, yes, we have a very
strong program that we call the National Network to Eliminate
Disparities, and a couple of years ago, we also created an
Office of Behavioral Health Equity. And the National Network to
Eliminate Disparities in Behavioral Health, which we call NNED,
has worked with the Human Interaction Research Institute and
the Valley Nonprofit Resources to offer 20 of our NNED
organizations, there are about 500 in the network. It is a
learning community.
And we have specifically worked on coaching Latina multi-
family group therapy and taken an organization or a program
called a multi-family group program. It is based on a well-
validated program and really tried to push it out. So we are
trying to identify programs that work and then trying to help
minority providers be able to push that out as well.
So we are trying to create more minority providers. We are
trying to support them, train them, and then trying to take
evidence-based practices and get it out as well.
Ms. Roybal-Allard. Okay. Thank you.
Mr. Alexander. No more questions. We want to thank you all
for being here today, and I would like to thank the committee
members for engaging in a very productive committee hearing.
And I would remind the committee members that we have
another meeting scheduled April the 10th. What time is it? At
10:00 a.m., April the 10th.
Okay. The committee stands adjourned.
Thank you.
[The following questions were submitted for the record.]
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Thursday, April 25, 2013.
BUDGET HEARING--DEPARTMENT OF HEALTH AND HUMAN SERVICES
WITNESS
HON. KATHLEEN SEBELIUS, SECRETARY, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Mr. Kingston. The committee will come to order, and I
welcome everyone for the final hearing of the year, for Labor
Health and Human Services Education and related agency
subcommittee. We have had a number of hearings. I think we
would all like to spend more time and getting more questions
with every agency, but we don't get to, but we are ending on a
strong note with Secretary Sebelius today, and I know that
everyone on all sides at all angles and all accounts have lots
of different questions.
I think one of the questions that we will want to talk
about it, and I think we have given some heads up on it, is the
request for--about the reprogramming and transfer request, and
we will discuss that in more detail, but let me yield the floor
to Rosa DeLauro.
Ms. DeLauro. Thank you very much, Mr. Chairman, and
welcome, Madam Secretary, delighted to have you here with us
this morning.
As we discuss the President's budget, I believe it is
important that we keep in mind a very key point. This budget
assumes that the sequestration scheduled for 2014 is replaced
with a more sensible and balanced deficit reduction package
such as the one being proposed by the President. I very much
hope we will succeed in doing that, but I have my doubts. And
if we are not successful, the budget for HHS will look very
different. Sequestration will reduce the 2014 cap on non-
defense discretionary appropriations by roughly
$37,000,000,000, and the Labor HHS bill accounts for almost a
third of the non-defense discretionary total. I would like to
hear, Madam Secretary, what the impact of this will be.
Moving to the budget before us, one proposed increase I am
particularly pleased to see is the focus on investment in early
childhood. This is--there is a tremendous need in America for
further investment in high quality and readily accessible child
care and learning opportunities for infants and toddlers, and
while I have some questions about the proposal, I am glad to
see this budget moves us in the right direction.
The President's budget also requests appropriations to
continue implementation of the health insurance marketplaces
under the Affordable Care Act. That is exactly the right thing
to do. The ACA is the law of the land, and our constituents
deserve to access quality insurance options on its exchanges.
It is unconscionable that Congress failed to provide the
funding needed this year, and as a result, HHS has been forced
to divert resources away from other critical public health
priorities.
The ACA has the potential to transform health care in this
country, increasing preventive services, eliminating pre-
existing conditions, and reinforcing our longstanding
bipartisan support of community health centers.
I am encouraged that the administration requests additional
funding for the National Institutes of Health. Patients across
the country rely on research supported by the NIH, and other
health agencies like the health care research and quality
program in order to find out how we can prevent, diagnose
earlier and better treat diseases like cancer.
We also rely on public health agencies like the CDC to
protect us from new diseases, like the avian flu virus that has
affected more than 100 individuals in China, and to detect and
control diseases here at home. Even before sequestration,
appropriations for the CDC had been reduced by more than
$725,000,000 in 2010. When you add sequestration, the numbers
are even worse.
I am pleased that the administration has requested funding
to restore cuts made to the Title X family planning program in
recent years.
There are a few things in this budget, Madam Secretary,
that I can't support. One is the proposed $445,000,000
reduction to the Low Income Home Energy Assistance Program,
LIHEAP. I am opposed to the proposed halving of the community
services block grant.
Yet another is the fact that no additional discretionary
appropriations will go to combat health care fraud and abuse.
It now looks like the President will seek mandatory funding for
this. Now, I also understand that the request has been made now
3 years in a row, and that we have had no increase from the
majority side of our committee. So that what we need to do is
increase this $311,000,000 which allows us to be able to combat
health care fraud and abuse. The effort returned $7 to the
Treasury for every $1 it spent.
There are a number of other important issues I hope we can
discuss today, including the strengthening of access to mental
health services, especially in the wake of the tragedy at Sandy
Hook Elementary School in Newtown.
As a member of the Connecticut delegation, I can only tell
you that it doesn't get any easier to speak about, and our kids
need access to quality services after traumatic events like
Newtown. We need to do a better job of protecting our children,
and we need to do a better job in making sure that they have
access to mental health care.
I look forward to our discussion this morning and to your
testimony. Thank you again for joining us today.
Thank you, Mr. Chairman.
Mr. Kingston. Mrs. Lowey.
Mrs. Lowey. Thank you, Chairman Kingston, Ranking Member
DeLauro. Thank you, Secretary Sebelius for appearing at today's
hearing.
I joined this subcommittee 20 years ago. With hard work,
bipartisanship and a healthy allocation, the subcommittee can
profoundly improve the lives of our constituents. I have been
privileged to support efforts, including doubling biomedical
research at the NIH to investigate the causes and treatments
for breast cancer, autism, diabetes, Alzheimer's and a number
of other diseases and disorders, strengthening our public
health system through CDC investments, and expanding Head Start
to give more children as many opportunities as possible.
As the subcommittee readies its fiscal year 2014 bill, we
must keep in mind that $2,500,000,000,000 in deficit reduction
has been enacted, the vast majority of which is within the
jurisdiction of the Appropriations Committee. Even without
sequestration, discretionary spending is on a path to be at its
lowest percentage of GDP in the last 45 years. HHS' initiatives
cannot absorb further cuts.
While I am supportive of key increases in the budget
request, particularly for NIH, the proposed increase is less
than one-third the amount lost to sequestration this year.
There are a number of examples of investments this subcommittee
makes that save taxpayer dollars. The 3-year rolling average of
return on investment for the Health Care Fraud and Abuse
Control Program is 7.9 to 1. For every public dollar invested
in family planning care, nearly $4 in Medicaid expenditures are
averted; and for chronic disease, the more we invest in
prevention, the less we spend on treatment in future years.
The fiscal year 2014 budget request includes a number of
promising new initiatives, including the President's BRAIN
proposal, $130,000,000 to help educators and parents recognize
signs of mental illness, and increased resources for Head Start
and child care.
However, I am concerned with a number of proposed
reductions, including to children's hospital graduate medical
education, LIHEAP and the Community Services Block Grant. Once
again, I would like to thank the Secretary. I look forward to
today's discussion. Thank you.
Mr. Kingston. Do any other members have an opening
statement?
If not, Madam Secretary, the floor is yours for 5 minutes,
and we are going to stick strictly to the five-minute rule as
we always have, so--some committees are a little bit more
relaxed about it, but we have a lot of people--we like to take
several rounds, so thank you.
Opening Statement
Secretary Sebelius. Well, thank you, Chairman Kingston and
Ranking Member Lowey and DeLauro and members of the
subcommittee. I am pleased to have the chance to be with you
today to discuss the President's 2014 budget for the Department
of Health and Human Services.
This budget supports the overall goals of the President's
budget by strengthening our economy and promoting middle class
job growth. It ensures that the American people will continue
to benefit from the Affordable Care Act. It provides much-
needed support for mental health services and takes steps to
address the ongoing tragedy of gun violence; strengthens
education for our children during their critical early years,
to help ensure they can succeed in a 21st century economy;
ensures America's leadership in health innovation so that we
remain a magnet for jobs of the future; and it helps reduce the
deficit in a balanced sustainable way.
I look forward to answering your questions about the
budget, but first I would like to briefly cover a few of the
highlights.
The Affordable Care Act is already benefiting millions of
Americans, and our budget makes sure we can continue to
implement the law. By supporting the creation of new health
insurance marketplaces, the budget will ensure that starting
next January, Americans in every State will be able to get
quality health insurance at an affordable price. Our budget
also addresses another issue that, as Congresswoman DeLauro has
already said, has been on all of our minds recently, mental
health services and the ongoing epidemic of gun violence.
While we know that the vast majority of Americans who
struggle with mental illness are not violent, recent tragedies
have reminded us of the staggering toll that untreated mental
illness can take on our society, and that is why the budget
proposes a major new investment to help ensure that students
and young adults get the mental health care they need,
including the training of 5,000 additional mental health
professionals to join our behavioral health workforce.
Our budget also supports the President's call to provide
every child in America with access high quality early learning
services. It proposes additional investments in new early Head
Start child care partnerships, and it provides additional
support to raise the quality of child care programs and promote
evidence-based home visiting for new parents.
Together, these investments will create long-lasting
positive outcomes for families and provide huge returns for
children and society at large. And our budget also ensures that
America remains a world leader in health innovation. We make
significant new investments in the NIH that will lead to new
cures and treatments and help create good jobs. It provides
further support for the development and use of compatible
health electronic record systems and improved care
coordination, and it includes funding to ensure that our Nation
can respond effectively to chemical, biological and nuclear
threats.
I want to especially thank committee members for your
support of our efforts to provide a safe environment for
unaccompanied children who enter our country. As you know, we
have seen a growing number of children coming into the country
without any parents or guardians, and our budget includes
additional funds to help ensure an estimated 26,000
unaccompanied children are safe and healthy.
Even as our budget invests in these critical areas, it also
helps reduce the long-term deficit by making sure that programs
like Medicare are put on a stable fiscal trajectory. Medicare
spending per beneficiary, as Ranking Member Lowey has said,
grew at just four-tenths of 1 percent in 2012, thanks in part
to the $800,000,000,000 in savings in the Affordable Care Act.
But the President's 2014 budget would achieve even more
savings. For example, this budget will allow low income
Medicare beneficiaries to get their prescription drugs at lower
Medicaid rates resulting in savings of more than $120 billion
over the next 10 years. In total, the budget would generate an
additional $371,000,000,000 in Medicare savings over the next
decade on top of the savings in the Affordable Care Act.
To that same end, our budget also aggressively reduces ways
across our Department. It includes an increase in mandatory
funding for our Health Care Fraud and Abuse Control Program, an
initiative that saved taxpayers nearly $8 for every dollar
spent on it, and it supports additional efforts to reduce
improper payments in Medicare, Medicaid and CHIP and to
strengthen the Office of the Inspector General. This all adds
up to a budget guided by the administration's north star of a
thriving middle class, promoting job growth, keeping our
economy strong in years to come, while helping to reduce the
long-term deficit.
I am sure many of you have questions, Mr. Chairman, and I
am happy to take those now. Thank you.
Mr. Kingston. Thank you very much, Madam Secretary.
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AFFORDABLE CARE ACT IMPLEMENTATION
Mr. Kingston. I think the first question that we have, or
that I have is that the projection for implementation of
Obamacare in 2013 was 1.2 billion, but now it looks like you
are requesting, and are going to use 1.7 billion, which is
certainly a big swing, but also, I have concerns where this
money comes from. Some of it comes out of the CDC prevention
programs, for example, or biomedical research, NIH and other
programs like mental health training, suicide prevention,
Alzheimer's disease and prevention outreach, just for a few
examples, and so I would like to know, you know, I would like
you to react to that, and I want to add up the additional
fiscal year 2013 funds that I understand that are being used.
CMSS made it Obamacare base of 154,000,000 at CMS; residual
Obamacare implementation fund, 223,000,000; proposed 1 percent
transfer for authority, which we will review once the operating
plans are submitted; and prevention public health funds of
554,000,000, and non-recurring expense funds of 450,000,000
that comes to this total of 1.7 million.
So it looks like you are cobbling together some money, and
I don't--I guess the question is, at what point do you know if
you have enough? And if you don't get this, how are you going
to be able to implement Obamacare?
Secretary Sebelius. Well, Mr. Chairman, as you know, we did
not have a 2013 budget, and we made a request in the debate
over the continuing resolution for additional funding
particularly for outreach and education. That was not granted
by the United States Congress. It is our job to implement the
law, and we have millions of Americans looking forward to the
opportunity for affordable health care, so we have used the
authorities that I have as Secretary to reprogram some of the
prevention funding to use specifically for outreach and
education, to use our non-recurring expense fund for one-time
IT expenses, and to take advantage of the secretarial transfer
authority to add additional resources.
I think the original bill contained $1,000,000,000 in
administrative funding, and at that time, the Congressional
Budget Office estimated that the administrative costs would be
closer to $10,000,000,000.
So we are now here in 2013 administering this law. We are
using every dollar that we have been allocated as carefully as
possible, but the highest priority for public health in this
country is to try and make sure that every American has good
health, and access to preventive services and ongoing health
care, and so we are continuing to implement the law.
Mr. Kingston. What is the total cost of implementation, do
you think? Is that 1.7 going to do it?
Secretary Sebelius. Well, as you know, the budget before
you, Mr. Chairman, asked for an additional $1,500,000,000.
Mr. Kingston. And that would do it in its entirety----
Secretary Sebelius. Well, we are----
Mr. Kingston. Or what would you say would do it in its
entirety?
Secretary Sebelius. I mean, we are, at this point, asking
for the resources that we think are appropriate, the basic
infrastructure to run the Federal marketplaces and the Federal
hub are built with the resources that we have. We are still
relying on not only the resources we are able to put together,
but outside partners to help with outreach and education, which
is a critical part of the program success. If people don't know
the choices they can make, if they don't have access to
enrollment help and information, we will struggle to get people
enrolled.
So, the resources we have requested, again, are in
anticipation of additional funding coming in with user fees
from the marketplaces once they are set up, but also to use for
outreach and education.
Mr. Kingston. Okay. And if you take say the funds from CDC
to do this, what will the impact be on CDC?
Secretary Sebelius. Well, what we have done, Mr. Chairman,
these are not CDC budget dollars. They are the Prevention Fund
dollars that are part of the Affordable Care Act. Many of those
programs are administered by the Centers for Disease Control
and Prevention. We have made some very tough choices continuing
some of the basic operational issues around tobacco cessation
and control, around obesity prevention, looking at chronic
disease programs with the community, transformation grants,
trying to keep whole the major initiatives, but also
recognizing that the public health direction around the
Prevention Fund is outreach and education involving preventive
services, private insurance and Medicaid linking uninsured and
underinsured individuals to preventive services on an ongoing
basis, so we are balancing tough choices. We would prefer that
our budget actually be fully funded. That is what our request
was. That didn't happen, so we are trying to make it work.
Mr. Kingston. Okay. Ms. DeLauro. Thanks.
IMPLEMENTATION OF THE AFFORDABLE CARE ACT
Ms. DeLauro. Thank you very much, and thank you, Madam
Secretary. It is important to point out that the request was
made for the implementation fund, but it was denied by the
Congress.
FIREARMS RESEARCH & NATIONAL VIOLENT DEATH REPORTING SYSTEM
With that, let me just talk about the budget proposal for
two increases for the CDC injury prevention center. That is in
conjunction with what the President has talked about as his
``Now is the Time'' initiative. This involve violence and
firearms. One increase is to support additional research in
this area; the other is to expand to all States the National
Violent Death Reporting System that collects extensive data
regarding deaths from all forms of violence.
What is the purpose of the violent death reporting system,
what benefits would be obtained from expanding it to cover more
States, what benefits would you hope to achieve from additional
public health research into firearms-related violence?
Secretary Sebelius. Well, as you know, Congresswoman,
Centers for Disease Control and Prevention is responsible for
investigating, surveilling and gathering information around
preventable injuries, around public health crises--and
certainly firearms and deaths related to firearms are a
significant issue here in the United States. They cause about
87 deaths a day in America--suicides, unintentional firearm
deaths, and intentional firearm deaths. There is over $47
billion in related health costs, loss of productivity, loss of
life, medical issues directly related to firearm injuries and
deaths.
So, it is a significant public health issue, and making
sure that the data is collected accurately, that it is reported
accurately and that people can then assess what is happening
and look for ways to lessen and reduce the impact of firearm
violence is part of making America a healthier place and
restoring some resilience in health community by community.
TITLE X
Ms. DeLauro. Thank you. With regard to Title X family
planning, I mentioned the increase. The program offers major
benefits in reducing unintended pregnancies and also a range of
other services--treatment for STDs, screenings for cancer. What
do you see as the public health benefits of a Title X program,
what arguments would you want to make to this subcommittee
regarding the importance of the proposed increase?
Secretary Sebelius. Well, I think, as you have already
said, Congresswoman, Title X, which has been a very important
public health initiative for decades, is serving about
5,000,000 clients a year and providing not only important
family planning services, helping families make choices about
spacing of pregnancies, but cancer screenings, cervical and
breast cancer screenings, and primary health care in many
facilities across this country. They serve a very low income
population, often uninsured and underinsured, and more and more
clients are making those their providers of choice, so we see
this as a critical infrastructure for healthy families, healthy
pregnancies, and screening for early detection of diseases.
In breast cancer alone, what we know is early detection,
the survival rate after 5 years is almost 98 percent. If you
wait until year 3 or 4, the death rate rises dramatically, so
early detection really is a life-or-death issue in some of
these screening cases. And again, Title X programs provide
those very necessary health services.
PRESCRIPTION DRUG ABUSE
Ms. DeLauro. I know that from experience on ovarian cancer.
A survey by State directors for alcohol and drug abuse
found that virtually all State directors consider prescription
drug abuse and misuse to be a top issue impacting their States.
I am going to get to the question because my time is going to
run out.
Do you agree that we face a prescription drug abuse
epidemic? I want to applaud CDC for the work that they are
doing in this area. Are there things in your budget proposal to
address that epidemic? I would note that overall, the budget
request for SAMHSA proposes to cut substance abuse programs by
more than $100,000,000.
Secretary Sebelius. Well, actually, we have a cross-
department group working actively in this area, collecting
data, looking at all the information around prescription drug
abuse. I do share the concern that it is a rising issue and one
that has actually surpassed illegal drug use in some areas. So
we are looking at all kinds of ways we can partner with States,
because States run a lot of the initial screening devices. They
collect data. FDA just made a very important move, we think,
recently, which is to take the original form of OxyContin off
the market and substitute a new formulation for OxyContin that
is much harder to use in illegal ways, and much harder to make
into substances that either can be snorted or inserted, which
is what was found to be happening.
So I think that move, in and of itself, will help control,
but we are looking at all the tools that we have and we would
love to work with this committee in these efforts.
Mr. Kingston. Mr. Alexander.
Ms. DeLauro. Thank you.
PUBLIC HEALTH SERVICE ACT EVALUATION TAP
Mr. Alexander. Thank you, Mr. Chairman, comment and then a
question. We have talked--we have heard you say something about
outreach and education a couple of different times already this
morning, and I find it interesting how that the National
Institutes of Health, a few weeks ago we were talking with Dr.
Collins about some of the concerns that he has. Two of his
biggest concerns, he said, are Alzheimer's and obesity.
Alzheimer's, we can't prevent, can't cure, can't prolong it, we
die from it or die with it. Over here, obesity, we can cure, we
can prevent it, we don't have to die from it, and we already
know, as we are eating a bag of potato chips, that they are not
good for us, so we have to question just the wisdom of spending
a gob of money on education when we already know some of things
that we do are not good for us.
But anyway, I want to ask a question that expands or
touches on something that Chairman Kingston was talking about a
while ago.
You are authorized to tax, or to tap, as you like to call
it, authorize programs of up to 1 percent. Their
appropriations, in order to conduct program evaluations, the
administration has asked for an increase. In fact, in 2014 the
request is to increase the tap to 3 percent or effectively move
around $1,300,000,000 of resources through this nontransparent
budget trick.
Last year, the subcommittee held that tap to 1 percent. I
am not sure why we continue using this mechanism. For example,
while the request supposedly provides the National Institutes
of Health $31,000,000,000 for medical research, in reality it
shifts about 1,000,000,000 to other activities within your
Department. The intent of the authority is to provide support
for program evaluations, of course, when in reality, again, the
funds are to support program operations within your office.
So the question is, the projected $1,300,000,000 in tap
funds proposed for 2014, how much of those funds will be spent
on actual program evaluations?
Secretary Sebelius. Well, Congressman, as you know, the
Congress sets the amount of the tap and the dollar amount that
we can use, and we will follow that closely. We have made a
recommendation to you of what we think would appropriately
cover everything from research and evaluation efforts going to
program initiatives, but we will work with the committee, but
ultimately, it is the decision of Congress what that amount is,
and as you say, you limited the amount to 1 percent. We will
follow the directions and work with the committee about the
appropriate amount.
Mr. Alexander. Do you still think this is the way it should
be done instead of just appropriating the amount for each
program that we need to do so?
Secretary Sebelius. I think it is an effective tool to
allow us to actually look at initiatives that may have more
bearing 1 year than the next year, and rather than locking
money into one place, it allows us to acknowledge that a lot of
the programs in our Department impact all of the agencies, and
all of the agencies contribute. I think AHRQ is a good example
where they do unique efforts to work directly with providers,
and the work they do with providers actually impacts a lot of
the different agencies. It impacts NIH. It impacts CDC. So
having an opportunity for those larger agencies to contribute
to those important research and outreach efforts and change
protocol and inform providers, I think, has a mutual benefit.
Mr. Alexander. Thank you.
Mr. Kingston. Ms. Lowey.
HEAD START
Mrs. Lowey. Thank you. Madam Secretary, after more than
four decades of providing the support that children and
families need to succeed, Head Start still reaches only about
two-fifths of eligible preschool-age children. Early Head
Start, which has been in place since the mid 1990s, reaches a
mere 4 percent of eligible infants and toddlers. Clearly, there
is a tremendous amount of work that still needs to be done to
reach these families.
As you explain in your testimony, the President's budget is
requesting $1,400,000,000 in resources for a new Early Head
Start competitive program with a goal of reaching more than
100,000 additional children under the age of three who do not
currently have access to high quality early care. In the
Recovery Act, Congress provided funding for a targeted
expansion of Early Head Start, in particular.
Can you tell us if that has been successful? Am I correct
that the research is clear that this period of time in a
child's life is of critical importance and that the Early Head
Start approach is especially effective?
Secretary Sebelius. Congresswoman, the proposal that the
President has made in the 2014 budget and outlined a bit in the
State of the Union is one of the most exciting second-term
initiatives, and it really is a birth through five initiative,
recognizing that the single best investment we can possibly
make is getting all of the children in this country ready to be
productive citizens and live up to his or her full potential.
So our portion of this is infants, toddlers, and home
visiting; and as you say, the resources requested would
increase the number of children in Early Head Start and
actually add some cost-of-living increases and continue our
quality initiatives for Head Start, which has been proven to be
quite successful, not just in terms of getting children school-
ready, but in terms of long-term impact on their lives--fewer
dropouts from high school, fewer drug abusers, fewer end up in
any kind of correctional facility, more long-term success at
jobs. Any studies that have followed high quality child care
have proven that for high quality early education. So we think
this initiative, home visiting plus Early Head Start and child
care, raising the quality of child care, and there is also a
piece of this that deals with child care, and then working with
the States around expanded pre-K and kindergarten are probably
the best ways we can get America ready for the 21st century.
Mrs. Lowey. Thank you very much, and I hope that the bill
will reflect the statistics because as a mother of three and a
grandmother of eight and someone who visits schools all the
time, you really see the impact of early education, so I thank
you.
PREPAREDNESS
On hospital preparedness grants. Last week's terrorist
attack in Boston serves as a reminder of how vital it is for
hospitals to maintain a high level of readiness to deal with
disasters and mass casualty incidents. That means having
adequate stocks of the necessary supplies and equipment, but it
also requires planning, coordination and enough drills and
exercises to stay proficient.
Like New York, Boston happens to have a number of
outstanding hospitals and trauma specialists who played a
significant role in the impressive response to the bombings;
however, I am concerned that HHS grants to maintain and improve
hospital preparedness are being steadily reduced. Funding has
been cut from $420,000,000 in 2010 to $375,000,000 in 2012. Now
the President's budget request for 2014 proposes yet another
cut to $255,000,000. Why was that recommended? Can we be
confident that it won't have a detrimental effect on hospital
readiness?
Secretary Sebelius. Well, I think that the budget reflects
an ongoing interest in, as you say, training, preparedness, and
working with hospitals. Some of the cuts have been due to the
fact that some of the early dollars bought one-time equipment.
It doesn't need to be replaced because it is there. I think
that there is no question either watching the recent New York
example. When newborns were evacuated from NYU, and they knew
exactly where they were going and vulnerable patients were
evacuated from nursing homes, the hospital had search capacity,
the ambulance contracts work was successful due to the fact
that that had been planned for, and that had been talked about
and had been practiced.
We saw it again in Boston where injured people were able to
be quickly transported and taken care of, so we take these very
seriously. It happens in communities around the country and
that will be an ongoing effort for us to work on.
Mrs. Lowey. Thank you, Mr. Chairman.
Mr. Kingston. Mr. Womack.
MEDICAID EXPANSION
Mr. Womack. Thank you, Mr. Chairman, and thank you, Madam
Secretary.
As you know, this week, my home State of Arkansas signed
into law, pursuant to the recent session of the general
assembly, something rather innovative as it concerns insuring
people between 100 and 133 percent of Federal poverty level,
and providing you approve the proposal, our State is depending
on you to be a stable funding partner.
I also recognize that the Arkansas legislation that was
signed has an off ramp, a circuit breaker in the event that
promises made today perhaps aren't kept, but I have this
concern. The Supreme Court, in its ruling, said that Federal
Government can't condition the first dollar of Medicaid on the
expansion pursuant to the ACA; however, I am a little unclear
as to whether that means that if Arkansas opts, as they have,
into expansion and then decides later for whatever purpose,
whatever reason, that they have to employ this circuit breaker,
as it were, that we will be--we will be okay. I know you can't
speak for the U.S. Supreme Court, but what assurances can you
give our State that our circuit breaker is legit, is okay?
Secretary Sebelius. Well, Mr. Womack, I think it is an
important question, and when the Supreme Court ruled last
summer, they basically, if you will, divided Medicaid into the
traditional program, and then this sort of new Medicaid
program, which would allow States to take advantage of a
funding partnership outlined in the Affordable Care Act.
We have said from the outset in our guidance to States that
you can come in when you want into the new program and come out
when you want. What Arkansas did in their legislation was sort
of codify that. There is a lot of fear voiced with governors,
not just Governor Beebe, but I talk to governors virtually
every day and they say, well, what if Congress changes the
deal, what if, you know, we look at this funding and it
switches next year or the following year, which is why I think
it was important that the President and Gene Sperling, his head
of the Council of Economic Advisors made very clear that this
President, at least, is committed to the funding formula, but
beyond that, the guidance from HHS has been pretty clear from
the outset. If this is a financial detriment, you come out of
the new program and there is no impact on the traditional
Medicaid, and that is really what the Supreme Court said, is
that you can't use a threat of losing all of your Medicaid
dollars as a lever to convince States to come into the new
Medicaid program, so we really have two kind of separate groups
of people.
Mr. Womack. Are you personally concerned that a few years
from now that we may be having to trigger that circuit breaker?
Secretary Sebelius. Well, I am hopeful that won't be the
case. I think that, again, there is some incredibly impressive
work going on with governors and with the flexibility that we
have given governors around the Medicaid program. And Arkansas,
I have to tell you, is one of the States at the front of the
line, looking not only at this particular new legislation, but
looking at au pair systems, trying to figure out ways that they
can be delivering better care at a more cost-effective price.
We are really working closely with them.
As a former governor, I take these efforts very seriously.
We have new dual eligible efforts underway, and for the first
time last year, between 2011 and 2012, the spending on Medicaid
per capita around the country went down 2 percent. It is a
decrease, the first time really in the history of the program,
so we think there is some very encouraging projects underway. I
don't know what will happen 5 and 10 years from now, but
certainly that protection is there for States.
Mr. Womack. I recognize my time, Mr. Chairman. I have got
about 25 seconds left, so I know you are going to add that to
my next round questions, provided I am here. I yield back.
Mr. Kingston. I think we all want to learn more about
Arkansas.
Ms. DeLauro. Worth checking it twice.
Mr. Kingston. Yes. Ms. Roybal-Allard.
ADVISORY COMMITTEE ON HERITABLE DISORDERS
Ms. Roybal-Allard. Madam Secretary, I would like to begin,
first of all, by thanking you for using your authority to
continue the Advisory Committee on Heritable Disorders while
Mr. Simpson and I are working to get the reauthorization of the
Newborn Screening Saves Lives Act. We truly do appreciate that.
RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH
Two years ago, HHS released an unprecedented action plan to
address racial and ethnic disparities, and that plan cited
racial and ethnic approaches to community health known as REACH
as an exemplary program. GAO also praised REACH, and there were
more than 150 journal articles documenting the achievements of
the REACH program in reducing health disparities.
Your fiscal year 2014 budget eliminates REACH and instead,
points to the community transformation grants as the next stage
of CDC community-based programs. What evidence can you provide
to demonstrate that the CTG program will at least be comparable
to REACH in reducing racial and ethnic health disparities?
Secretary Sebelius. Well, Congresswoman, as you say, for
the first time, we do have an action plan based on health
disparities, and I think there is no doubt that REACH was an
initial test case for funding, and REACH, I think, funded about
eight organizations aimed at specific efforts to reduce health
disparities and deal with a lot of the chronic disease issues
that affect particularly disparate communities.
The community transformation grants actually fund 107
organizations, half of which are also REACH organizations. So a
lot of what REACH was doing is being taken over and amplified
by community transformation. We have taken what we have learned
from REACH and tried to actually expand it dramatically into
communities across the country, and it will be, I think, a much
larger lever to use in terms of reducing health disparities.
Ms. Roybal-Allard. I think the concern that has been
expressed is that, that those who are either current or former
REACH grantees have actually been unable to compete against the
much larger agencies and non-profits winning the CTG grants,
and so the result is that the organizations with REACH grants
that have had the greatest success of measurable change in the
health and wellbeing of racial and ethnic minorities with the
greatest burden of disease are not going to be participating in
the CTG, and the concern and what I am concerned about is that
their inability to successfully compete in the CTG grants will
impact their successful reductions in health disparities in
these most vulnerable minority communities.
And so there just seems to be a gap there that I think that
we need to look at so that we don't backslide in those areas.
Secretary Sebelius. Well, I would agree wholeheartedly that
we don't want to backslide, and my information is that half of
the REACH organizations actually also are community
transformation grant organizations, but we would be happy to
work with you and your staff to look at the details of the
organizations you are concerned about.
Ms. Roybal-Allard. And how do you plan to meet the goals of
the action plan itself? And do you have certain benchmarks that
have to be met?
Secretary Sebelius. We do. We are measuring them carefully.
And I think while there are a number of initiatives that have
proven successful, we think one of the single biggest
initiatives that we can make is fully implementing the
Affordable Care Act, so closing the gap with access to health
insurance, access to preventive benefits, having a healthy home
for families who right now struggle with that may make the
largest difference we could possibly make in health disparities
in this country.
Ms. Roybal-Allard. Okay. I can see that my time is almost
up, so I will reserve for the second round.
Mr. Kingston. Was it Dr. Harris or Mr. Fleischmann.
AFFORDABLE CARE ACT IMPLEMENTATION
Mr. Fleischmann. I think Doctor--oh, okay. Thank you.
Thank you, Mr. Chairman. Good morning, Madam Secretary. I
am Chuck Fleischmann. I represent the Third District of
Tennessee, and to follow up on some of my colleagues'
questions, we have heard numerous mentions of the Department's
intentions to transfer funds from various accounts to implement
the Affordable Care Act.
I am particularly concerned about your proposals to use
$500,000,000 more for ACA implementation than you previously
predicted you would need, especially given your Inspector
General's concerns about exchange implementation. You have
demonstrated a willingness to redirect funds for your purposes.
I have two questions.
What changes have you made to support States that are
looking at buying the expansion population into the exchange?
And my second question is will you be pushing back the exchange
implementation to adjust for unforeseen problems that have
arisen and that have led you to seek additional funds for
implementation?
Secretary Sebelius. Well, Congressman, first of all, I
think we have sought funds in the budget process. We sought
funds in the CR process. Having failed in both of those efforts
through the work of the United States Congress, we are then
using the resources available within the Department to make
sure we implement the law of the land.
I am not quite sure I understand your question about the
States who want the expansion population in the exchange, but
as you heard Mr. Womack say, Arkansas, which has a plan to use
their Medicaid dollars to purchase coverage for individuals
from a company offering coverage in the exchange and then
provide wrap-around coverage, we are working very closely with.
We have not yet had a specific proposal from Governor Beebe
around what their 1115 waiver would look like, but we are eager
to get it now that the legislation has passed.
I have had many conversations with Governor Haslam about
his interest in that possibility. He is watching, I would say,
the Arkansas situation closely. We have expressed an eagerness
to work with him outlining what the law allows us to do and
what it doesn't allow us to do, but we are working with a
number of governors around the expansion population and what
the flexibility for the States may look like.
Mr. Fleischmann. Well, okay, but let me ask you a follow
up. Will you be pushing back the exchange implementation,
though? Are you going to push it back, or what are your plans?
Secretary Sebelius. No, sir.
MEDICARE
Mr. Fleischmann. Okay. Let me ask you a question, if I may,
in the time I have got left about hospitals and the bad debt
situation. My question regards the administration's proposal to
cut Medicare, bad debt payments by $25.5 billion while asking
for rather sizable funding increases in other parts of the
budget. This cut to providers, in and of itself, seems to be
particularly misguided at a time when Medicare already
underpays hospitals, according to MEDPAC, and when seniors in
my district are struggling to make ends meet, but what I find
most curious is the administration's rationale for the cut, and
I quote, ``this proposal would more closely align Medicare
policy with private payers.''
I am sure you are aware that the fixed price system under
Medicare is completely disconnected from the private pay area
where hospitals have the flexibility to negotiate. There is no
negotiation today under Medicare's fee for service system.
Government sets the price as well as the beneficiary cost share
amount, period.
May I respectfully remind the Secretary that the
administration has stood in the way of repeated efforts to
modernize Medicare and really allowing policy with private
payers instead of paying lip service to it when you want to cut
the hospitals but not grant them the same tools to negotiate
what they now have in the private system.
How can you reconcile this inconsistency?
Secretary Sebelius. Well, Congressman, I think that what
has happened with Medicare over the past several years is we
have been working very closely with private payers around the
country, and they are extremely enthusiastic about the
framework given to us, thanks to the Affordable Care Act--to
begin to shift Medicare to a value-based payer as opposed to a
volume payer. We are starting to implement a number of those
changes. We are pleased with the 250 or more accountable care
organizations, many of which include hospitals which have now
come together voluntarily to look at different ways to deliver
care and actually share in the savings.
We have hospitals really engaged in efforts around reducing
hospital-acquired infections and other issues which drive up
cost and lower patient care. So I think the framework around
Medicare dealing with hospitals is very different than it
looked 4 years ago, and, in fact, is, I think, moving in a very
positive direction for patients and for providers.
Mr. Kingston. Ms. Lee.
Ms. Lee. Thank you very much. Good to see you, Madam
Secretary, and thank you for being here.
RYAN WHITE
I am pleased to see that the budget included the needed
increase for the minority AIDS Initiatives as well as the Ryan
White program, so continued support of Ryan White is very
critical while we assess the impact on--as it relates to HIV
and AIDS, as it relates to the Affordable Care Act and how this
transition is going to happen.
RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH
Let me follow up with Congresswoman Roybal-Allard's
question as it relates to ethnic and health disparities. You
know, I was disappointed to learn that half of the available
$949,000,000 in the preventive--it is what, Prevention and
Public Health Fund, would be used for the Affordable Care Act,
that half of that has been cut. Secondly, of course, the cut to
the REACH program, which Congresswoman Roybal-Allard laid out.
Then what we are looking at also is the fact that now the
exchange health plans, they really don't include community
physicians who have traditionally provided care to low income
and minority communities. Many of the minority providers that I
have spoken with who practice independently are already
experiencing competition with community health centers and
other federally qualified health centers, specifically African
American physicians are really going to be impacted by this.
And so what I see now is sort of a, you know, a compilation
of cuts and provisions of the Affordable Care Act and budget
and sequestration that really will impact minority communities
in terms of our efforts to close these disparities. It seems
like we are getting attacked over and over and over again, and
so I am wondering how we are going to pick up the pieces now
because we have made so much progress, but I just see this
going backwards and people are very concerned.
Secretary Sebelius. Well, I share your concerns that the
worst of all worlds is to retreat from what has been
implemented, an aggressive approach to closing health gaps.
What I would tell you, Congresswoman, is we would have much
preferred to have had the resources given directly for the
Affordable Care Act so we could fully implement the law and
have the full funding of the Prevention Fund go to a variety of
programs.
That was not the case when Congress finished with our CR,
so we made some decisions, and the dollars that are being
redirected for this year from the Prevention Fund will be for
outreach efforts, education efforts and enrollment efforts
connecting people who are uninsured and underinsured with the
new benefits available to them in the Affordable Care Act.
So, many of the communities of color, many of the
communities who have huge health gaps will, for the first time,
be looking at the opportunity to have fully covered health
benefits, but unless they are enrolled, unless they know what
is coming, unless they have people helping with the application
process, it won't happen.
So I think that while on one hand there are some specific
program cuts or flattening of budgets, on the other hand, there
will be a huge outreach and enrollment effort that will involve
many of those same individuals and connecting them with health.
Ms. Lee. But the trend, though, is going the opposite
direction. I understand what you are saying, but you have cut
actually 15 million say from the Office of Minority Health
Services. That cut----
Secretary Sebelius. Well, the overall spending on minority
health issues has actually increased in our department-wide
efforts. It is not necessarily in that office.
Ms. Lee. I understand that, but that office was the
centralized office. It was going to try to make sure that this
works. And now what I am worried about is it is so dissipated
that it may not work, that we are going to have to pick up the
pieces in a few more years to get back to where we are now.
Secretary Sebelius. Well, again, we would be happy to give
you and Congresswoman Roybal-Allard a report on what the plan
says, where we are, what the metrics say, where we see
ourselves going at the end of 2013. We will do a detailed
update on the issues of concern.
Ms. Lee. Okay. And are we going to have a second round, Mr.
Chairman, because I want to get back to the traditional
community providers?
Mr. Kingston. Yes.
Ms. Lee. Okay. Thank you very much. Thank you, Madam
Secretary.
Mr. Kingston. Dr. Harris.
INDEPENDENT PAYMENT ADVISORY BOARD
Mr. Harris. Thank you very much and thank you for coming
before the committee.
As a physician, I have got to ask you a couple of questions
from what I hear some of the concerns in the physician
community. First and foremost is the Independent Payment
Advisory Board. My understanding is that the members were
supposed to have been recommended by last September. It is now
April. Is there a timeline for appointment of these members?
Well, there is a timeline. We already know the President
has already missed it. Is there a new timeline or revised
timeline? Are these appointments ever going to be made or are
you going to ultimately have to make those decisions?
Secretary Sebelius. Congressman, the law provides for the
President to make appointments to the Independent Payment
Advisory Board. In consultation with Congress, he has actually
written to the leaders in both the House and the Senate, the
minority and majority, in asking for suggestions for Members to
be appointed. Ultimately he would nominate and the appointees
would then go to the United States Senate for confirmation.
Secretary Sebelius. According to the independent actuary
and the Congressional Budget Office, given the trend lines of
Medicare, it is not anticipated that any IPAB recommendation
would even be targeted until 2019.
Mr. Harris. Sure, and I understand that, Madam Secretary.
Secretary Sebelius. The consultation is underway.
Mr. Harris. Okay, in the absence of the Independent Payment
Advisory Board being appointed, though, all I am saying is, you
would have to make the decisions. Is that right?
Secretary Sebelius. No, sir, that is all under the
construct of the Independent Payment Advisory Board.
Mr. Harris. So if they are never appointed, what happens?
Secretary Sebelius. It doesn't exist.
RECOVERY AUDIT CONTRACTORS AUDITS
Mr. Harris. Okay. The second one is the RACs audits. We are
hearing, you know, from the hospital association, especially,
they say when they survey their hospitals, about 70 percent of
those, when they are appealed, they are overturned. You can
just get back to me off-line about that. I mean, that is of
great concern to me because both hospitals and physicians spend
a great inordinate amount of time dealing with these RACs
audits, and it never shows up, you know, when we claim that
Medicare is so efficient, you know, we don't take into account
the back office costs of dealing with these RACs audits.
Secretary Sebelius. Well, sir, if I could just respond for
one moment. I think that while there are a number of claims
overturned, less than 3 percent of the claims are ever
appealed. So about 97 percent of the RAC recommendations
actually are implemented, and then of the ones that are
appealed, a portion are overturned.
Mr. Harris. That is on part B, Madam Secretary. I am not
sure the same is true on the hospital side. On part B that is
true.
RATE REVIEW
In your opening statement you said, and I will quote you,
``Every American will get quality insurance at an affordable
price.'' And I think you used the word ``every.'' Now, here is
the problem I have got. Yesterday, our nonprofit insurer,
CareFirst BlueCross BlueShield of Maryland insures 70 percent
of the individual market in Maryland, announced it will have to
raise its rates on the exchange an average of 25 percent, with
a range of a slight decrease to 150 percent increase for the
youngest, healthiest, who apply for insurance.
So I have got to tell you, that certainly, that person who
is going to get that 150 percent increase is not going to feel
that they are getting quality insurance at an affordable price,
because Madam Secretary, I will tell you that, you know, you
have been quoted saying, well, they get a better benefits
package. Well, in fact, in their filing, they said that only 2
percent of that average increase was due to an increase in
benefits because Maryland, as you know, already has the second
best benefits in the country because of our mandated package.
So, in fact, they said in their filing that the taxes actually
account for a larger part of that increase than the increase in
benefits.
How am I going to explain to those individuals that their
increase is--these are individuals. These are the ones, and
again, Maryland has a high-risk pool, so we have already
factored into account that had affordable care not worked,
everybody with a preexisting condition could have gotten
insurance in the high-risk pool.
How am I going to tell them that this was actually good for
that 25-year old healthy person who now has to make the choice
between paying that small penalty or paying a whole lot more
for the insurance under the exchange.
Secretary Sebelius. Well, I think there are several things,
Congressman. I have not gotten any independent information
about Maryland other than The Washington Post article, so I am
taking my data from that. First of all----
Mr. Harris. I would be more than happy to share with you
their filing.
Secretary Sebelius. Well, the company has submitted a
filing and there is a rigorous review process now. So this is
the starting place and I can tell you as a former insurance
commissioner, that is unlikely to be the end of the discussion.
The second piece of news is that it appears Maryland will
have more competition thanks to the Affordable Care Act than
they do right now. Two new companies are coming in the market,
and several other companies filed rates at the same time that
First Care filed rates that are significantly lower, and don't
have the kind of whopping increase that First Care has
requested. Thirdly, for a lot of the young and healthy, the
under 30-year-olds, they will have a choice of a catastrophic
policy, or the full benefit policy, which is likely not only to
be significantly less, but also have some subsidies to help pay
those premiums.
So I think there are a variety of factors, but it looks
like the Maryland market will be significantly more competitive
than it is now, and for the first time, consumers will be able
to see the rates side by side and make some choices.
Mr. Kingston. Mr. Joyce.
AFFORDABLE CARE ACT IMPLEMENTATION PLAN
Mr. Joyce. Thank you, Mr. Chairman. Good morning, Madam
Secretary.
Secretary Sebelius. Good morning.
Mr. Joyce. There have been many concerns raised about the
Affordable Care Act. Is there any written plan of
implementation that you have been considering?
Secretary Sebelius. I don't know what you are referring to.
There is no one written plan. I mean, there are timelines.
There are build plans. There are contracts.
Mr. Joyce. Right, is there something we can review now on a
quarterly basis to know how it is being implemented?
Secretary Sebelius. Absolutely.
Mr. Joyce. Can you make that available to us?
Secretary Sebelius. We would be happy to share what we can,
certainly.
Mr. Joyce. Okay, because the other problem I have is
exchanges, at least in Ohio, it views the same way, that the
prices are going to continue to go up. Do you have anything to
contradict that?
Secretary Sebelius. Well, again, sir, rates are just
beginning to be filed. There will be a negotiation process in
every State in the country between now and the fall when the
final rates will be published. I have no current information
from the State of Ohio.
INDIRECT MEDICAL EDUCATION FUNDING
Mr. Joyce. Okay. There is a--the other problem that we have
in the Cleveland area, we have the UH, and the Cleveland
Clinic, and obviously, they are facing a 91,000 physician
shortage, and at 130,000 physicians that should grow to by
2025. And while I appreciate the administration's emphasis on
primary care, surely, it is split evenly between specialists
and primary care physicians. The budget proposes a 10 percent
decrease in Medicare indirect medical education funding.
Teaching hospitals receive this funding to compensate them for
higher costs associated with sicker, more complex patients that
they care for, and they provide unique services that are not
available at other hospitals, such trauma centers, burn units
and standby capacity.
A 10 percent cut will not help finance them in the training
of next-generation physicians when we know there is already a
looming shortage and will do nothing to expand the need for
primary care. In some areas there is a shortage in subspecialty
areas. In teaching hospitals maintaining a top level of trauma
center, standby services are expensive. Has the administration
considered the impact of this cut on teaching hospitals and
their ability to maintain these critical services?
Secretary Sebelius. Yes, sir, we have, and again, in a more
robust budget time, we would make different decisions. We are
looking carefully at MedPAC's, the advisory body that looks at
Medicare costs and expenditures, recommendations in this area
and they have suggested that the cut would be not only fully
compensate hospitals for the training program, but could come
out of the overhead. So we are trying to make sure that we have
the same number of training slots, but reduce some of the
overhead that wasn't directly related to the residency slots in
hospitals as we go forward. But this recommendation came
directly from MedPAC.
Mr. Joyce. Thank you, I yield back my time.
HEAD START
Mr. Kingston. Thank you. Madam Secretary, I wanted to get
back to your comments to Ms. Lowey on Head Start, and I have
not been a critic of Head Start, but I have read the study, or
scanned the study. I don't want to say I have read the whole
thing, but this was a study that HHS did, and it certainly
contradicts the statements that were made, and I will just read
directly from it.
It says: ``In summary, there were initial positive impacts
from having access to Head Start, but by the end of third
grade, there were very few impacts found for either cohort, or
any other four domains of cognitive, social, emotional health,
and parenting practices. The few impacts that were found did
not show a clear path of favorable or unfavorable impacts on
children.''
And you know, as we try to figure out, you know, in Head
Start, I don't think you can find a more noble concept, but the
results aren't there. I visited many, many Head Start
classrooms, and I am always impressed with what I see going on,
but the statistics don't bear out because I go there and I get
emotional about it, and it looks good, and it feels good and
all that, but the science, if you will, doesn't bear that out.
Where did you get your statistics on the proven reduction
in dropout rates and better grades, and the numbers you just
studied, because it is not on here.
Secretary Sebelius. That is correct, Mr. Chairman. You are
citing the impact study which looked at kids who were in Head
Start in 2003, about 10 years ago. The Impact Study tracted
them.
Mr. Kingston. I think it started in 2008, didn't it?
Secretary Sebelius. No, I think the report was out in 2008.
The kids were in the program 10 years ago, and then they
tracked them, and there is no question that what they found is
a leveling out of what had been significant improvements. As
children leave the Head Start program, they may not continue
that.
What has been found in studies that actually longitudinally
follow children for a longer period of time, is that the
positive----
Mr. Kingston. Well, can you tell me what studies those are
specifically?
Secretary Sebelius. Yes, I would be happy to get them for
you, these are longitudinal studies that follow kids for 20
years, and they look at----
Mr. Kingston. Well, the reason I said that, is Head Start,
unfortunately, has moved into a more political kind of arena
that I think any of us would want it to, meaning that, you
know, if you are for Head Start, you love children, if you are
against it, you obviously hate children. You hate teachers. You
hate education. I mean, it is one of those things where in
Washington, things spin out of control rapidly in the rhetoric
debate. And so we have got a lot of studies out there and you
know, the New Jersey study is pro, and the California study is
against it. But this was your study.
Secretary Sebelius. I understand, sir, and we are taking
those findings seriously. We have done a lot to implement some
of the changes that we felt were important, improving teacher
quality, looking at more curriculum. I would say that there is
a much stronger partnership right now with the Department of
Education which is part of this Early Education Initiative, as
well as the fact that with the President's insistence, the
lower-performing Head Start programs are now recompeting for
grants for the first time ever in the program. We are not just
assuming that if you have been a Head Start operator, you can
continue to be a Head Start operator.
So the 25 percent lowest performing programs are
recompeting across this country as we speak, and that has never
been done before. We would like to make sure that if children
are enrolled in early education, they are in the highest
quality programs possible.
Mr. Kingston. But you have studies to show that there is a
lower dropout rate, and higher grades?
Secretary Sebelius. Yes, there is a study that indicates
that with early education, just 1 year of early education, that
children have a much different lifetime performance. The long-
term payoff to Society means less school dropouts, drug use,
engagement in criminal activity--The study showed a reduction
in those instances, and I would be happy to provide that for
you.
Mr. Kingston. Yes, and also, if you would tell me where
this longitudinal study was wrong? Where, you know, you are
saying the impact----
Secretary Sebelius. No, I am saying they are looking at
children in the third grade. You wouldn't have children
dropping out in the third grade one way or the other. So some
of the factors that we are looking at that----
Mr. Kingston. But, I mean, the premise of the study, this
was what they were asked to study, and this is how we are going
to make our investment decision, and the study came back with
a----
Secretary Sebelius. Well, what it said, there was a
definite impact on these children as they entered school.
Mr. Kingston. And then what?
Secretary Sebelius. They definitely were caught up with
their peers as they enter school. Those positive impacts begin
to fade as they get closer to the third grade. Whether that is
what is happening to them in the elementary school, the lack of
the Head Start wraparound, I mean, I think there are a number
of factors. But the fact that they are school ready when they
hit school is part of what Head Start was all about.
Mr. Kingston. Yeah, and well, I think what I would be
interested in is, you know, a blind, let's look at this as if
it was a new program. Is this where you would put----
Secretary Sebelius. Sure.
Mr. Kingston [continuing]. Money or not. And so I think
that is what we would like to see, and I yield to Rosa.
Ms. DeLauro. Just a quick point on that. The study's number
one finding was that Head Start children enter kindergarten
performing above their peers in all measurable categories. The
study you reference looked at children who entered 10 years
ago. The significance of that is that since then, a number of
changes have been made to the Head Start program because of
some of the findings here, and that includes improvement in the
quality and credentialing of teachers. You have got 92 percent
of Head Start teachers have an AA, a BA and an advanced degree
in the field related to early childhood education.
That is well over the 50 percent threshold that was set in
the 2007 reauthorization for that year, so there have been a
number of changes. And maybe, Mr. Chairman, you and the
Secretary can talk about this, about the changes that have been
made, I don't want to go into all of them.
Secretary Sebelius. Sure.
Ms. DeLauro. And for instance, there is a 2010 report of
Maryland Montgomery County Public Schools showing that students
who went to full-day Head Start pre-K needed only half of the
special education services as their fellow kindergartners. So I
think there needs to be that fulsome conversation about that,
because there were some issues. They have been dealt with, and
I think we need to then look at where the changes are. It is
one of the most important of programs that we have ever
embarked on in terms of making our children ready to learn as
they enter school.
AFFORDABLE CARE ACT PROGRESS AND SUCCESSES
Madam Secretary, there is agreement that one of the keys to
improving the long-term budget picture is finding ways to
reduce the growth of health care costs while improving quality
and access. The Department has taken a number of initiatives
and demonstration projects aimed at the goal, mostly under the
auspices of the Affordable Care Act.
I would like you to tell us about some of those efforts,
how they are progressing. I am going to throw in this last
question as well. This there are provisions in the ACA designed
to reduce the rate of increase in health insurance premiums.
Medical-loss ratio as an example, rebates to customers when too
much of what an insurance company collects in premiums is used
for other things.
In this context, what results have you observed from the
new rules so far? What are some of your efforts to cut the
costs? What have medical-loss ratio or other things of that
nature already in place done?
Secretary Sebelius. Well, Congresswoman, as you know, there
are sort of two pieces of this puzzle. One is the insurance
market, and there has been a lot of attention and focus on the
insurance market, the new marketplaces, which frankly, will
affect a number of Americans, but certainly not all Americans.
Most people with employer-based coverage will see very
little change with the new marketplace. A lot of folks who are
in self-insured plans or large government plans, won't see much
change.
So on the new market side, you are absolutely right. There
has been a lot of attention on new rules for insurance
companies, and one of them is that $0.80 of every premium
dollar collected has to be spent on health costs, not overhead
costs, the so-called 80/20 rule. So last year about
$2,000,000,000 was sent back to customers across the country.
Ms. DeLauro. $2,000,000,000?
Secretary Sebelius. $2,000,000,000.
Ms. DeLauro. Thank you.
Secretary Sebelius. So people got checks from their
insurance companies, and we have seen companies actually file
the lowest level of rate increases over the last 3 years than
has been the trend line for over a decade because there is now
much more rigorous review at the State level. And I think that
is all good news for consumers.
On the delivery side, which I think is frankly the more
significant piece of the Affordable Care Act because it really
affects everybody insured and uninsured. What kind of care do
you get? What sort of population health do we have? How are we
spending those underlying health care dollars? There is a lot
of incredible innovation underway; a lot of it driven by the
private sector using electronic tools to empower consumers,
using electronic health records to finally measure results and
figure out what is going on and locate the cost outliers.
We are driving programs to these accountable care
organizations; new collaborative efforts between doctors and
hospitals to figure out ways to improve health and lower care;
medical home models, trying to keep people out of the hospital
in the first place; looking at preventable readmissions.
For the first time in decades, we are seeing an actual
decrease in the number of Medicare patients who are released
from the hospital and go right back in because of the care they
are receiving in that interim period of time, and one new
study--I know I am on a yellow light, but since we all love
babies here, you will, I think, find this interesting.
Mr. Kingston. Why don't you hold that, because we do love
babies and we will get back to the baby question.
Secretary Sebelius. All right.
Mr. Kingston. It sounds like a piece of good news, and we
look forward to it. Mr. Alexander.
PREVENTIVE HEALTH AND HEALTH SERVICES BLOCK GRANT
Mr. Alexander. Madam Secretary, the Preventive Health and
Health Services Block Grant. Your budget request eliminates
that again. For more than 30 years, State and local health
departments have relied upon the flexibility of this block
grant to meet their unique needs and problems with local
solutions, ranging from preventative cancer screening to
emergency medical services. A large percentage of these funds
are used to address the prevention and control of chronic
diseases.
Last year, this subcommittee provided $100,000,000 for the
block grant an increase of over the fiscal year 2012 budget.
Your budget justification says that these activities could be
more effectively and efficiently implemented elsewhere. It is
not often that people come into our office and say hey, this
Federal program is working. Let's not change it. Let's not
improve it. It works from the local to the State level, but yet
we are trying to change it. We are trying to eliminate it.
Now, your budget justification assumes that the Affordable
Care Act prevention and public health funds will be available
to help meet these needs, but as we have heard today,
oftentimes these funds are being used to just implement the
Affordable Care Act.
So the question is, can you elaborate on the rationale
behind the elimination of this program, and what impact do you
think these cuts will have on the States that we all represent.
Secretary Sebelius. Well, Congressman, first of all, I
think the effort to refocus our health system on preventive
health, and try to keep people healthier in the first place is
probably the single best way that we can reduce health costs.
So efforts are underway to focus on a number of the key drivers
of chronic disease and health costs. Smoking is a number one
target, and we now have a variety of efforts in place that look
at ways to reduce smoking, and I would say that the funding
proposal offered by the President for the Early Childhood
Initiative may be a significant additional piece of that
puzzle, which is increasing the cigarette tax, because we know
that young smokers are particularly price sensitive.
So that effort is funded outside of the block grant. We now
have the prevention funds available through the Affordable Care
Act, and will have over $500,000,000 throughout the country
dedicated to various prevention efforts, including the
Community Transformation Grants which are in 107 areas, and
looking at chronic disease prevention and ways to reduce the
toll of preventive issues.
And as people engage in the fully insured market, either
with access to Medicaid or with access to new private health
insurance, private health plans must include a package of
preventive health benefits that are offered with no copay and
no coinsurance; childhood immunizations, and cancer screenings,
are of particular help to individuals to stay healthy. So we
think those efforts actually not only focus on preventive care,
but ramp it up significantly, and it is not necessary to run
parallel programs any longer.
Mr. Alexander. I yield back, Mr. Chairman.
Mr. Kingston. Thank you, Ms. Roybal-Allard.
HEALTH CAREER OPPORTUNITY PROGRAM AND AREA HEALTH EDUCATION CENTERS
PROGRAMS
Ms. Roybal-Allard. Madam Secretary, two other goals in the
HHS action plan to reduce racial and ethnic health disparities
were to increase racial and health and ethnic diversity in the
health professions, and to increase the diversity and cultural
competency of clinicians. To date, the only HHS programs that
help accomplish these goals are the HRSA Title VII programs.
Your fiscal year 2014 budget cuts them by 15 percent and
eliminates both the Health Careers Opportunity Program, and the
Area Health Education Centers Program.
As the Nation prepares to implement the largest health care
coverage expansion in history, I am trying to understand why
the only two pipeline programs that address the needs of a
growing minority in this country are being eliminated.
How do you expect your fiscal year 2014 budget to help
increase racial and ethnic diversity in today's and in
tomorrow's workforce, and specifically, what programs are you
supporting or depending on to ensure the linguistic and
cultural competency of clinicians and their retention in the
health professions?
Secretary Sebelius. Well, yesterday, Congresswoman, we
published some new guidelines around cultural competency--
language competency for health providers that have been
underway for some time because we do take very seriously the
notion that if you have language or cultural barriers, that
could be as large a barrier as having any access to a health
provider. So those have been underway with our Office of Civil
Rights, and have just been promulgated, and I will be happy to
get a copy to your office knowing of your interest in this.
We also have some very specific programs aimed at health
professionals overall, and I would say our office leaders are
very sensitive to the notion that we have to have additional
recruitment and retention efforts around minority providers, so
doubling of the National Health Service Corps which is underway
is one of those efforts which brings a lot of, not only
providers from underserved communities to participate, but they
get to go home and practice medicine and get rid of their debt.
And that has been enormously successful.
So we are going to have 7,100 new National Health Service
Corps slots. We have new programs for physicians assistants and
nurses, again, with a recruitment effort that is also aiming at
the minority community as part of that.
I would say we have more general workforce efforts that are
trying to increase capacity, and we feel that that may be a
stronger way to encourage and recruit minority providers than
separate disparate programs which only have a small funding
stream. But to make that a part of what the health disparities
plan calls on, is that every program, every leader, every asset
that we have should be focused on reducing racial and ethnic
barriers.
So rather than running little streams of money that are
focused on certain things and letting everybody else off the
hook, we have made it clear to all senior leaders that every
effort, so all of the programs HRSA is running, have an eye on
minority recruitment and minority retention.
NIH is paying special attention to the diversity of
researchers, which has been a real problem and developed
everything from mentoring programs to special training programs
to try and reach out at a much earlier stage and make sure that
the research community has a more diverse look about it, and so
we are trying to pay attention to this at every step along the
way.
Ms. Roybal-Allard. Okay. I have to share the feeling that
Congresswoman Lee has that somehow we are going backwards. So I
think it is going to be important that we do have that sit-down
meeting to better understand, you know, what it is you are
trying to accomplish there.
Secretary Sebelius. Sure. I would be glad to do that.
Ms. Roybal-Allard. Okay. Thank you.
Mr. Kingston. Dr. Harris.
INDEPENDENT PAYMENT ADVISORY BOARD
Mr. Harris. Thank you very much. Madam Secretary, you just
have to get back to me on this, but I had the staff pull the
code on the Independent Payment Advisory Board and under
paragraph 5, it clearly says that if the board fails to submit
a proposal, then actually the Secretary shall develop it. So
you will just have to get back to me online why you think this
doesn't apply to you.
CHILDREN'S GRADUATE MEDICAL EDUCATION
In regard to your statement about the importance of mental
health, you know, I notice that the CHGME program at Children's
Hospital is cut by about two-thirds, and obviously, those funds
do fund pediatric psychiatry. Don't you think that we are, in
fact, going to have a problem training people who are able to
deal with psychiatric problems in children which could lead to
gun violence by cutting back this training?
Secretary Sebelius. Well, again, Congressman, we have tried
to allocate in this budget the funding for the training slots,
and not the indirect costs related to pediatric training. We
have analyzed the costs for residents in the pediatric
hospitals. That is what this budget reflects, so we will train
the same number of pediatric residents. We just don't have the
overhead----
Mr. Harris. Madam Secretary, you know, this idea that
somehow we can ensure, you know, 10 or 20 million more people
and cost less, that we can train the same number of people with
less money, you know, that just flies in the face of every rule
of economics, but again, you know, I am concerned about a two-
thirds cut to pediatric training programs because having been
on a medical faculty, I would just ask you just to make sure
that, you know, Maryland Medicare Waiver is threatened, and,
you know, I just ask to make sure that your Department works
with our departments to make sure that that gets considered,
our Medicare waiver.
CONSCIENCE PROTECTIONS
I want to spend the rest of the few minutes on an area of
great concern to me which is the conscience protection under
the HHS mandate. My first question is, what is the time frame
for issuing the final rule now that the comment period is over?
Secretary Sebelius. Congressman, we are in the process of
analyzing the comments, and the rule will be promulgated in the
next couple of months.
Mr. Harris. Okay, next couple of months. Now, let me ask
you, and I have to get very specific because, you know, I
looked and you are named in a whole lot of lawsuits on this. A
lot of people obviously feel very strongly on this topic of the
HHS mandate because of the religious, I think, the encroachment
on religious beliefs that it has. And the one I am going to ask
about specifically is Hobby Lobby because actually have a
store, a shop--actually, they have a shop in many districts.
This very specific problem is with, you know, the week-
after pill, which is not really a week-after pill. It is the 5-
day after pill, Ella. I want to ask you first, since you have
mandated that it be covered, do you believe that it can cause
an abortion, that it is an abortifacient drug, Ella. Not any
other drug, Ella, which is ulipristal.
Secretary Sebelius. I am not a scientist, and don't pretend
to be one. I know that the FDA scientists do not believe that
Ella, or Plan B, are abortifacients based on their impact on
the reproductive cycle. That is how they are classified. They
are classified as a contraception, not an abortifacient.
Mr. Harris. Well, I understand that is the way are
classified, but I am going to disagree. I think the FDA is not
clear on Ella. And the European Medical Agency says, quote:
``The ability to delay maturation of the endometrium likely
results in a prevention of implantation,'' which is basically
how an abortifacient would work. So I take it your answer is,
you believe it is not an abortifacient and you are progressing
based on that.
Secretary Sebelius. Again, I don't designate. You should be
very thankful that I don't designate drug classifications.
Mr. Harris. Well, Madam Secretary, it is not really true
that you are not classifying them because what you are doing--
--
Secretary Sebelius. But the scientists do, and they have
examined this and they have listed the only recommendation----
Mr. Harris. Madam Secretary, what do you mean, the
scientists? The European Medical Agency has said it can do it.
Secretary Sebelius. FDA has scientists who look at drugs
and compounds, and do clinical trials, and look at medical
results. The only thing that the IOM recommendation said, which
we incorporated, is that FDA-approved contraception and
contraceptive devices should be included as----
Mr. Harris. So even if they are abortifacients, and even
if----
Ms. DeLauro. Would the gentleman yield?
Mr. Harris. I am not going to yield time on this topic. I
have reviewed----
Ms. DeLauro. You said something that was inaccurate.
Mr. Harris. Madam Secretary, by functioning, by saying that
abortion is not covered, but these abortifacients are, because
it is controversial whether they are, you are, in fact, saying
they are abortifacients. And I will tell you, I can't
understand why in the world you would not make an exception for
that that would allow the Hobby Lobby to go, to comply with
their conscience on that issue?
Now, there are other issues involved, but for them it is
specific. And the cost of this is $40. That is it. It is not a
drug you take every day. It is $40. And that is what this
argument is about. And you all are dug in. I am disappointed.
But let me turn to the--well, if with we have a third round, we
will turn to the other problem which is that your requirement
on religious institutions make them pass the unethical behavior
on to a third party which is a real ethical problem. And I
don't think you and your Department appreciate what an ethical
problem it is, but I will get to that in-depth if we go a third
round. Thank you, Mr. Chairman.
Mr. Kingston. I was going to get some coffee, but I don't
need it. We appreciate the passion on the panel up here. Ms.
Lee.
OFFICE OF MINORITY HEALTH
Ms. Lee. There is a lot of passion here, let me tell you.
Thank you, Mr. Chairman. This is National Minority Health
Month. The Tri-Caucus Black, Hispanic, Asian Pacific American
Caucus, we are going to the floor at noon to talk about
minority health, ethnic disparities, and the benefits of the
Affordable Care Act to minority communities.
A couple of things, Madam Secretary, I wanted to say. First
of all, the diffusion of these efforts, and I understand what
you are saying in terms of the general workforce effort to
increase capacity and make sure everyone is focused on
diversity efforts, but you have to have, I guess, a centralized
focus so that these efforts will work, and with cutting the
Office of Minority Health by $15,000,000, I am really worried
that a lot of these efforts are going to go away.
COMMUNITY & SAFETY NET PROVIDERS
The question I asked earlier about the--let me just quickly
reiterate it. The traditional providers in our community who
provide access to care, they have been around for a long time,
community physicians, they have traditionally cared for many of
the underserved. They don't have this infrastructure in place
that the Affordable Care Act requires, and there are no
requirements in the exchange plans to include Safety Net
providers including community physicians who have traditionally
provided care, such as African-American and Latino physicians,
and they are really feeling the squeeze.
We are sending you a letter on this, Madam Secretary. I
want to talk to you about it. But can you kind of give us some
sense what to do, what they should do at this point because
they are not included, and they are going to be wiped out for
the most part?
Secretary Sebelius. Well, I am a little baffled as to why
they wouldn't be included in network plans. I assume that many
of the providers that you are talking about are currently part
of a network plan.
Ms. Lee. Not really. A lot of the--a lot of the minority
physicians are not, and that is the problem because they are
not--the exchange health plans don't require the Safety Net
providers to be part of these plans now. And the majority of
them aren't.
Secretary Sebelius. I guess I need the letter from you,
because I am not quite sure. If they are not part of an
insurance network, I mean, if they are part of any insurance
network, any company, that would make them automatically part
of the exchange.
So if someone can go with their Blue Cross card to a
minority provider, someone could go with their Humana card to a
minority provider, then they would be part of the exchange by
virtue of that plan being offered on the exchange. If you are
talking about designating individual doctors as essential
community providers, that is not something that was done in the
bill, and I am not sure, in fact, how we would ever do that.
There are categories of providers that are designated as
essential community providers, but individual doctors are not.
Ms. Lee. Okay, I understand that and we will send you a
letter. The National Medical Association is very concerned
about this and other groups around the country about how this
will ultimately play out.
NURSING SHORTAGE & MINORITY NURSES
Let me ask you about nurses. Registered nurses, advanced
practice nurses, they are expert clinicians who provide high-
quality and cost-effective care in every care setting in every
community. And they are especially in demand in our medically
underserved areas. Despite, you know, this need, according--and
this is the American Association of Colleges of Nursing--their
enrollment and graduation survey, they are saying the nursing
schools were forced to turn away 79,000 qualified applications
from entry-level baccalaureate graduate nursing programs in
2012, citing faculty vacancy as a top reason.
And so we are trying to figure out in your budget request,
I think it was level to the 2012 enacted amount of $24,500,000,
yet this huge need, this huge shortfall is a big issue in terms
of our health care system's growing reliance on the need for
nurses. And I have a mother who was 88, a sister with multiple
sclerosis. I am in hospitals, emergency rooms all the time, and
I can tell you, the nursing shortage is tremendous. The lack of
minority nurses is glaring, and travel nurses, you know, do a
great job, but you know, they shouldn't have to travel. You
know, we should have nurses in our own communities to provide
the badly needed services that they provide.
Secretary Sebelius. Well, I certainly share your belief, in
all deference to Dr. Harris, that nurses lift more than half
the sky in most health systems, and most patient contact is
often with a nurse in providing the patient information. So
HRSA has spent a lot of time and effort directing new funding
to nurses, to nurse practitioners, and to advanced nurse
practitioners. We are trying to work with States around their
often restrictive scope of practice.
Mr. Kingston. Madam Secretary.
Secretary Sebelius. Oh, I am sorry.
Mr. Kingston. We are going to try to do a third round, so
Mr. Joyce.
Mr. Joyce. Thank you, Mr. Chairman. I will yield my time to
Dr. Harris.
STATE LICENSING AUTHORITY FOR MEDICAL PROFESSIONALS
Mr. Harris. Thank you very much. Let me just follow up on
that the States have restrictive scope of practice but that is
within the realm of a State's licensing authority, is that
correct?
Secretary Sebelius. Yes, sir.
Mr. Harris. I mean, there is no Federal licensing authority
in scope of practice?
Secretary Sebelius. I said, we are trying to work with some
States, yes.
Mr. Harris. But you claim that they are restrictive, but
from their point of view, they are proper. I mean, I
understand, and believe me, I love nurses. My daughter is a
nurse. She is going to be a nurse practitioner. I understand,
but this is the problem that the Federal Government looks at
the States and says, see, what you are doing, we think is not
right. You are too restrictive. But it is up to the States to
make that final decision. I just want to emphasize that. It is
up to the States.
Secretary Sebelius. But if a State has a serious
undershortage of primary care providers and have not allowed
trained providers to practice----
Mr. Harris. Well, Madam Secretary----
Secretary Sebelius. All we do is have a conversation. It is
totally up to them.
Mr. Harris. Madam Secretary, in your opinion, they are
trained to be equivalent, but it is up to the States in the
end, and I hope the Department doesn't take coercive action on
those grounds.
Secretary Sebelius. We have never suggested taking coercive
action.
Mr. Harris. Well, again, to claim that they are
restrictive, when in fact, they are adequate for the State,
that is a States-right issue, and a strong States-rights issue.
CONSCIENCE PROTECTIONS
But let's get back to what we were talking about a little
bit before. Because I still want to express a grave concern
over a company like Hobby Lobby, which is privately owned, it
is not public, and its owners feel strongly, they hold strong
religious beliefs that conflict with some of the HHS mandate.
What is their option going to be when the new rule comes
out virtually unchanged, they are subject to the mandate, and
if they continue to insure their employees as they want to,
they would be violating their conscience. My understanding is
their choice is, you either violate your conscience or you
don't provide health insurance. Am I missing something in
between?
Secretary Sebelius. Well, I think, Congressman, the law of
the land will apply to employers across the board with some
exceptions that we have outlined, and in the case of Hobby
Lobby or other nonreligious employers, imposing their religious
views on their employee choice is not really an option.
Mr. Harris. Madam Secretary, it is not imposing a religious
view on their employees. They are paying out of their private
moneys, these are privately-held companies, they are paying for
this insurance. So their options, in my mind, will be we either
violate our ethics, which I would suggest they should never do
because of a Federal Government mandate, or they will just
choose to pay the penalty and send people into the exchanges,
violating the President's promise that if you like your plan
you get to keep it. Because I will bet the vast majority of the
Hobby Lobby employees, in fact, like their plan.
And Madam Secretary, they will not get to keep it under the
current structure of the HHS mandate. But let me talk, because
I think the Department is missing a very, very significant
ethical question here, and that is, we will talk about the
quote ``religious institutions,'' the subject of a lot of these
lawsuits, because their position is quite clear, and you know,
students of ethics will understand this, that if by providing
insurance for their employees, no matter what scheme or shell
game you play with who is going to pay for the morally
objectionable coverage, they will be allowing their employees
to have access to that, no matter who pays for it.
The analogy is, you know, a Catholic hospital, for
instance, can't refer for abortion. They can't say, you know
what, we don't want to do this, but as long as somebody else
does it, or somebody else pays for it, that is okay. Because
Madam Secretary, that is just plain unethical. So what is the
options if they feel that way, their ethical religious
construct is that, aren't their options exactly the same?
We either violate our ethical religious construct, and we
are not talking about Hobby Lobby. We are talking about the
University of Notre Dame, a Catholic institution, one of the
plaintiffs, the Archdiocese of New York, the Diocese of Dallas,
the Archdiocese of Washington. They would have to violate their
moral ethical construct, or they just have to send all of their
employees into the exchange. And again, most of their employees
probably feel they kind of like the insurance product they
have, but once again, they are not going to be able to keep it
because of the HHS mandate. Am I missing something? Those
really are the only two choices. You either comply with what
the Federal Government mandates, or too bad.
Secretary Sebelius. A couple of things. First of all, no
diocese is included in this law at all. They may be in the
lawsuit. They are not in the law because they have fallen under
the total exemption that involves churches. Secondly, the
commitment was to find an appropriate balance between having a
religious employer not offer, pay for, or refer people to
coverage that they find objectionable. On the other hand,
giving employees the right to exercise his or her own religious
values and choose coverage that they would find to be healthy
for themselves and their families. And I think that is what our
commitment is. That is what we intend to do when we promulgate
the final rule.
We have actually had a number of very positive comments
from entities like the Catholic Health Association, who has
been working with us. Other entities that are looking at this
with regard to their--you might find that amusing, but they are
enthusiastic about what the rules would allow them to do and
feel that it very much is in line with their----
Mr. Harris. None of these lawsuits were dropped. The
Catholic Health Association does not represent any of these
plaintiffs. Mr. Chairman, I yield back the time.
MARKETPLACES
Mr. Kingston. Madam Secretary, we are going to go to
another round, try to do 3-minute questions, so we will try as
you can tell, we have a lot of interest.
What my question is, and in terms of if a State has
rejected setting up an exchange, then the Federal Government
steps in and does the exchange. But I understand that there is
an administrative fee for that, 3.5 percent, true, or is it----
Secretary Sebelius. The user fee is for the companies who
will be offering plans in exchange, and they will pay a user
fee. Yes, sir.
Mr. Kingston. What is the statutory basis for that, and----
Secretary Sebelius. The law requires the exchanges
eventually to be self-sustaining and the user fees are the way
to get us there.
Mr. Kingston. Is there any challenge to that 3.5 percent or
is everybody accepting it?
Secretary Sebelius. So far as I know, there is no
litigation, no. And these are new customers, clearly, for the
insurance companies.
Mr. Kingston. Yes. And have you put out the process for
selecting, if the Federal Government comes in and sets up an
exchange, then are you doing it with Federal employees? Are you
doing it with contractors, and you are accepting bids for
proposals?
Secretary Sebelius. Well, there are a couple of pieces of
the puzzle. There is a Federal hub, if you will, that all
marketplaces will use a data center to verify as Social
Security numbers, and income numbers, and qualifications for
the tax credit. Then there are individual exchange hubs,
private plans in each State, in Georgia, which has chosen not
to operate a State-based exchange, and there will be a Federal
exchange, but it will be a Georgia-specific plan with Georgia
companies who offer products to Georgia citizens. The benchmark
will be based on the small group market in Georgia, so I think
as far as the consumer's experience goes, I am not sure they
will have any idea whether or not it is a Georgia plan or run
by the Federal Government.
Mr. Kingston. And have you put out the criteria for who
would run, who would qualify to submit proposals? Is that out
there yet?
Secretary Sebelius. Yes, sir. That is what we are talking
about in terms of rates coming in. Insurance companies are now
submitting rates to be part of these marketplaces, and they
will negotiate about whether or not the rates that they submit
are actually ones that are justifiable based on an actuarial
analysis, and then those rates will be finalized, and then
those market plans will then be available to consumers starting
October 1st.
Mr. Kingston. Okay. Rosa.
ADVANCED MOLECULAR DETECTION
Ms. DeLauro. Thank you, Mr. Chairman. I just have one
comment. I think when your boss' ideology determines your
health care, we are certainly into a whole new world. Let me
just talk about CDC for a moment, and the advanced molecular
detection proposal.
Secretary Sebelius. Tom Frieden will be so pleased.
Ms. DeLauro. This is one of the places where I am excited
about additional funding for food safety, for control of health
care associated infections, and for this new advanced molecular
detection initiative.
My understanding is that the basic idea is to modernize the
CDC's capacity to use the technologies to do a better job, if
you will, of tracking pathogens, recognizing patterns of
diseases. And my understanding is also that CDC has fallen
behind in the adoption of new technology. It used to be the
gold standard and that has fallen behind, and now there is an
urgent need to modernize.
So I don't know if you are an expert in this area. I
certainly am not, but can you give us your understanding of
what this initiative is, and what it is meant to do and why it
is needed?
Secretary Sebelius. Well, you are absolutely right.
Congresswoman, the CDC has been the gold standard in
surveillance, monitoring, and identification, and we are
seeing, actually, some of that good work bear very important
fruit with the emergence of this new avian flu in China. CDC,
actually over the last number of years, has worked very closely
with China to help build their CDC capacity and in fact,
provided a lot of technical assistance.
So we now have a relationship where we are getting daily
communications from China. We are able to track what is going
on. One of the important CDC scientists is in China as we speak
as part of their team monitoring this disease. But CDC needs
new capacities, and the advanced molecular detection system is
a multiyear expenditure that would greatly enhance, increase,
and update their surveillance capacity. There is an increase in
the budget this year, but we would see this as a several-year
effort that would actually bring CDC's lab capabilities up to
the gold standard once again.
Ms. DeLauro. Okay, tell us about the babies. You have 35
seconds. If----
Secretary Sebelius. Well, let's just say in terms of saving
money in a very, I think, encouraging way, one of the areas
that was looked at was so-called elective early deliveries.
Deliveries not because of any kind of health emergencies, but
babies were being delivered prior to 39 weeks, for the
convenience of the doctor, the convenience of the patient, and
a variety of things. There are huge health differences between
a baby is carried to full term, and a 36- or 37-week baby.
Focusing on that, providing some best practices, drilling down
on that experience has helped hospitals in some cases go from
20 percent early elective deliveries to almost none. Great
reduction in NICU days, great reduction in lifetime issues
around the baby, and it is just an example of identifying an
easy fix and then having hospitals really engage in it.
Ms. DeLauro. Thank you. Thank you very much.
Mr. Kingston. Mr. Joyce.
Mr. Joyce. Thanks. I will yield my time to Dr. Harris.
RELIGIOUS EXEMPTION TO MANDATE
Mr. Harris. Thank you very much. Let me just follow-up a
little bit about the religious exception here because of
course, the churches itself, are not the--the churches
themselves are exempt, but everything else the churches do, the
archdiocese, the diocese, they, of course, are not exempt. They
are subject to the rule. And the rule being, again, and I guess
I have to ask you, I mean, that is the basis of their lawsuits.
It is not that you didn't exempt them. It is that you didn't
exempt their related activities, their charities, their
hospitals, their schools. Is that the basis of their lawsuit
from what you understand? Obviously, they are exempt, so they--
--
Secretary Sebelius. Yes.
Mr. Harris. Okay, so what you are doing is under the
current structure of the rule, and again, it really is an
accounting gimmick. What you are doing is saying, you can offer
the insurance, but by offering the insurance, so I am just
going to get it straight, the construct that you are creating,
by them offering insurance to their employees, their objection
is that that creates the ability, in fact the necessity, of
their employees getting coverage for something they find
morally objectionable. Because under the exception, their
employees have to get it. There is no choice. They have to get
it. A third party will do it, or the TPO will contract with
someone or the insurer will attempt to bury the costs somewhere
else.
Secretary Sebelius. If the employee chooses that coverage,
they would use it, yes.
Mr. Harris. That is right, so the option is----
Secretary Sebelius. They would have the option to choose
the coverage.
Mr. Harris [continuing]. To be not covered, or to be
subject to this which would violate the ethical construct of
the organization that, because I am not talking about the
employee now. I am talking about from the employer's point of
view. Their point is, they would either have to offer this
product to everyone, or they offer it to no one.
Secretary Sebelius. Again, the employer would not pay for,
would not refer, and would not provide the coverage.
Mr. Harris. Madam Secretary, how is that not referring? If
automatically upon offering an insurance product, that person
automatically gets the other product. How is that not
referring?
Secretary Sebelius. Well, it isn't automatic, Doctor, and
what we have done is outline a variety of possibilities. In one
case, the insurance company would directly offer an alternate
policy directly to employees, not referred to by their
employer, but directly to employees. And in fact, insurance
company data indicates that providing contraceptive coverage is
actually a reduction in the plan, so the benefit would go to
the employer. If there is a third-party administrator, the
third-party administrator would offer the coverage and then
there is some alternate possibilities. And we are evaluating
comments and we will promulgate a final rule.
Mr. Harris. Ethically, how is that different from the
church organization offering the coverage themselves? How is
that ethically different? You have somehow separated it
ethically, but it is exactly the same.
Secretary Sebelius. They do not refer, they do not pay for,
and they do not recommend the coverage. I don't know how it
could be clearer. They are not involved.
Mr. Harris. Thank you.
Mr. Kingston. Mr. Joyce.
AFFORDABLE CARE ACT IMPLEMENTATION TIMELINE
Mr. Joyce. Thank you, Secretary. And I want to follow up on
what I first asked you because maybe I wasn't very clear, but
since I am new. You are obviously a very intelligent lady, and
somewhere you probably have some documents in which you lay out
for yourself or can sort of show the implementation of the
Affordable Care Act as it is moving along. I was wondering if
there is somewhere I could make those same things available for
myself so I could explain it to the people at home, and if
there is something that is going to be updated on a quarterly
basis, because I would like to stay up to speed, because there
are so many questions being asked, and I don't seem to have the
answers and I haven't heard all of the answers here today.
Secretary Sebelius. Well, we would be happy, Congressman,
to provide you with documents that give you a timeline, and
what is coming, and where we are, and what we anticipate coming
in the next quarter and the quarter beyond that, yes, sir.
Mr. Joyce. And whether or not the exchanges will be coming
on time.
Secretary Sebelius. Yes, sir.
Mr. Joyce. Okay. Great, thank you very much. I have no
further questions.
Secretary Sebelius. Sure.
COMMUNITY TRANSFORMATION GRANTS
Mr. Kingston. Madam Secretary, I wanted to ask a little bit
about Community Transition Grants, and I have raised the issue
with Tom Frieden on that, and I am certainly a CDC fan, but I
do feel that Community Transition Grants is kind of junk
science. I mean, you go out and get the health departments and
you get them all ginned up about superficial stuff, and they
come back and say let's reduce sugary beverages, like, oh, I
haven't thought about that one.
And as you may know, the stimulus bill actually had
$266,000,000 in Community Transition Grants just for the CDC.
And I think it was in 2010 or 2011, but to me, gosh,
$266,000,000, put it to a lab and a chemist in the back room.
Let them do, as you had mentioned earlier, what FDA just came
back with on the OxyContin, something society needed, something
everybody wanted. But here is an example of a grant
solicitation, and I am reading directly, it says: ``To limit
the density of fast-food outlets,'' and it is featuring high
calorie, high sodium, low nutritional foods, and encouraged
retail venues to provide access for healthier foods; zoning to
regulate the number of fast-food restaurants in a given area.
I mean, it just seems so silly, first, to be doing it on a
Federal level, you know. If, for example, I like to ride my
bike and I think in Irving, California, 14 percent of the
people ride bikes. And that is really to me a good thing, and
you know, you can find out about that. But that didn't take a
Federal grant to come up with that. And then here is one, a
Philadelphia grantee, in their report, came back, campaigned
for a $0.02 tax on sugary beverages, and it came up one short
vote in city council. Now, nothing makes our constituents more
livid than paying tax dollars to lobby for a policy, whatever
it is, whether you agree about it or not, but you know, again,
you know, why not put the money in the lab with the scientists
who can really figure out how to cure cancer?
Secretary Sebelius. Well, I would like to do both, and I
think if you look at chronic disease, a lot of it is not going
to be solved by a pill or a cure. It really is going to be
solved by, helping to make the healthier choice, the easier
choice.
Mr. Kingston. I guess the part of my--and I hate to
interrupt you, but part of my concern is, none of this is
original thinking. You know, and for $256,000,000, we want to
have original thinking, and I understand the local community
group wants to solicit for higher taxes on something and lower
zone in a fast food, but it is to me, you know, they are not
really adding anything to the table. And you know, it is----
Secretary Sebelius. I would say, chairman, we have had a
health system that spends 92 cents on every dollar treating
sick people, and about 8 cents of every dollar trying to get
people healthy in the first place and keep them healthy. So
there were some Recovery Act dollars spent really pushing money
to communities, and it was called Communities Putting
Prevention to Work, so we engaged with mayors and city councils
and community activist groups who did everything from bike
paths and walking trails, looking at food deserts and trying to
give incentives to people to bring fresh fruit and vegetables
into areas where there weren't enough, working with local
schools to update and upgrade what the kids were eating and----
Mr. Kingston. And my time has expired. Here is what I told
my friends in the, you know, the agencies that kind of make it
easier on us. You know, in this budget constraint----
Secretary Sebelius. I hear you.
Mr. Kingston. We can't have this, but you know, let's see,
you know, if you come up--look, for example, and you know the--
the 1 percent reduction in cancer each year and the reduction
of polio, now the three countries and all that, that is
something everybody can get behind and, you know, the taxpayers
feel better about it, our constituents do, and so let me yield.
AFFORDABLE CARE ACT
Ms. DeLauro. Thank you, Jack. I would just say this to you,
that the fact of sugar in obesity has been determined by
scientists, so it is based on science and there is something
there.
Let me just make a final comment, and I know the Secretary
has to leave. I just would say this. The House voted for the
Affordable Care Act, the Senate voted for it, the President
signed it, the Supreme Court upheld it. We had an election in
which it was vilified, and in fact, it was overwhelmingly the
President was elected.
We now have the Affordable Care Act. Our job is to
implement it and to make sure that it works well, and I just
want to say to you, Madam Secretary, I want to just say thank
you.
Some of the problems that were there about people who are
uninsured, those who can't afford insurance, lifetime limits,
premiums, gender rating, the threat of coverage being canceled
based on technicalities, all of those things are being
addressed, phasing out of annual and lifetime limits on
coverage, prohibition on denying coverage for children based on
pre-existing conditions, ban on rescissions of coverage.
We are moving forward. Much has been implemented. The fact
of the matter is let's get on with it, let's make changes where
there need to be changes, but let's be able to do what the law
of the land says. We are going to work to provide insurance. In
fact, at this moment, the Affordable Care Act has helped to
hold down premium increases, and there are new consumer
protections. The marketplace will increase that effort, and we
will have more transparency in what we know is in our insurance
policies.
I say to those who can't deal with the fact of life that we
have this law of the land, let's move forward and do the right
thing and get over it and not try to deny the funding for it
that it needs in order to survive to say, aha, it didn't work.
It will work if we work at it collectively.
Thank you very much, Madam Secretary.
Mr. Kingston. Dr. Harris.
LOBBYING
Mr. Harris. Yeah, just very, very briefly, Madam Secretary,
just to follow up with what the chairman's last line of
questioning was. Those community preventive service task force
grants and the community anti-drug coalition of America grants
that, you know, were alleged now to have involved State or
Federal lobbying, I got to ask you a question. Does the
Department intend to go after them for recouping that just like
you left the hospitals and doctors? I mean, are you going to
recoup those grants from those organizations that violated
their agreements not to do Federal or State lobbying with the
monies, or bring action or ask the Attorney General to take
action against them?
Secretary Sebelius. That is not underway. We have
definitely gone back to grantees indicating that there is a
strict prohibition. We have done retraining of all grantees. We
are watching very closely. I think there is one instance where
a community grantee, in addition to a lot of other things that
they were doing, did lobby a local entity, and that was
immediately stopped by the CDC.
Mr. Harris. And do you give the physicians and hospitals
the same opportunity when your auditors find something to
actually just perhaps advise them, or do you just go ahead and
ask for recoupment of the money?
Secretary Sebelius. I think there is the same kind of
negotiation to figure out what it is that they have done,
whether or not they indeed violated, and often there is a
negotiated settlement, and that is the way it is done.
Mr. Harris. Thank you very much. Thank you, Mr. Chairman.
Mr. Kingston. Thank you. And Madam Secretary, I just wanted
to touch base on one thing that we can talk about later, but,
you know, with the situation with Boston and here and there, I
just think we are, you know, in a world now where we can expect
attacks, and because of that, I do have some worry and I think
we don't discuss about BioShield enough in our country. The
BioShield fund has been reduced. I am worried about
pharmaceuticals being able to develop the things and have the
market. I mean, that is one area where I think Republicans and
Democrats can agree. There has to be a subsidy for the research
and development, and it is reduced in this, and so I--do you
want to comment on that? I see----
Secretary Sebelius. I think there is a budget
recommendation for BioShield. It is a one-year recommendation
given the fact that again we are now operating under a CR. We
have not had an increase in BioShield since 2012, so we think
it is a very important program and we would love to work with
you on it.
Mr. Kingston. Well, I think there are things that we can,
you know, really find great common ground on, and I think we
are finished here. I mean, there is tons more questions. We can
just bring her back tomorrow. I would like to have----
Ms. DeLauro. Talk about sugary drinks.
Mr. Kingston. The hobby lobby would like to yield some time
to Rosa now.
We will adjourn. I do want--there were some things I had
talked to you about in terms of Georgia.
Secretary Sebelius. Yes.
Mr. Kingston. About waivers and seafood, I think that
Rosa----
Secretary Sebelius. Maryland has an issue also, and I can
check up on that.
Mr. Kingston. If you could----
Secretary Sebelius. Sure.
Mr. Kingston [continuing]. Follow up with us, and we
certainly appreciate your time, and thanks for being with us.
Secretary Sebelius. Sure.
[The following questions were submitted for the record.]
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W I T N E S S E S
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Page
Clancy, Carolyn M................................................ 1
Collins, Francis S............................................... 1
Colvin, Carolyn.................................................. 269
Conway, Patrick.................................................. 1
Delisle, Deb..................................................... 335
Frieden, Tom..................................................... 1
Hyde, Pamela..................................................... 335
Sebelius, Hon. Kathleen.......................................... 413
Wakfield, Mary................................................... 1