[Senate Hearing 113-768]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2015
----------
WEDNESDAY, MAY 7, 2014
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:02 a.m., in room SD-138, Dirksen
Senate Office Building, Hon. Tom Harkin (chairman) presiding.
Present: Senators Harkin, Durbin, Reed, Mikulski, Shaheen,
Moran, Shelby, Alexander, and Johanns.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF TIMOTHY LOVE, CHIEF OPERATING OFFICER,
CENTERS FOR MEDICARE AND MEDICAID SERVICES
OPENING STATEMENT OF SENATOR TOM HARKIN
Senator Harkin. The Appropriations Subcommittee on Labor,
Health and Human Services, Education and Related Agencies will
please come to order.
Each year this subcommittee questions the Secretaries of
agencies under our jurisdiction. But because Secretary Sebelius
has resigned and the nominee to serve as the next HHS
Secretary, Mathews Burwell, has not yet been confirmed, we are
sort of in an odd situation, so we decided on a different
approach for HHS this year.
We have before us today leaders from each of the HHS
operating divisions that have the large proposals in the
President's budget, new programs as well as programs with
proposals for significant increases and/or cuts.
So this is a great opportunity for this subcommittee to get
answers from the leaders most responsible for implementing our
bills, so I look forward to this. Each of your agencies
administers at least one program that holds special interest
for me, and I am sure for others on this committee.
Overall, the budget request for HHS is $1.5 billion less
than last year. The budget request is consistent with the
overall funding levels in the Bipartisan Budget Act. That
agreement partially restored cuts from sequestration and
prevented further cuts to nondefense discretionary programs in
2014 and 2015.
However, as this budget request shows, this committee knows
all too well that cuts to nondefense discretionary spending
over the last several years have forced some very difficult
decisions.
The Administration for Children and Families (ACF), I have
been deeply committed to expanding access to high-quality early
learning programs for most of my career. I am pleased with the
budget's proposed $270 million increase for Head Start and the
$57 million increase for the Child Care and Development Block
Grant. This bill honors significant investments this committee
made in those programs just last year.
I am particularly interested in hearing more today about
the ACF work in implementing the $500 million provided last
year to expand Early Head Start, including the establishment of
new Early Head Start-Child Care Partnerships.
At the same time, I am deeply concerned about proposed cuts
to the Community Services Block Grant program and LIHEAP (Low
Income Home Energy Assistance Program).
For CDC (Centers for Disease Control and Prevention), Dr.
Frieden and I have had conversations about the importance of
public health. The challenge of public health is that when it
is working well, no one should notice it. We in the U.S. notice
it least because the Centers for Disease Control and Prevention
is a world-class public health institute.
In fact, that is why I was pleased to allocate funding in
2014 to create a program to help other countries create their
own CDCs to organize their health systems around public health
and data.
So I look forward, Dr. Frieden, to hearing about progress
on that effort.
Dr. Wakefield, it is nice to have you back on Capitol Hill,
where you are no stranger here. You spent most of your career
here with both Senator Burdick and Senator Conrad, both of whom
were great leaders in rural health and rural healthcare. Your
career has demonstrated your commitment to delivering high-
quality care to those who need it most, and I can think of no
greater calling and no greater mission than HRSA's (Health
Resources and Services Administration), which is to increase
access to comprehensive primary care services for medically
underserved communities.
So that is why I am deeply troubled by the repeated budget
proposals to cut or delay health center openings and to reduce
the number of pediatricians and nurses that we train. I will
also have a question about integrative medicine and how we are
doing with that.
Last but not least, the Centers for Medicare and Medicaid
Services (CMS). Although Ms. Tavenner is unable to attend
today--her mother passed away just last evening--I want to
congratulate CMS, its leaders and staff, on the latest
enrollment estimates, including 8 million people who signed up
for coverage in the State and Federal exchanges, close to 5
million in Medicaid and the Children's Health Insurance
Program. So despite a rocky start with that Web site, the
Affordable Care Act remains the most significant human services
legislation in decades. It is giving millions of men, women,
and children affordable insurance options for the first time.
So I look forward to hearing from you, Mr. Love, about the
steps CMS is taking to ensure that the people who signed up for
coverage have access to and receive quality care.
I am particularly interested in hearing about two things:
CMS's continued efforts to reduce healthcare fraud and abuse.
As we know from our data, for every $1 we spend in that area,
we are getting $8 returned to the Treasury in savings. So that
work is critical to ensuring that Medicare is available for
millions of Americans for generations to come.
PREPARED STATEMENT
The other is, again, the provision of prevention and
wellness programs under CMS and how that is being implemented
in the Affordable Care Act.
So I hope that the format of this hearing will give us
renewed appreciation for the breadth of human needs that HHS
serves every year. So I look forward to all of your testimony.
Before Senator Moran starts his statement, Chairwoman
Mikulski submitted a statement to be inserted for the record.
[The statement follows:]
Prepared Statement of Chairwoman Barbara A. Mikulski
Today we are here to discuss the fiscal year 2015 budget request
for the Department of Health and Human Services. I would like to thank
Chairman Harkin and Ranking Member Moran who worked so hard to enact
the 2014 Omnibus. By negotiating with their House counterparts, we were
able to ensure HHS would no longer have to operate under a continuing
resolution or sequestration.
This hearing is part of the Senate Appropriation Committee's
mission to hold more than 60 hearings in a span of 6 weeks and to
complete all of our appropriations work by October 1. We will begin the
process of marking up our bills on May 22, and hope to consider this
subcommittee's bill sometime in June.
It saddens me to acknowledge that this will be the last LHHS
appropriations bill authored by Senator Harkin. However, it should also
inspire us to get the LHHS bill to the Senate floor for the first time
in 7 years. It would be a fitting way to pay tribute to Senator Harkin,
who has either chaired or served as the ranking member of this
subcommittee for the past two decades.
I look forward to hearing from our panel of witnesses, which
represent HHS' Administration for Children & Families (ACF); Centers
for Disease Control and Prevention (CDC); Centers for Medicare &
Medicaid Services (CMS) and Health Resources and Services
Administration (HRSA).
I hope all of you touch on how the Health and Human Services'
budget will help to create jobs and support innovation, while
protecting the public's health and providing kids with quality
healthcare, child care and a jump start on education.
Mr. Greenberg, I will want to discuss two areas of ACF's budget
request with you: Child Care Development Block Grants (CCDBG) and
Unaccompanied Alien Children.
Senator Burr and I worked together on a bipartisan reauthorization
of the CCDBG program that followed regular order and had an open
amendment process on the Senate floor. We were able to make important
reforms that improved the quality of care children receive. I was
thrilled to see our bill pass with overwhelming bipartisan support and
a vote of 96-2.
I appreciate that your fiscal year 2015 request increases funding
levels for CCDBG, but additional funding will still be needed to ensure
that the reforms in our bill are implemented effectively. Kids must be
taken off waiting lists and provided with the child care they deserve.
While your requests for CCDBG give reason for optimism, I am very
disappointed with the budget you have requested to tackle the issue of
Unaccompanied Alien Children. You have asked for level funding even
though you had to transfer millions of dollars to this program in
fiscal year 2014 in order to fulfill your needs.
I am worried because these are some of our most vulnerable
children. They have left their countries and travelled thousands of
miles to enter the United States, often fleeing violence to avoid
becoming victims of abuse or organized crime.
Their journey here is often riddled with danger--these kids put
their life, health and safety in jeopardy. Along the way, they risk
being subjected to trafficking and the violence they were attempting to
escape. These brave children deserve our consideration.
On April 22, I convened a bipartisan, bicameral staff level meeting
with various Federal agencies that are responsible for these
unaccompanied alien children. We learned that the number of
unaccompanied children entering the United States is rising.
In fiscal year 2012 there were 14,000. In fiscal year 2013 there
were 25,000 and that number is projected to balloon to 60,000 for
fiscal year 2014. This issue is not going away--we expect tens of
thousands more to enter the country in fiscal year 2015--and we need to
keep these children in mind when appropriating our resources.
What I need from you is a better estimate of the budget you will
need to provide these kids with proper services so you don't have to
transfer funds in the future.
Dr. Frieden, as America's chief public health officer, I look
forward to hearing your plans for new and existing initiatives.
How do you plan to continue the creation of blue zones, which were
supported by $80 million in Community Prevention Grants?
I hope you will delve into how you plan to use the $45 million in
funding to improve global health security. What will your approach be
in helping other countries build and strengthen their own Centers for
Disease Control as well as improve early detection and response to
epidemics?
You have also requested $30 million to combat antibiotic resistance
by quickly identifying deadly microbes and use common sense practices
to protect patients from infection. I encourage you to work with Dr.
Peter Pronovost of Johns Hopkins, his checklist has proven very
effective in reducing central line infections.
Lastly Dr. Frieden, I am keen to hear more about the $16 million
budgeted to address prescription painkiller abuse.
Administrator Wakefield, I look forward to hearing about your work
to strengthen the healthcare work force and increase the number of
primary care doctors, nurses, pediatricians and dental providers in
underserved communities.
I am also interested in hearing how communities, families and
patients are benefiting from the additional funding dedicated to health
reform and community health centers.
Finally, Mr. Love, I have particular interest in CMS because it
employs over 4,200 in my home State of Maryland. CMS does important
work to process Medicare claims, increase access to health insurance,
prevent fraud and abuse, help States expand their Medicaid programs,
support new healthcare delivery innovations and implement healthcare
reform.
I want to hear how this budget will enable you to fulfill those
crucial responsibilities. I also want to know what specific plans you
have to increase health insurance enrollment; improve the functionality
and operation of the Federal health insurance exchange; and help States
expand their own Medicaid programs.
I understand that there are some proposals in this budget that will
not be universally supported across the aisle--that's the nature of any
bill or budget. We all have things we like and things we don't like,
but we must try to refrain from making any one issue a ``deal
breaker.''
It is my hope, however, that we can work together to come to an
agreement. I think we all recognize that sequesters and continuing
resolutions are not an effective way to run a Federal agency like the
Department of Health and Human Services. Our Nation is better off when
we work together and govern together.
Senator Harkin. I will now turn to our ranking member,
Senator Moran, for his opening statement.
STATEMENT OF SENATOR JERRY MORAN
Senator Moran. Mr. Chairman, thank you very much.
Before I give my remarks, let me express my condolences to
Marilyn Tavenner and her family. We have a good, solid working
relationship with Marilyn, and I really do express my sincere
concern and care for her loved ones. We are sorry for the loss
of her mother.
I am, Mr. Chairman, disappointed that the Secretary of
Health and Human Services is not here today. In my view, she
declined, refused to testify, to talk about and defend the
budget request.
I know there were numerous press accounts last week about
this issue, and what I know about it is that our staff invited
all Cabinet Secretaries under the purview of this committee
with the option of certain dates. We asked those Cabinet
Secretaries to accept one of those dates, and we do it in
whoever accepts first gets that date.
And Secretary Sebelius accepted the opportunity to testify
at a hearing to be held on April 2, and then at her request, we
moved her opportunity to testify to May 7, to accommodate her
schedule.
The Department of Health and Human Services budget requests
nearly $70 billion for fiscal year 2015, and I would expect the
head of any Department, regardless of its budget size,
regardless of its budget request, to appear before the Senate
Appropriations Committee to discuss and defend, for our
consideration, their thoughts on that budget.
More closely, the total discretionary and mandatory budget
combined of Health and Human Services for fiscal year 2015 is
$1.02 trillion. That is more than the amount of the
discretionary budget cap for the entire Federal Government. And
so we get the view of how big Health and Human Services is.
And I, certainly, appreciate the individuals who are here
to testify today. I know that you have expertise and
experience.
But none of you can testify to the overall strategy or
management of the Department. Not one person on the panel
before us can explain the give-and-take that goes into
determining how funding is allocated throughout the entire
budget. Not one witness here with us today can answer the
questions regarding the priorities of the Department as a
whole. And not one of the panelists can speak to why specific
decisions were made.
All of these questions would be answered by a Secretary.
And in that role, I believe she should be here. And I am
disappointed that she declined to appear before our panel
today.
I have worked hard to be a valuable and hardworking member
of the Appropriations Committee. I have praised Barbara
Mikulski and her leadership of our Appropriations Committee.
There has been a great desire to get us back to regular order.
Her leadership, along with Senator Shelby, has been very much
appreciated by me and I assume by all members of the
Appropriations Committee.
And I wanted to make certain that the circumstance we find
ourselves into today doesn't become a norm for the
Appropriations Committee. In my view, regular order would
require that a Cabinet Secretary be here to discuss and defend
his or her budget.
And I want the committee's work to be responsible and
received well and to be respected. And I think we lose
something if we easily forgo the opportunity to have a
conversation with a Cabinet Secretary.
My colleagues tell me, who have been here longer than I
have, that no one can remember a Cabinet Secretary declining to
appear before their appropriations subcommittee. Whether or not
that fact is exactly true or not, I am not certain. But at
least for those who have told me, there is no recollection of
that not being the case.
And I want to make clear from my perspective, and I hope
this is not a Republican/Democrat perspective, is the
Appropriations Committee is deserving of the respect of a
Cabinet Secretary to be here in front of us to have the
conversations necessary for us to make decisions, to elucidate
the facts surrounding the appropriations request, and to make
sure that we do our jobs as appropriators as best as we can to
our abilities.
So, Mr. Chairman, I used my opportunity in my opening
statement to, certainly, express my respect for the folks who
are in front of us, but to indicate my disappointment at the
absence of the Secretary.
Thank you, Mr. Chairman.
Senator Harkin. Thanks, Senator Moran.
Again, I just want to make it clear, in statements referred
to last week, and since I made the statements, I want to
respond in kind. I want to make it very clear that as the chair
of this subcommittee, I never formally asked or invited the
Secretary to appear. Staff started working this stuff out,
trying to figure out dates and all that kind of stuff, when it
is mutually agreeable.
In between time, Secretary Sebelius submitted her
resignation. And then the President nominated Ms. Burwell to be
the head of HHS. Budget hearings, these kinds of budget
hearings, look forward. They look at what is coming. That is
what the budget is about, next year.
Secretary Sebelius is not going to be here next year. But
Ms. Burwell hasn't taken over yet. And so we were sort of in a
kind of limbo.
I will admit that this is my idea, to have the heads of the
agencies under HHS that have the lion's share of the funding to
come here.
I said earlier to the group, I said a lot of times if I
were asked to appear and testify on something under my
jurisdiction, I would have all my staff in back of me, backing
me up, because they are the repository of the knowledge. They
are the ones who carry out this.
Secretaries, Senators, we have sort of a broader vision of
things. And so I thought it would be interesting, and perhaps
even hopefully maybe a precedent to have the people here who
actually do the work, and who carry out the bulk of the
spending of the money that we appropriate.
And so there is nothing sinister or anything other than
that. If we were having an oversight hearing over the past,
yes, you would have someone like that here who was responsible
for implementing things in the past. But that is not why we are
here. We are talking about the budget for the future and what
that is going to be about. And that is why I set this up in
this way.
Each of you here, your statements will be made a part of
the record in their entirety. We will start left to right. We
will start with Mr. Love, if you can sum up in 5 minutes, also
Mr. Greenberg, Dr. Frieden, Dr. Wakefield. And then we will
start our rounds of questioning.
So, Mr. Love, please start, and if you can just sum it up
in 5 minutes.
SUMMARY STATEMENT OF TIMOTHY LOVE
Mr. Love. Thank you, Mr. Chairman.
Chairman Harkin, Ranking Member Moran, and members of the
subcommittee, thank you for the invitation to discuss the
Centers for Medicare and Medicaid Services' discretionary
budget request included in the President's fiscal year 2015
budget.
I am appearing today on behalf of Administrator Tavenner,
who the chairman and ranking member graciously acknowledged her
loss last night. I will do the best I can as her understudy.
My name is Tim Love, and I was appointed CMS's chief
operating officer in January of this year. As a career public
servant, I have spent nearly 3 decades in public service,
including the United States Navy, a Peace Corps volunteer, and
over 22 years in CMS.
I would like to begin by saying that our agency is
committed to strengthening and modernizing the Nation's
healthcare system to provide access to high-quality care and
improved care at lower costs for beneficiaries and consumers
enrolled in our programs.
I would like to thank the subcommittee for the support you
have provided CMS that allows us to carry out this important
work.
Our fiscal year 2015 budget request allows CMS to build on
the successes we have achieved in helping more Americans obtain
healthcare coverage while improving the quality and value of
the care provided.
CMS has led efforts to expand affordable health insurance
coverage to Americans through the health insurance marketplace.
We are pleased to report that at the end of the first
enrollment period, 8 million Americans have signed up for
private health insurance. An additional 4.8 million Americans
have enrolled in a State Medicaid program during this period.
In addition to the marketplace, CMS continues to serve 54
million Americans through Medicare, 65 million through
Medicaid, and nearly 6 million through the Children's Health
Insurance Program, also known as CHIP.
Our fiscal year 2015 program management budget request
enables reforms in healthcare delivery, while continuing to
support the ongoing Medicare, Medicaid, and CHIP programs, as
well as the marketplace.
The CMS budget supports fraud prevention and the reduction
of improper payments, which are top priorities for the
administration. The program integrity investments in the budget
are projected to yield $13.5 billion in savings for Medicare
and Medicaid over the next 10 years.
Our budget includes a package of Medicare legislative
proposals that will save $407 billion over 10 years, while more
closely aligning payments with actual costs of care,
strengthening provider payment incentives to promote high-
quality care, and by creating incentives for beneficiaries to
seek high-value services.
PREPARED STATEMENT
Together, these measures will extend the hospital insurance
trust fund solvency by 5 years.
Our budget reflects the administration's commitment to
fiscal responsibility while providing CMS with the resources it
needs to support demographic trends in Medicare, Medicaid, and
CHIP, and continued administration and oversight of the
marketplace.
We look forward to continuing our work with this
subcommittee, and I would like to thank you for your time this
morning.
[The statement follows:]
Prepared Statement of Timothy Love
Chairman Harkin, Ranking Member Moran, and members of the
subcommittee, thank you for the invitation to discuss the Centers for
Medicare & Medicaid Services discretionary budget request included in
the President's fiscal year 2015 budget. Our request will allow us to
build on the successes we have achieved in helping more Americans
access healthcare coverage and improving the quality and value of care
provided across our delivery system.
In fiscal year 2014, CMS led efforts to expand affordable health
insurance coverage to Americans through the Health Insurance
Marketplace. We are pleased to report that 8 million Americans have
signed up for private health insurance through the Marketplace and more
than 4.8 million more Americans enrolled in Medicaid and the Children's
Health Insurance Program (CHIP). Additionally outside experts estimate
that millions more enrolled directly with insurers for new high-quality
coverage. In 2015, we will continue our work to expand quality,
affordable coverage to millions of Americans. In addition to the
Marketplace, CMS continues to serve 54 million Americans through
Medicare, 65 million through Medicaid, and nearly 6 million through
CHIP.
Fixing America's healthcare system doesn't stop with guaranteeing
that everyone has coverage. To address the rising costs of healthcare,
we must improve the way that healthcare is delivered, including the
coordination and safety of care. We are working closely with providers,
hospitals, and others to improve our healthcare delivery system for all
patients. Already, we have made significant progress. For the second
consecutive year, overall health costs grew more slowly than the
economy as a whole. We have also seen low spending growth per enrollee
in 2012 for Medicare (0.7 percent), Medicaid (1.3 percent), and private
health insurance premiums (2.7 percent).
We began tying Medicare payments for hospitals to their readmission
rates, and saw the 30-day, all-cause readmission rate decline in both
2012 and 2013. In 2012, Medicare Accountable Care Organizations (ACOs)
began participating in the Shared Savings Program that encourages
providers to invest in redesigning care for higher quality and more
efficient service delivery, without restricting patients' freedom to go
to the Medicare provider of their choice. The program is off to a
strong start with 338 Medicare ACOs participating in the Shared Savings
Program. We are encouraged by the interim results and we look forward
to final performance year one results later this year.
program management
The budget for CMS Program Management enables reforms in healthcare
delivery while continuing to support the ongoing Medicare, Medicaid,
and CHIP programs in CMS, as well as the recently implemented Health
Insurance Marketplace. The request also accommodates substantial
increases in CMS' workload because of demographic trends and program
changes driving higher Medicare and Medicaid enrollment and implements
responsibilities assigned in the Affordable Care Act and other
legislation related to Medicare, Medicaid, and CHIP. The fiscal year
2015 discretionary budget request for CMS Program Management is $4.2
billion, an increase of $108 million above fiscal year 2014. This
request will allow CMS to continue to effectively administer Medicare,
Medicaid, and the Children's Health Insurance Program (CHIP), as well
as new health insurance reforms contained in the Affordable Care Act.
With Medicare enrollment projected to grow to 55 million
beneficiaries in fiscal year 2015, CMS will require additional
resources to effectively oversee the programs. For example, the budget
requests an additional $49 million in Survey and Certification funds to
conduct mandated Federal inspections of key facilities--such as nursing
homes--serving beneficiaries. This increase is needed to complete
surveys at frequencies consistent with statutory and policy
requirements, given continued growth in the number of participating
facilities, increased survey responsibility, and inflation. The budget
improves survey frequencies for dialysis facilities, nonaccredited
hospitals, ambulatory surgical centers, and other providers.
Additionally, this budget requests funding to survey community mental
health centers for the first time.
private insurance and the marketplaces
The Affordable Care Act provides vital new protections for
consumers receiving or shopping for private health insurance. New
reforms ensured that essential care will become a standard part of most
private health insurance plans, and that consumers can continue to rely
upon their insurance when they become ill. Consumers are able to
purchase more efficient coverage due to rate review and medical loss
ratio protections. By providing one-stop shopping, the Marketplace has
helped individuals better understand their insurance options and
assisted them in shopping for, selecting, and enrolling in high-quality
private health insurance plans.
The budget includes $629 million for CMS activities and
administrative expenses to support Marketplace operations in fiscal
year 2015. For the federally facilitated Marketplace (FFM), CMS
performs eligibility and appeals work, certification and oversight of
qualified health plans, payment and financial management functions, and
operates the Small Business Health Options Program (SHOP). As a part of
this work, CMS operates a number of IT systems to support the
Marketplaces, such as the system that operates FFM functions including
eligibility, and plan management. The data services hub provides
eligibility verification services to all Marketplaces through
interfaces with trusted data sources in other Federal departments.
Other IT costs include hosting services and data management systems.
Additionally, CMS oversees operations of State-based Marketplaces
and provides technical assistance as needed. To help individuals better
understand their coverage options, CMS provides Marketplace consumer
assistance through a call center and website for the FFM, as well as
in-person support through Navigator grants.
program integrity
The fiscal year 2015 budget supports fraud prevention and the
reduction of improper payments, which are top priorities of the
administration. For fiscal year 2015, the budget invests a total of
$428 million in new Health Care Fraud and Abuse Control Program (HCFAC)
and Medicaid program integrity funds. Together the program integrity
investments in the budget will yield $13.5 billion in gross savings for
Medicare and Medicaid over 10 years. The budget also proposes
legislative changes to give HHS important new tools to enhance program
integrity oversight; cut fraud, waste, and abuse in Medicare, Medicaid,
and Children's Health Insurance Program (CHIP); and generate an
additional $1 billion in program savings over 10 years.
The HCFAC investment supports efforts to reduce the Medicare fee-
for-service improper payment rate and initiatives of the joint HHS-DOJ
Health Care Fraud Prevention and Enforcement Action Team task force,
including Strike Force teams in cities where intelligence and data
analysis indicate high levels of fraud, and the Health Care Fraud
Prevention Partnership between the Federal Government, private
insurers, and other stakeholders. CMS will also make further
investments in innovative prevention initiatives, such as the Fraud
Prevention System that analyzes all Medicare FFS claims using
sophisticated algorithms to identify suspicious behavior. In fiscal
year 2015 and beyond, CMS will continuously refine these technologies
to better combat fraud, waste, and abuse in Medicare, Medicaid, and
CHIP. Finally, these funds will support more rigorous data analysis and
an increased focus on civil fraud, such as off-label marketing and
pharmaceutical fraud.
improving the efficiency of medicare and medicaid
The budget includes a package of Medicare legislative proposals
that will save $407.2 billion over 10 years by more closely aligning
payments with costs of care, strengthening provider payment incentives
to promote high-quality efficient care and making structural changes
that will reduce Federal subsidies to high-income beneficiaries and
create incentives for beneficiaries to seek high-value services.
Together, these measures will extend the Hospital Insurance Trust Fund
solvency by approximately 5 years. The budget seeks to preserve
stability in the Medicaid program and CHIP during the first full year
of the Affordable Care Act expansion of coverage while also including
$7.3 billion in Medicaid savings and $345 million in CHIP investments
over 10 years to make Medicaid and CHIP more flexible, efficient and
accountable.
conclusion
The President's fiscal year 2015 budget request reflects the
administration's commitment to fiscal responsibility, while also
providing CMS with the resources it needs to support beneficiary growth
in Medicare, Medicaid, and CHIP, continue administration of the FFM,
and conduct effective oversight of State-based Marketplaces. Thank you
for your interest in CMS' efforts to strengthen and modernize the
Nation's healthcare system to provide access to high-quality care and
improved health at lower costs, and I look forward to continuing to
work with the subcommittee on these important issues.
Senator Harkin. Thank you, Mr. Love.
Mr. Greenberg, for the Administration for Children and
Families.
STATEMENT OF MARK H. GREENBERG, ESQ., ACTING ASSISTANT
SECRETARY, ADMINISTRATION FOR CHILDREN AND
FAMILIES
Mr. Greenberg. Chairman Harkin, Ranking Member Moran,
members of the subcommittee, thank you for inviting me to
discuss the 2015 budget proposals for the Administration for
Children and Families.
Mr. Chairman, I want to begin by thanking you for your
years of leadership and your support of ACF programs over this
time. In particular, your leadership in education for the
Nation's youngest children has been critical for Head Start and
to advancing the Nation's early education agenda. We wish you
the very best for your retirement.
Senator Harkin. Thank you very much. I am looking forward
to it.
Mr. Greenberg. ACF's budget supports programs serving our
most vulnerable children and families, including victims of
domestic violence, of human trafficking, youth and foster care,
runaway and homeless youth, and others.
In my opening statement this morning, I will focus on our
early childhood initiatives, but I would be happy to discuss
other aspects of our budget in response to your questions.
Research shows that one of the best investments we can make
in a child's life is high-quality early education. In 2015, the
President has renewed his call for investments to create a
continuum of high-quality early learning services for children
from birth through age 5. The initiative would expand voluntary
evidence-based home visiting programs, expand access to high-
quality care for infants and toddlers through Early Head Start-
Child Care Partnerships, and help States provide high-quality
preschool for 4-year-olds in low- and moderate-income families
through a partnership with the Department of Education.
We appreciate this committee's strong support for the Early
Head Start-Child Care Partnerships in 2014. Our budget requests
$650 million to support and expand those partnerships. The
funding will assist communities in increasing access to
programs that meet Early Head Start standards of quality for
infants and toddlers.
Through the partnerships, Early Head Start programs and
child care providers will work together to provide high-
quality, full-day services, offering comprehensive support to
meet the needs of working families and to prepare children for
preschool.
We are seeking an increase of $270 million for the Head
Start program in order to maintain current service levels. That
would bring the total funding for the program to $8.9 billion.
The 2015 request for the child care and development fund
involves both mandatory and discretionary funds, a total of
$6.1 billion between mandatory and discretionary. It would
support subsidies for 1.4 million children and important
initiatives to raise the quality of child care.
PREPARED STATEMENT
In discretionary funding, we are seeking an additional $57
million. We are also proposing that of the discretionary
funding, that $200 million be targeted to help States develop
higher health and safety standards, to improve monitoring, to
increase provider quality through evidence-based professional
development, and to improve access to information for parents
choosing a child care provider.
In concluding, ACF's budget strives to promote the economic
and social well-being of children, individuals, families, and
communities. It addresses critical needs in a period of limited
Federal resources.
And I would be happy to answer any questions. Thank you.
[The statement follows:]
Prepared Statement of Mark H. Greenberg
Chairman Harkin, Ranking Member Moran, and members of the
subcommittee, thank you for supporting the Administration for Children
and Families (ACF) in fiscal year 2014 and for inviting me to discuss
ACF's proposed budget for fiscal year 2015. In addition to an overview
of ACF's budget, I would like to share with you three areas in which we
are working to address important needs: (1) early childhood
development, (2) unaccompanied alien children, and (3) reducing the
over-prescription of psychotropic drugs for children in foster care.
fiscal year 2015 budget
The fiscal year 2015 budget request for ACF is $51.3 billion. ACF's
budget supports expanding access to high-quality early education to
prepare our youngest children for success in life. Funds are also
included for programs that serve our most vulnerable children and
families, including victims of domestic violence and human trafficking,
and runaway and homeless youth. In addition, the budget supports
important improvements in Head Start, Child Care, and Child Support.
The budget includes mandatory funding for a new demonstration, in
partnership with the Centers for Medicare & Medicaid Services, to
address the over-prescription of psychotropic drugs for children in
foster care. The budget also proposes to create subsidized job
opportunities for low-income parents by redirecting $602 million in
Temporary Assistance for Needy Families (TANF) funding to a Pathways to
Jobs initiative.
The fiscal year 2015 discretionary request for ACF is $17 billion,
a decrease of $637 million below fiscal year 2014, reflecting a fiscal
climate that forces difficult choices among worthy programs. The budget
advances high-quality care for infants and toddlers as part of the
President's plan to help prepare America's children for success in life
by expanding access to early education. Additional investments are also
included to continue a groundbreaking study of children at risk of
abuse or neglect and of children in the child welfare system, and to
study the prevalence of youth homelessness and the characteristics of
homeless youth in order to better advance efforts to end youth
homelessness.
early childhood development
As the President stated in his State of the Union Address, research
shows that one of the best investments we can make in a child's life is
high-quality early education. These programs can help level the playing
field for children from lower income families by improving school
readiness through increased vocabulary and social and emotional
development. In fiscal year 2015, the President renews his call for a
series of investments that will create a continuum of high-quality
early learning services for children beginning at birth through age 5.
This initiative would expand current Federal investments in voluntary,
evidence-based home visiting programs, expand access to high-quality
care for infants and toddlers through HHS' Early Head Start--Child Care
Partnerships, and help States provide high-quality preschool for 4 year
olds in low and moderate income families through a partnership with the
Department of Education.
We appreciate the strong support provided by this committee for
Early Head Start--Child Care Partnerships in fiscal year 2014. The
budget requests $650 million, an increase of $150 million above fiscal
year 2014, to support and expand the Partnerships. This funding will
assist communities in increasing access to early learning programs that
meet Early Head Start standards of quality for infants and toddlers.
The funds will be competitively awarded to new and existing Early Head
Start programs. Applicants may propose to partner with child care
providers that serve lower income children, especially those receiving
Federal child care subsidies, or to expand existing services. Through
these partnerships, Early Head Start programs and child care providers
will work together to provide high-quality full-day services that offer
comprehensive supports to meet the needs of working families, and
prepare children for preschool, in a variety of settings.
An increase of $270 million is sought for the Head Start program in
order to maintain current service levels. This will bring total funding
for the program to $8.9 billion. In addition to the EHS-CC
Partnerships, this funding level includes over $8.2 billion to provide
services for an estimated 929,000 slots for Head Start and Early Head
Start children and their families. The budget continues to include $25
million in transitional funding for the Designation Renewal System to
minimize disruption of services to Head Start children and families
during the transition period to new Head Start providers from low-
performing Head Start programs.
The fiscal year 2015 request for the Child Care and Development
Fund is $6.1 billion, which includes $3.7 billion for the Child Care
Entitlement and $2.4 billion for the Child Care and Development Block
Grant. The total funding level represents an increase of $807 million
over fiscal year 2014 in combined discretionary and mandatory funds,
and will support subsidies for 1.4 million children--approximately
74,000 more children than would otherwise be served. Of the $2.4
billion available in discretionary funds for child care, $200 million
is targeted to help States raise quality by developing higher health
and safety standards, improving monitoring, increasing provider quality
through evidence-based professional development, and improving access
to information for parents choosing a child care provider.
unaccompanied alien children
Unaccompanied alien children (UAC) apprehended trying to enter the
United States unaccompanied by a parent or guardian are among the most
vulnerable populations ACF serves. By law, ACF must accept UAC into its
care and custody upon referral from the Department of Homeland Security
or other Federal agencies. These children reside in State-licensed
shelter facilities until ACF can place them with sponsors, usually
parents or other relatives. The annual number of arriving UAC has
increased from 6,560 in fiscal year 2011 to an estimated 60,000 in
fiscal year 2014. Reasons for this increase are complex, but a key
factor is the high level of violence in Honduras, Guatemala, and El
Salvador, the countries of origin for most UAC.
In the last 3 years, ACF has streamlined its placement process,
reducing the average amount of time unaccompanied alien children spend
in shelters. ACF has cut the average length of stay for all UAC from 75
days between fiscal year 2005 and fiscal year 2011 to 35 days in fiscal
year 2014. ACF has also been able to decrease the per bed costs by 5
percent. Despite these efforts, total UAC costs have increased
significantly due to the rising number of UAC.
As directed by Congress, ACF is working with the Departments of
Homeland Security, State, and Justice--in an effort to better
understand the reasons for the increase in the number of UAC arrivals
and develop strategies for managing rising UAC costs. We appreciate the
committee's willingness to provide UAC funding based on updated arrival
estimates in fiscal year 2013 and fiscal year 2014. This action has
enabled ACF to serve all incoming UAC without reducing services for
refugees. We are continuing to monitor the flow of UAC in 2014 and will
keep the committee updated on what impact this will have for the amount
of funding needed in 2015.
addressing the over-prescription of psychotropic drugs for children in
foster care
May is National Foster Care Month, which provides us an opportunity
to reflect on the efforts we've made on behalf of the vulnerable
children we have taken into our care. Children in foster care receive a
disproportionate level of prescriptions of psychotropic medication
compared to other children receiving Medicaid. A 2011 Government
Accountability Office report using Medicaid claims from five States
found that 20 percent to 39 percent of children in foster care received
a prescription for psychotropic medication in 2008, compared with 5
percent to 10 percent of children not in foster care.
For fiscal year 2015, ACF's budget includes a request for $250
million over 5 years in mandatory funding to support State efforts to
reduce over-prescription of psychotropic medications and improve
outcomes for young people in foster care by scaling up evidence-based
psychosocial interventions, in concert with a Medicaid demonstration.
This initiative will encourage the use of evidence-based screening,
assessment, and treatment of trauma and mental health disorders among
children and youth in foster care in order to reduce the over-
prescription of psychotropic medications. This new investment and
continued collaboration will improve the social and emotional outcomes
for some of America's most vulnerable children.
conclusion
In conclusion, ACF's budget strives to promote the economic and
social well-being of children individuals, families, and communities.
This budget addresses critical needs in a period of limited Federal
resources. Again, thank you for the opportunity to discuss ACF's
proposed budget with you. I would be happy to answer any questions you
may have.
Senator Harkin. Thank you very much, Mr. Greenberg. And
thank you for your kind words. I appreciate it. And thank you
for your long work in this whole area.
Dr. Frieden, welcome back.
STATEMENT OF HON. THOMAS R. FRIEDEN, M.D., M.P.H.,
DIRECTOR CENTERS FOR DISEASE CONTROL AND
PREVENTION
Dr. Frieden. Thank you very much, Mr. Chairman, Ranking
Member Moran, and members of the subcommittee. We appreciate
this opportunity to share with you our plans for the coming
year. And we thank you for your support in 2014, and I will be
able to discuss how some of that support is already being
brought to bear to protect Americans better.
CDC works 24/7 to protect Americans from threats, whether
they come from this country or anywhere in the world, whether
they are infectious or noncommunicable, whether they are
intentional manmade or naturally occurring.
Last week, the U.S. had its first case of MERS coronavirus,
the Middle East Respiratory Syndrome, which has been highly
lethal in several countries of the Middle East and has been
exported to countries in Europe.
This is the first case we had in the U.S. It was in a
traveler who went from Saudi Arabia to London to Chicago and
took a bus to Indiana, where he has been hospitalized.
And this really emphasizes that we are all connected by the
air we breathe, by the water we drink, by the food we eat. And
diseases anywhere are just a plane ride away.
One of the things we do at CDC is to respond to
emergencies. And a few years ago, the U.S. Ambassador to Africa
said to me that CDC is the 911 for the world, and I thought,
that is wonderful, but really, what we want to do is make sure
that countries all over the world have their own public health
911, so that they can find, stop, and prevent health threats at
the source.
That will protect us better. That will protect them better.
And that is what our Global Health Security Initiative is for
the 2015 budget proposal.
This will allow us to do better at finding and stopping
things like Ebola. We currently have a team in West Africa. The
first time West Africa has had an Ebola virus outbreak. It has
been large, highly lethal.
And outbreaks like this destabilize countries. They kill
people. They also undermine economic development. And they
affect us in the United States.
In fact, the SARS (Severe Acute Respiratory Syndrome)
outbreak 10 years ago cost the world more than $30 billion in
just 3 months. So we have plenty of good reasons to invest in
global health security, and the 2015 request is for a $45
million expansion of what we have done in 2013 and 2014 to
better protect countries and better protect ourselves by having
a safer world.
The second major initiative that we are proposing for 2015
is addressing a second growing threat to Americans, and that is
antimicrobial resistance, drug-resistant bacteria.
We are seeing now at least 23,000 deaths, at least 2
million illnesses, about $20 billion in healthcare costs in the
U.S. from drug-resistance. We are losing really our last lines
of defense. These are miracle drugs.
I am trained as an infectious disease physician. I
practiced before there was treatment for HIV (human
immunodeficiency virus), and then I saw the wonders of HIV
treatment, and how that transformed the world. I worked in
tuberculosis control for many years and I, unfortunately, took
care of patients for whom there were no drugs to treat.
We are potentially facing a challenge that we will have no
drugs to treat common infections, if we don't address
antimicrobial resistance more effectively and urgently. And we
are confident that we can make real progress.
Our 2015 request is for $30 million, a 5-year program that
we are confident will be able to cut two of the most deadly
threats in terms of microbial threats to the U.S., what is
called CRE, or carbapenem-resistant enterobacteriaceae, and C.
difficile. Each of these is a very big problem. We think we can
cut them in half in 5 years with this support, as well as
reducing other problems. Just for one of those conditions, that
would save $2 billion over 5 years.
The third major new initiative we are proposing is on
prescription opiate abuse, and this is a huge problem. It is
one of the very few problems that is getting worse in terms of
health in this country. We have had a fourfold increase in the
number of people dying from prescription opiate abuse, and that
is related to a large increase in prescriptions of these drugs,
which are very important for drugs for patients with pain
palliation, such as those with terminal cancer, but are being
overused to a very great extent.
We are confident that with this resource, what we will do
is support States to do a better job helping patients and
helping doctors use these dangerous medications as effectively
as possible, and drive down overdoses and overdose deaths.
PREPARED STATEMENT
So I want to thank you again for your support in 2014. We
are already using the support you gave us through the Advanced
Molecular Detection Initiative to do rapid sequencing of the
MERS coronavirus case that is already in the U.S. so we can
better understand that case. So thank you for that. Public
health really is the best buy, and I very much look forward to
answering your questions.
[The statement follows:]
Prepared Statement of Thomas Frieden, M.D., M.P.H.
Good morning, Chairman Harkin, Ranking Member Moran, and other
distinguished members of the subcommittee. It is a pleasure to appear
before you as Director of the Centers for Disease Control and
Prevention (CDC), the Nation's leading health protection agency and an
operating division of the Department of Health and Human Services, to
discuss CDC's fiscal year 2015 budget request. Today I would like to
focus on how CDC works 24 hours a day, 7 days a week to protect
Americans from health threats, and how we propose to make even more
progress in fiscal year 2015. We thank this committee for supporting
CDC through your 2014 appropriations.
CDC works 24/7 to keep America safe from health, safety, and
security threats, both foreign and domestic. Whether diseases start at
home or abroad, are chronic or acute, curable or preventable, human
error or deliberate attack, CDC fights disease and supports communities
and people to do the same. For fiscal year 2015, CDC has requested
additional funding to accelerate the fight against three growing
threats--the risk of infectious disease threats from around the world,
growing resistance to antibiotics, and the increasing epidemic of
prescription drug overdose.
working to provide health security 24/7
CDC helps save lives 24/7 by preventing, detecting, and controlling
the growing risks of infectious disease outbreaks, emerging infectious
diseases, drug-resistant bacteria, and natural and manmade hazards and
disasters. We provide emergency response support, technical expertise,
and critical rapid development of prevention technologies, including
vaccines and other medical countermeasures.
CDC provides boots on the ground presence in the United States and
throughout the world, supported by our state-of-the-art laboratories,
which are critical to our Nation's safety and health. With this
committee's support, CDC is now building our advanced molecular
detection capacity, unlocking microbial genomes to track and stop
outbreaks more effectively, and finding new ways to prevent these
outbreaks in the first place.
CDC's response to diseases such as influenza, salmonella,
hantavirus, HIV, and Ebola are highly visible ways CDC protects the
public from health threats, but it is often what the public does not
see every day that keeps Americans safe from ever-present health
threats. CDC plays a pivotal role in our country's ability to respond
to and mitigate potentially catastrophic events--such as pandemics,
natural disasters, and acts of bioterrorism--by ensuring that local,
State and global public health systems are prepared for public health
emergencies and by working to keep health threats from entering our
country.
CDC plays another critically important role protecting Americans
from the leading causes of death and disability. CDC applies life-
saving solutions that work to drive down the incidence of costly
diseases and improve the lives of Americans.
CDC leads prevention and health promotion efforts to improve health
and reduce chronic diseases such as heart disease, cancer, and
diabetes, which account for 75 percent of the $2.7 trillion in
healthcare costs spent in the United States each year. Together with
State and local partners, CDC deploys proven interventions to build
healthier communities. For example, CDC worked with Centers for
Medicare & Medicaid Services (CMS) and private-sector partners to
launch the Million Hearts initiative, which will prevent one million
heart attacks and strokes by 2017 through proven strategies such as
improving blood pressure control and promoting smoking cessation. Our
efforts to control chronic diseases are expanding in 2014, thanks to
the support of this committee.
keeping america and the world safe through global health security
Diseases and disasters know no borders; we are all connected by the
air we breathe, the water we drink, and the food we eat. CDC deploys
scientists and disease detectives globally 24/7, because outbreaks that
start in remote corners of the world can travel here as quickly as a
plane can fly. Detection and response time is critical. Diseases
infecting people around the world in the past 10 years--such as MERS
Coronavirus, SARS and H1N1 and H7N9 influenza--cost lives and caused
enormous economic disruption. These and other diseases have far-
reaching health, economic, political, and trade implications. Less than
a week ago we confirmed our first MERS case in the United States, and
CDC has a team on the ground helping to prevent the spread of that
deadly virus.
Our fiscal year 2015 budget requests $45 million to support
expanded global health security activities. Over the next 5 years, CDC
and U.S. Government partners, including the Departments of State and
Defense, will work with up to 30 countries to protect at least 4
billion people through global health security efforts. As an important
step toward this larger goal, CDC's funding request will allow us to
partner with up to 10 countries in fiscal year 2015 to advance global
health security, building on successful demonstration projects in
Uganda and Vietnam, as well as others currently underway. CDC will help
countries find threats faster, stop them closer to the source, and
prevent them wherever possible.
fighting antibiotic resistance
Antibiotic resistance--when bacteria do not respond to the drugs
designed to kill them--threatens to return us to the time when simple
infections were often fatal. Today, antibiotic resistance causes more
than 23,000 deaths, more than 2 million illnesses, and up to $20
billion in healthcare costs in the United States each year. Tomorrow
could be even worse: A simple cut of the finger could lead to a life-
threatening infection; routine surgical procedures, such as hip and
knee replacements, would be far riskier; and common complications of
life-saving treatments such as chemotherapy and organ transplants could
prove fatal.
Now is the time to address this threat. CDC's 2015 budget request
includes $30 million to detect and protect against antibiotic
resistance. With strategic investment over the next 5 years, CDC can
turn the tide on the most dangerous of these infections, including
reducing infections with CRE--the nightmare bacteria--by 50 percent and
reducing C. difficile infections by 50 percent. Reduction in C.
difficile alone will save 20,000 lives, prevent 150,000
hospitalizations, and cut more than $2 billion in healthcare costs.
Achieving these goals requires investments in laboratory capacity to
detect resistance across the Nation, implementing best practices for
infection control in healthcare settings, and improving antibiotic
prescribing practices.
reversing the prescription drug overdose epidemic
We are witnessing a new epidemic rapidly unfold in America: deaths
from prescription painkiller overdoses. Prescription painkiller
overdose deaths increased four-fold between 1999 and 2010, killing more
people than all illicit drugs combined--including cocaine and heroin.
The prescription drug overdose epidemic is driven in large part by
fundamental changes in the way healthcare providers prescribe opioid
pain relievers. We can prevent abuse of prescription drugs while at the
same time making sure patients receive safe, effective, and appropriate
pain treatment. CDC's fiscal year 2015 budget requests $16 million to
work with States and the healthcare system to begin to reverse this
epidemic.
As the Nation's health protection agency, CDC has led the way in
identifying the connection between inappropriate opioid prescribing and
resulting overdose deaths. CDC's proposed investment would target
States with the highest burdens of prescription drug overdose to
implement proven strategies to reverse the trend, including assisting
insurers and clinicians in improving coordination of care for high-risk
patients; supporting development and effective use of universal, real-
time, and actively managed prescription drug monitoring programs--
State-run prescription tracking databases; and evaluating State
programs and policies to build the evidence base for overdose
prevention.
Public Health Challenges in a 24/7 World
In the next few years, CDC and our Nation must face both new and
ongoing challenges to protect our health security in a time of fiscal
constraint. We must accurately detect and quickly respond to numerous
and unpredictable disease threats, whether natural or man-made. We must
also ensure that CDC is able to protect Americans from the leading
causes of death and disability that weaken our economic productivity
and global standing. Thank you for your continued support of CDC's
important work to serve this Nation, and I am happy to answer your
questions.
Senator Harkin. Thank you, Dr. Frieden.
Dr. Wakefield.
STATEMENT OF HON. HONORABLE MARY K. WAKEFIELD, PH.D.,
R.N., ADMINISTRATOR, HEALTH RESOURCES AND
SERVICES ADMINISTRATION
Dr. Wakefield. Good morning, Mr. Chairman. Before I begin,
I too want to acknowledge your upcoming retirement and
personally thank you for the support you have given to the
programs that are operated through the Health Resources and
Services Administration across the years. Clearly, you place a
high priority on the communities and the populations that are
served by these programs. So thank you for that.
I should also provide a little bit of a shout-out to your
staff. Over the years, too, they have just been terrific, both
in advancing your goals and the goals of this committee.
With that, Mr. Chairman, Ranking Member Moran, and members
of the committee, thank you for the opportunity to testify
today on behalf of the Health Resources and Services
Administration.
HRSA is the primary Federal agency charged with improving
access to healthcare services for people who are medically
underserved because of their economic circumstances or because
of geographic isolation or serious chronic diseases, among
other factors.
To address these issues, HRSA's programs work through
partnerships. We engage in partnerships with States, community-
based organizations, academic institutions, healthcare
providers, and others to strengthen the Nation's primary care
infrastructure, to bolster the healthcare workforce, and to
achieve health equity.
I want to take just a few minutes to provide the committee
with an overview of HRSA's priorities for fiscal year 2015.
In terms of strengthening the primary care infrastructure,
our community health centers program support community-based
organizations that provide comprehensive primary care services
in medically underserved communities.
Health centers provide a really wide range of services,
medical services, dental, behavioral services. And frequently,
those services are located in one setting.
I think it is important to note, too, that when it comes to
health centers and that infrastructure, nearly half of all of
them are located in rural communities.
The HRSA budget includes $4.6 billion for the health
centers program. This funding will enable us to serve about 31
million patients, and that is an increase from about 21 million
patients that were reported in our most recent data.
That care is provided through 9,500 service delivery sites,
and those sites stretch across the Nation. They are in every
State, in the District of Columbia, Puerto Rico, the U.S.
Virgin Islands, and the Pacific basin.
In fiscal year 2015, $100 million is allocated to fund 150
new health center sites that will serve an additional about
900,000 patients.
HRSA also has a priority focus on supporting a highly
skilled healthcare work force through health professions
training, through curriculum development, and through
scholarships and loan repayment programs.
In order to increase the availability of high-quality care,
HRSA health workforce programs provide targeted support for
health professions, and for parts of the country where
shortages of health professionals exist.
To this end, the HRSA budget includes a new workforce
proposal to increase the supply of needed healthcare providers
that are well distributed across the country.
One of our most important primary care workforce programs
is the National Health Service Corps. The corps works to build
healthy communities by supporting qualified health providers
dedicated to working in rural and urban areas of the country
where shortages of healthcare providers persist.
Employed by local primary healthcare sites including rural
health clinics and community health centers, National Health
Service Corps technicians work every day to promote health and
to treat illness and injury. In this case, too, nearly half of
all our current corps providers work in rural communities.
To meet the needs of both rural and urban underserved
populations, the President's budget includes the largest
increase in funding in the history of the National Health
Service Corps, and it is projected to support an annual field
strength of more than 15,000 providers from fiscal year 2015
through 2020. These are providers who will meet primary
healthcare needs of more than 16 million patients.
HRSA's health workforce funding will also support a new
competitive grant program, the Targeted Support for Graduate
Medical Education Program. This new program will fund teaching
hospitals, children's hospitals, and community based consortium
of teaching hospitals and other healthcare entities in order to
expand residency training with a focus on ambulatory, primary,
and preventive care.
Also integral to ensuring that vulnerable populations have
access to critical health services is the Ryan White HIV/AIDS
program. We now know that people living with HIV who are on
drug treatment and are virally suppressed are much less likely
to transmit the infection to others.
By helping people to stay in care and adhere to their
antiretroviral treatments, the Ryan White HIV/AIDS program
plays a critical role in preventing the spread of HIV.
Armed with this knowledge, the Ryan White program supports
the national HIV/AIDS strategy of reducing transmission by
serving patients across the care continuum.
HRSA also administers a number of other critically
important healthcare programs that collectively touch the lives
of millions of people across the country, including poison
control centers, national programs for countermeasures and
vaccine injury compensation, and Federal organ and blood stem
cell transplantation.
PREPARED STATEMENT
Across the agency, we take seriously the stewardship of our
programs and our responsibility for the funds that are awarded
to grantees and communities. And over the last few years, we
have developed a number of strategies to ensure the integrity
of the programs that we operate.
Thank you again for providing me with the opportunity to
share our work with you today, and I too will be pleased to
answer questions.
[The statement follows:]
Prepared Statement of Mary K. Wakefield, Ph.D., RN
Chairman Harkin, Ranking Member Moran, and members of the
subcommittee, thank you for the opportunity to testify today on the
Health Resources and Services Administration's (HRSA) budget request
for fiscal year 2015. HRSA is the primary Federal agency charged with
improving access to healthcare services for people who are medically
underserved because of their economic circumstances, geographic
isolation, or serious chronic disease. Our fiscal year 2015 budget
addresses these issues by providing critical investments in programs
that bolster our primary care infrastructure, strengthen the healthcare
workforce, and improve health equity.
bolster primary care infrastructure
To bolster the Nation's primary care infrastructure, the budget
includes $4.6 billion for the Health Center program, which supports
community-based, patient-directed organizations that provide
comprehensive primary care services in medically underserved
communities. Health centers provide a wide range of medical, dental,
and behavioral services, often making all of these services available
at one location. It is important to note that nearly half of all health
centers serve rural populations. The fiscal year 2015 investment will
allow health centers serve approximately 31 million patients, at nearly
9,500 service delivery sites and provide care in every State, the
District of Columbia, Puerto Rico, the United States Virgin Islands,
and the Pacific Basin. The budget also allocates $100 million to fund
150 new health center sites that will serve an additional 900,000
patients.
strengthen healthcare workforce
HRSA is also charged with strengthening the healthcare workforce by
supporting the education and distribution of a highly skilled primary
care workforce through training, curriculum development, and
scholarship and loan repayment programs. To this end, the budget
provides $1.8 billion for health workforce programs and makes new and
strategic investments to strengthen our supply of healthcare providers
that are well-distributed throughout the country.
One of our most important primary care workforce programs is the
National Health Service Corps. Employed by local rural health clinics,
community health centers, and other primary care sites, Corps
clinicians work every day to promote health and treat illness and
injury in rural and urban areas of the country where access to care is
limited and where shortages of healthcare professionals persist. Nearly
half of all current Corps providers work in rural communities. The
President's budget includes $810 million for the Corps in fiscal year
2015, which represents the largest level of funding in the history of
the Corps. This level of funding is projected to support an annual
field strength of more than 15,000 providers over fiscal years 2015-
2020 and serve the primary healthcare needs of more than 16 million
patients annually.
HRSA will also invest in our Nation's health workforce through the
new Targeted Support for Graduate Medical Education (GME) program,
which will expand residency training in primary care and other high-
need specialties with the goal of encouraging innovation in training
models and greater accountability for GME funds. This program will
support 13,000 residents over 10 years through competitive grants to
teaching hospitals, children's hospitals, and community-based consortia
of teaching hospitals and/or other healthcare entities.
The budget also invests $144 million to develop the Nation's
nursing workforce through programs that, among other strategies,
support the enhancement of advanced nursing education and practice,
increased nursing education opportunities for individuals from
disadvantaged backgrounds, and an expanded nursing pipeline. The budget
also provides for two new workforce initiatives, including $10 million
to support a new Clinical Training in Interprofessional Practice
program to increase the capacity of community-based primary healthcare
teams to deliver quality care. In addition, $4 million is provided to
fund new Rural Physician Training grants to help rural-focused training
programs recruit and graduate students likely to practice medicine in
rural communities.
achieve health equity
HRSA considers our work with special populations and eliminating
health disparities a top priority. The budget includes $2.3 billion for
the Ryan White HIV/AIDS Program to improve and expand access to care
for persons living with HIV/AIDS. As a payor of last resort, the Ryan
White Program funds services not covered by health insurance but which
are nonetheless critical to ensuring that individuals living with HIV
are linked into care and started on anti-retroviral drug regimens. Due
to the Affordable Care Act, many Ryan White clients will continue to
gain access to health insurance or see improvements in their current
health insurance coverage in fiscal year 2015. In response to these
changes, as well as the evolving nature of the epidemic, the Federal
Government will continue to coordinate closely with State and local
governments and Ryan White Program grantees to ensure that vulnerable
populations living with HIV have regular access to quality HIV care and
life-extending medications.
The budget also proposes better serve the needs for women, infants,
children and youth by consolidating funds from Part D of the Ryan White
program to Part C. The consolidated program will emphasize care across
all vulnerable populations and will allow resources to be better
targeted to points along the HIV care continuum and to populations most
in need throughout the country.
One of our largest programmatic areas focused on special
populations is our maternal and child health programs. The HRSA budget
includes funding through fiscal year 2024 to extend and expand the
Maternal, Infant, and Early Childhood Home Visiting program, through
which States are implementing evidence-based home visiting programs
that enable nurses, social workers, and other professionals to work
with at-risk families and to connect them to assistance that supports
the child's health, development, and ability to learn. These programs
are strictly voluntary and have been shown to improve maternal and
child health and developmental outcomes, improve parenting skills and
school readiness.
In addition to the investments in health centers and the National
Health Service Corps that will improve access to healthcare in rural
areas, the budget provides $125 million for targeted programs to assist
Americans living in rural communities through the HHS Office of Rural
Health Policy, which is housed within HRSA. The Office serves as the
Department's primary voice on rural health issues and funds a number of
State and community-based grant and technical assistance programs to
help meet the healthcare needs of rural communities.
HRSA also makes investments in a number of other critically
important healthcare programs that collectively touch the lives of
millions of people across the country. These include the 340B Drug
Pricing Program, which provides discounts on outpatient prescription
drugs to program that serve a high number of low-income patients, and
efforts to support Federal organ and transplantation oversight, as well
as efforts to promote awareness of organ transplantation issues and
increase organ donation rates.
conclusion
In fiscal year 2015, HRSA will continue its efforts to strengthen
the safety net by expanding and enhancing primary care services,
primary care health professionals, services for low-income individuals
and people with serious health conditions, such as HIV/AIDS or in those
in need of an organ transplant. We will continue to leverage our work
on important health services for mothers and children, and targeted
health professions training. HRSA will also continue to work in
partnership with other Federal entities, State and local governments,
private organizations, and Members of Congress to strengthen access to
care with the aim of improving the health of millions of Americans.
Thank you again for providing me the opportunity to discuss HRSA's
fiscal year 2015 budget with you today. I am pleased to respond to your
questions.
Senator Harkin. Thank you very much, Dr. Wakefield.
We will now start a series of 5-minute questions, and I
will start off.
EARLY HEAD START-CHILD CARE PARTNERSHIPS
Mr. Greenberg, I want to start with you, the Administration
for Children and Families. The budget request includes $150
million to expand Early Head Start, including the new Early
Head Start and child care partnerships. This subcommittee had
provided $500 million for the same purpose last year. I
understand the grant competition for these fiscal year 2014
funds will be announced in the next couple weeks. There is a
lot of excitement and interest in communities across the
country, because of this.
So could you talk, just very briefly, about ACF's vision
for these new Early Head Start-Child Care Partnerships,
because, as I understand it, what we were trying to do,
obviously, in promoting more Early Head Start, we recognize
that there are a lot of different providers of child care out
there. They are doing good jobs, too, but we want them to be
coordinated with Early Head Start, not one-size-fits-all, but
how can we start coordinating it, so these kids are ready to go
to kindergarten, basically, and first grade? Is that the idea?
Mr. Greenberg. Thank you, Mr. Chairman. Yes, it is.
I should say, we are very excited about the Early Head
Start-Child Care Partnerships, and we have been struck over the
last number of months, as we have talked and worked with Head
Start programs and child care programs, and those interested in
early childhood across the country, how much excitement there
is.
Mr. Chairman, as you indicate, the basic concept is that
there are very high standards that apply in the context of
Early Head Start, but only a very small number of eligible
infants and toddlers are able to participate in the Early Head
Start program. A much larger number are in child care settings
across the country, and the child care settings vary
considerably in their quality.
The vision for the partnerships is that Early Head Start
providers will actively work with child care providers in their
communities. In doing so, that will ensure that Early Head
Start services can be provided to children in child care
settings, and at the same time, there is a potential to use
this as a way of raising the overall quality of child care that
can benefit a much larger group of children.
So we are excited about it. There is tremendous enthusiasm
in the field. We are expecting a strong and vigorous
competition. And we are seeking additional funding, because we
know that in this first round of competition, we will only be
able to respond to what is likely to be a fraction of the
interest that is out there in moving this direction.
Senator Harkin. Thank you very much, Mr. Greenberg.
GLOBAL HEALTH SECURITY
Dr. Frieden, we included $7.5 million in last year's
omnibus for CDC to establish national public health institutes
in developing countries. A lot of this came about because of a
trip I took with you to Africa one time. And what we saw was a
lot of fragmentation in these countries, different departments
doing different things and taking a long time to determine what
was causing an outbreak, or where it was located, how it was
being transmitted.
So the idea was to help set up CDC-like structures in other
countries. As you know, CDC sort of sets the standard for the
world. I noticed China has even called its own public health
institute the China CDC. That speaks volumes.
So we put that $7.5 million in there. It was, hopefully, to
start this, to make your agency's job easier when there are
disease outbreaks. So now the budget for next year zeroed out
this initiative.
So tell me what that is all about. And how does your budget
request for $45 million for global health security fit in with
this initiative?
Dr. Frieden. Thank you very much, Senator Harkin. Thank you
for your leadership on this and so many other issues. I think
your understanding and commitment to public health have been
extraordinarily helpful in getting us the progress that we have
made.
And as we have seen when we go around the world, the
leading question I am asked is how can we have our own CDC?
With these resources, we have put out a call and asked
countries what they would like to do.
We have more than 30 countries interested in doing more in
this area. We anticipate giving five countries cooperative
agreements to expand an existing public health institute and
make it more of an effective program, and three countries to
begin that planning process so they can have something in the
future.
The budget always has hard choices, and we wish things
could be in this that aren't. However, I do think there is a
synergy between the Global Health Security Initiative and
national public health institutes. Global health security is
about helping other countries best find, stop, and prevent
disease outbreaks within their borders.
In order to do that, they need a laboratory network. They
need trained epidemiologists. They need emergency operations
centers. They need a way of operating. And to do that, they
have to have effective national public health institutions.
So I think there is a great deal of synergy between these
programs. Resources are not what we would all wish they would
be for the kind of programs that we would like to run, but I do
think the national public health institutes program is a very
important one.
Senator Harkin. My time has run out. I want to follow up on
that, maybe in the next round, because, one, it seems to me it
is facilities, bricks and mortar, laboratories. It seems like
the other one is setting up systems. And I don't know how that
is working out with both of these.
Senator Moran.
Senator Moran. Mr. Chairman, thank you very much. In
deference to my colleague from Nebraska who has an Ag Committee
hearing, I will yield my time to Senator Johanns.
Senator Johanns. I thank the ranking member. Sometimes we
are called to be in two places at once, and I appreciate it,
because that is an important hearing also.
Let me just start out and say, thank you for being here.
We, certainly, appreciate it.
I would like to offer a comment, though, about the absence
of Secretary Sebelius. I have been in the chair of a Cabinet
Secretary before. I am astonished, absolutely blown away, that
she is not here today.
I am a fairly new member to the Appropriations Committee,
and I can't think of more important work than what we do. We
guard the taxpayer's dollar.
We not only look forward in these hearings to what is
coming in the next year. We look back at how those dollars were
spent in the past year. So I am very troubled by the fact that
she is not here.
It is part of the job of being a Cabinet Secretary. I had
the honor of being a Cabinet Secretary. And at one point in
that career, the chairman of this committee was also my
chairman of my committee of jurisdiction.
There never would have been a day where, if I was asked to
appear before a committee he was chairing, that I would not
have attended. That simply would not have happened.
Most importantly, what we do here is we try to assure
Nebraskans and people across this country that tax dollars are
spent wisely.
I can tell you, having been in your chair many times, I am
not sure I would describe it as a pleasant experience, but it
was important that I defended the priorities in the budget that
I proposed to Congress.
And as long as I was Secretary, there was no one else that
could replace my presence.
So by not being here, Secretary Sebelius and, I feel, the
White House, too, because they could direct that she be here--
is sending the message that somehow they are not accountable,
not accountable to me, not accountable to my colleagues, but
most importantly, not accountable to the American taxpayer.
Leadership is not about convenience and being available
when it works into someone's schedule. It is about accepting
responsibility for the job you have taken on.
The fact of the matter is that this budget was compiled
under the Secretary's watch. No one else's. She was in charge.
Not only that, she is still running this agency.
Unfortunately, her absence speaks volumes about lack of
transparency.
The Secretary's time at HHS has, certainly, not been a
picture of success. Last month, a nonpartisan Congressional
Research Service report revealed that the administration has
failed to meet more than half--more than half--of the 83
statutory deadlines required under Obamacare. She is the
Secretary. I should have the right to ask about that. And the
Department of HHS was responsible for virtually all of those
missed deadlines.
This administration has unilaterally delayed or changed
parts of the healthcare law more than 20 different times.
Again, virtually all of these delays are under the jurisdiction
of HHS. So we have a slew of missed deadlines, changes to the
law that, quite honestly, we haven't approved in Congress.
But if anything, that would underscore the importance of
her being here, to justify that, to tell me why she thinks she
has the ability to do that.
Last year during the appropriations process, I actually
offered an amendment that required HHS to be more transparent
in spending on Obamacare. I was very pleased that the language
was included in the final appropriations package.
It required the Department to submit in this year's budget
request an outline of the sources of funding used to implement
the healthcare law's exchanges, and specifically how the
Department used that money. But she is not here to answer for
that. Unbelievable.
I don't believe the HHS budget came close to following
those requirements, and I have the requirements right here. Why
should I not be entitled to ask her about that?
So I want to reiterate my disappointment. I think it was
important that I use my time to express this. I hope somehow
the message gets back to the White House that we are serious
about oversight. We are serious about transparency. And we are
serious when we ask Cabinet members to attend our hearings.
Mr. Chairman, thank you very much.
Senator Harkin. Thank you, Senator Johanns.
And while we might have some disagreements on certain
things, we both agree on one thing: It is time to retire.
Senator Johanns. And we are.
Senator Harkin. Senator Mikulski.
Senator Mikulski. Thank you very much, Mr. Chairman. Thank
you for holding this hearing.
I wanted to come for several reasons. One, of course, is
our responsibility to do due diligence on these budgets. But
also to thank the men and woman at this table and the people
who work at the agencies that they are the executive leadership
of. I want to thank them for their service.
In each and every way and every day, our country is better
and safer, and our children's lives are brighter, because of
your leadership, your executive ability, your trying to guide
us during great times of budgetary turmoil and uncertainty. And
then facing sequester, facing furloughs, facing uncertainty,
and facing a rather skimpy cost-of-living increase.
So I want to thank you. I want to thank people at each and
every one of these agencies for the job that you do. And I know
the other day, they gave the so-called Sammies awards for
thanking people for their service, but we can't do the job we
want to without that.
Each and every one of you, we could have had a separate
hearing on the work that you do, from the CDC, to CMS, to
Children, and HRSA, et cetera.
But today, because of a sense of urgency to really hold our
hearings, do our due diligence, and be able to avoid a lame
duck, we are working on a bipartisan, bicameral basis to
restore regular order.
I want to thank Senator Shelby, for all of his cooperation,
and then my chairs and my ranking, to be able to accomplish
this.
Our goal is to be able to move our committees in an
expeditious way, and then to be able to complete our work by
October 1. It is a bodacious, audacious effort, because it has
not been done since 1996. Since 1996, the Congress of the
United States has not completed this. So we are going to give
it a go, and we are going to give it a try.
ADMINISTRATION FOR CHILDREN AND FAMILIES' FISCAL YEAR 2015 BUDGET
REQUEST
I am going to focus my time, though, with you, Mr.
Greenberg. Ordinarily, I go with health and talk to CMS, talk
to CDC, and talk to HRSA. But I am going to focus on you today
for two reasons: One, early childhood; and then the other, the
unaccompanied children.
I want to thank Senators Alexander, Shelby, Harkin, and
Burr. We led a bipartisan effort here on children.
First of all, in last year's appropriation, we put money
into Head Start, and we did it by working together. And you
felt that plus-up. So we say Congress did. This is the Congress
that did it. This is the Congress that did it.
And then working on a bipartisan basis, we passed the Child
Care Development Block Grant (CCDBG) that had not been
reauthorized in, again, over 20 years, by working together.
So let me get to my question. Is this budgetary request--
first of all, let's go to the CCDBG grant--enough resources to
implement the new authorizing legislation that was passed on a
bipartisan basis, particularly on the quality initiatives?
Mr. Greenberg. Thank you, Senator Mikulski, for your
comments. I first just want to recognize how much we appreciate
the bipartisan support in the appropriations process and the--
--
Senator Mikulski. We appreciate the thanks, but I have 5
minutes.
Mr. Greenberg. Okay, so for the requirements of the bill
that would strengthen health and safety, and strengthen
consumer education, and strengthen a number of other aspects of
State performance, States, if their funding is limited, States
will need to make judgments within their block grant funds
around prioritizing.
Senator Mikulski. I am getting lost here. Do you have the
money or don't you? I mean, is this enough or not?
Mr. Greenberg. The budget request that the administration
made was one that was recognizing the importance of additional
funding for child care, both for access and for quality. It is
also a budget request that is necessarily constrained by the
figures that we are operating within.
Senator Mikulski. Can we go to the Head Start program? You
say the additional $270 million will maintain current service
levels.
Now, we love the President's new initiative. But what we
feel right now is we have to keep going on that which we have,
where we don't have new programs, new regs, new compliance
standards, but keep that which we are doing.
Now is this Spartan, skimpy, or do you think adequate?
Because there is a code word here: To maintain current service
levels. I am concerned about this, that it is not really
enough. And, again, there is strong bipartisan support for Head
Start here.
And I might say, on the other side of the dome, too.
Mr. Greenberg. Sure. And in the Head Start request, we did
structure it in order to maintain current services, certainly,
to go further than that would have required additional funding.
And we were constrained in what we could request in
discretionary funding.
Senator Mikulski. So what I hear you saying is that what we
are doing here is good, but it is going to be barely enough to
meet that which we already have on the books.
I am not trying to put you on the spot.
Mr. Greenberg. Sure.
Senator Mikulski. So let me then go to unaccompanied
children. I am really frustrated about this.
Colleagues, I would really ask you, knowing your concern,
both as Senators and fathers, and so on, we have children
pouring over the border from Central America. These are
unaccompanied children. We have, like, boat people, but they
are border children.
They are pouring over the border. The numbers are
escalating. When they come over, HHS picks up these children.
We don't want to warehouse them. We try to put them in foster
care.
They are being sent by their families to escape the
violence in Central America.
There was a little girl from Ecuador who, when she was
moved to a shelter, hung herself in the shower. And she had
been on the road all by herself, and she was 11 years old, and
she had been on the road for 2 months.
Now Sebelius called me when I was doing the omnibus, asked
for more money because they didn't have it. They underestimated
the numbers.
So we put in more money. Barbara Mikulski, a social worker,
working with Richard Shelby, who was not going to leave
children warehoused in Quonset huts, and, I must say Hal Rogers
and Nita Lowey, we put the money in.
Now, I have been saying to the Administration, ``Tell me
what you need, and don't stick us with the bill at the end.''
And I feel that you are not telling me what you need. I really
don't feel that HHS is telling me what you need.
So you have gone from--and I say this to my colleagues,
please go to page 5 of the testimony--in 2011, it was 6,500
kids. In fiscal 2014, it was 60,000. We have gone from 6,500 to
60,000, and everybody is saying you can't give me the numbers
because you can't make the estimates.
Well, what do you think?
Really, I have taken this up to Sebelius. I have taken it
up to Burwell. I am taking it to John Kerry. Senator Harkin has
done the same. I know I have the support from--we just need to
know.
We have to look out for these children while we work on
root cause. I have been down to root cause before. While we
were working on root cause, we still have thousands of
unaccompanied children whose parents paid coyotes and someone
to bring them over the border to safety.
Mr. Greenberg. So, as you indicated, Senator, the numbers
have gone up very dramatically over the period since 2011. And
the numbers continue to grow.
The children are principally children from Guatemala and
Honduras and El Salvador. The best indications are that there
are a mix of reasons, that the violence that is occurring in
these countries appears to be a significant contributing
factor. Additional factors are economic conditions, and in some
cases, family reunification. So there are a set of reasons. But
the numbers do continue to grow.
For HHS, our responsibility is----
Senator Mikulski. Mr. Greenberg, I so respect you. You have
such a long history of fighting poverty. But if HHS does not
receive enough funding for this program where we have
adequate--not adequate--we need real projections.
The Department of Homeland Security could end up holding
these children in cells intended for adults unless we come to
grips with what are we going to do and how we are going to
bridge this while we are looking at the root cause.
So I don't want to take the time of my colleagues. Members
have been waiting patiently. Senator Harkin did this. I am
going to stop.
But this is a humanitarian crisis, and we have to go to the
edge of our chairs to at least get the estimate for fiscal year
2015.
Thank you, Mr. Chairman. I just felt the committee needed
to be aware of this because this is not only a funding problem,
it is a humanitarian crisis. But our failure to appropriate
could exacerbate the humanitarian crisis.
Mr. Greenberg. Senator Mikulski.
Senator Mikulski. I need numbers. Thank you very much. My
time is up.
Senator Harkin. Senator Moran.
Senator Mikulski. Thank you. And thank you, colleagues. I
really think this is a new hot potato here.
Senator Harkin. A huge issue. And it is a funding issue
that confronts not only HHS, but also Homeland Security, too.
Senator Mikulski. And the Department of State.
Senator Moran. Mr. Chairman, thank you very much.
I apparently established a precedent. I am going to soon
yield to the ranking member, the Senator from Alabama.
But, Madam Chair, while you and your colleagues,
counterparts in the House, and Senator Shelby, work on trying
to figure out the gap of $4 billion in the Federal Housing
Authority that creates huge problems for all of the
appropriations process, this, in my view, is the issue in this
subcommittee that is very similar--a $1.1 billion gap, we
believe, that somehow needs to be addressed, based upon the
tremendous humanitarian need.
And while all of us are sympathetic broadly to humanitarian
needs, particularly when it comes to children, it is
exacerbated. So it is a high priority.
But my point would be: We have a similar problem to what we
have in Federal housing here in this budget as a result of this
issue.
Let me yield the balance of my time to the Senator from
Alabama, the ranking member.
Senator Shelby. Thank you.
Thank you, Chairman Harkin.
First of all, I want to just restate what I have said many
times--I appreciate what all of you do and what you are trying
to do. We are short of money, but not short of ideas, not short
of people that would be great scientific investigators, and so
forth. We have to make tough decisions. I hope we make some
wise ones.
But I support what you do, individually and collectively.
But now I want to direct my remarks not to you, but to
Secretary Sebelius.
On April 2, 2009, then-Governor Sebelius testified before
the Senate Finance committee at her confirmation hearing to
serve as Secretary of the Department of Health and Human
Services. At that hearing, the chairman of the Finance
Committee asked her the following direct question, and I quote,
``Do you agree, without reservation, to respond to any
reasonable summons to appear and testify before any duly
constituted committee of Congress, if you are confirmed?''
Governor Sebelius, at that time she was still Governor,
answered unequivocally, and I quote again, ``I do. And I look
forward to it.''
Well, the then-nominee gave us her word that she would
appear when asked to do so. Apparently, she has changed her
mind.
This subcommittee and, of course, the whole committee, has
two former Secretaries, Senator Alexander who was Secretary of
Education, and Governor--I call him Governor--Senator Johanns.
I thought his statement earlier was right on point.
What has not changed is this subcommittee's responsibility
to ensure that taxpayer dollars appropriated to HHS are spent
wisely. That is why we wanted Secretary Sebelius up here.
And in light of the failures of Obamacare, a lot of us
believe, it is entirely reasonable to expect the Secretary to
explain how she spent money previously allocated to her
Department before we consider her request for $60.8 billion
more.
Nevertheless, Secretary Sebelius has reneged on her promise
to the Senate and refused a reasonable summons to appear and
testify here today. Why? Because, according to the Obama
administration, she doesn't want to. That is not sufficient.
We deserve better than that. We deserve more respect on
this committee. Thank you.
Senator Harkin. Senator Reed.
Senator Reed. Thank you very much, Mr. Chairman.
And thank you, ladies and gentlemen, for your testimony.
LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM
Mr. Greenberg, we understand--it has been highlighted by my
colleagues--the fiscal pressures the Department is under. One
area which I have worked on consistently, on a bipartisan basis
with Senator Collins, is LIHEAP. And once again, the budget is
very disappointing, honestly.
We will do our best to try to restore funding. This is
critical, not just to our region of the country, but it is
particularly critical in the Northeast, because we are paying
energy prices that are sometimes three and four times the
national average. And so, less dollars with higher prices means
more and more families are literally cold in the winter.
And I think in the summertime, other parts of the country
have a similar problem with cooling.
My question is: I don't know what you can do at this point,
but I want to stress my disappointment. And can you give us an
idea of why we couldn't get more money into the LIHEAP budget
from the administration?
Mr. Greenberg. Senator Reed, thank you. The LIHEAP decision
was an extremely difficult one. It does simply reflect the need
to make decisions and make priority judgments among competing
priorities with limited discretionary funding.
For LIHEAP, we are very mindful of the tremendous
importance of the program. We are very mindful that it only
reaches a fraction of the eligible households, that for those
who it does reach, that the benefits that are provided are
limited in relation to their heating and cooling costs.
We are mindful of all those limitations. And this was
simply a judgment about priorities with limited discretionary
funds.
We have proposed, as part of the budget, to also move
forward on energy burden reduction grants, recognizing that a
part of an overall strategy has to be helping families develop
ways of lowering their energy costs.
But, fundamentally, this is about constrained resources.
Senator Reed. Well, I think, as you can anticipate, we will
try our best to rebalance.
HEALTHY HOMES AND LEAD POISONING PREVENTION
Dr. Frieden, let me move on quickly. CDC, the Healthy Homes
and Lead Poisoning Prevention Program, is another extremely
important program. Lead poisoning is a completely avoidable
childhood disease that can cause irreparable damage to
children. We have made progress. We were able to restore some
funding last year to CDC.
Can you tell us what your plans are to use these resources
and also to make them stretch further, go further, and help
more children?
Dr. Frieden. Thank you, Senator Reed. Thank you for your
support for this and other public health issues.
Lead poisoning prevention is critically important, as you
say. And CDC has a unique role in both surveillance, so we know
what is happening, and targeting interventions.
We know that even slight elevations in lead levels can
result in a lifelong reduction in both intellectual potential
and in earnings capacity, so it has major economic
implications.
What we will do with the funding restored by Congress is to
support roughly 30 city or State health departments to do a
better job at surveillance and targeting prevention to better
protect children and continue to drive down lead poisoning
rates.
Senator Reed. Thank you very much.
In this context, I have to thank Senator Mikulski and our
former colleague, Kit Bond. When they were leading the Housing
and Urban Development Subcommittee here, they targeted
remediation, so that we could literally get the lead out of
houses. And without Barbara's leadership, thousands and
thousands of children--and Senator Bond's--would have been not
only adversely affected----
Senator Mikulski. And Jack Kemp.
Senator Reed. And Secretary Kemp, too. So this was a
bipartisan effort. We like to see it that way.
HOME VISITING AND LEAD EXPOSURE
Final question: If I may, Dr. Wakefield, and that is, you
have a home visiting program. This relates to the lead
exposure. You have a home visiting program, and it is an
opportunity to check on many hazards, including lead exposures,
and to coordinate with CDC.
Can you tell us what you intend to do to coordinate between
these home visits and the Healthy Homes and Lead Poisoning
Program, so we are getting more bang for the buck? That is what
we want to do around here.
Dr. Wakefield. Sure. So the home visiting program is being
deployed in all 50 States, and it has as a basis, evidence-
based programs that are deploying nurses, social workers, other
health care providers, to families that choose to participate
in the program voluntarily.
But they are families that tend to be at risk, of course,
and living in at-risk communities.
So through the home visiting program now, we have over the
course of about the last year or so, infused in six of those
evidence-based programs information about lead poisoning
prevention and healthy housing.
So I know that is a priority for you and for other Members
of the Senate, and we have tried to embed that in the program
in a number--not all yet, Senator--but in a number of the home
visiting programs.
Senator Reed. And are you working with CDC?
Dr. Wakefield. We do very closely. And I have personally
had conversations with CDC on this topic.
Senator Reed. Thank you.
Thank you, Mr. Chairman.
Senator Harkin. Thank you, Senator Reed.
Senator Moran.
Senator Moran. Mr. Chairman, thank you. I thought it was
finally my time to talk, but Senator Alexander has asked that I
yield to him, and I am happy to yield.
Senator Alexander. I am glad we have such a yielding
ranking member.
I thank you for your courtesy, Senator Moran.
Mr. Love, I hope you will express to Marilyn Tavenner our
sympathy for the loss of her mother, and respect for the way
she does her job. And we look forward to seeing her soon.
Dr. Frieden, I wanted to especially thank you for the
terrific job the CDC did in the meningitis outbreak. You worked
fast and quickly. And by doing that, and the help that you gave
the Tennessee Department of Public Health, and Vanderbilt and
others who worked on that, you saved a lot of lives in that.
And to all of you, I think we all appreciate and respect
the work that you do and look forward to more informational
hearings.
But this is not an appropriate hearing. I think my
colleagues know I spend as much time as anybody on the
Republican side trying to make this Government work in the way
it is supposed to work.
I especially appreciate what Chairman Mikulski said about
the regular order, and I like the fact that she and Senator
Shelby and Senator Harkin and others and Senator Moran, are
trying to have us do our job with appropriations, and to do it
together in the way we are expected. So I am supporting that
effort, and intend to do everything I can to help her do that.
But this is not right for the Secretary of the Department
to not appear to defend the President's budget.
I was a Secretary. I am pretty sure I answered the same
question when I was asked, would I show up, when I was asked by
the committee. And I believe I did, whenever I was asked, at
least for this specific occasion.
And I notice that the chairman mentioned a couple times
that he is retiring this year. But if he is, I haven't noticed
it. If anybody from Iowa were to ask me if Tom Harkin was
slowing down in this year of his retirement, I would say, as
far as I can tell, he is speeding up. I mean, we have a hearing
every other day, it seems like. And he is busily doing his job,
and I am glad he is. I enjoy working with him. We have gotten
more done than any other committee in the Congress, authorizing
committee.
I notice that the Senator from Nebraska is also retiring,
and he not only came to this hearing, he is on his way to
another hearing.
So where is the Secretary of Health and Human Services? She
is still on the job. And if the Secretary of Defense were still
on the job and waiting for the next Secretary, and we were
invaded, or Ukraine happened, would the Secretary of Defense
not show up? That is not appropriate.
And it is more, I am afraid, than just the Secretary
playing hooky. I mean, this is getting to be a persistent
problem with this administration regarding, Article 1 of the
Constitution and the Congress, the representatives of the
people as an inconvenience.
I think Presidents ought to begin their terms by taking the
Cabinet down to Mount Vernon and reminding themselves that
while the chief executive is extremely important, the Founders
didn't want a king. And George Washington, who could have
stayed forever, as long as he lived, as President, imprinted
his humility and respect for the people on the Constitution
that he helped to write. And every President since then,
almost, has tried to stretch that envelope.
But this administration has gone further than any I can
remember, with its recess appointments and its czars and its
waiver authority for school boards and raising money privately
to do what Congress did not authorize to do and turning the
Senate into a place where the majority can do whatever it
wants, whenever it wants to get a result that the
administration wants. That is not the way our constitutional
framework was set up.
I hope I would say the same thing if we had a Republican
President whose Secretary didn't show up to testify before a
Republican committee.
We have Article 1 for a reason. We represent the people of
this country for a reason. We are here, ready to do our jobs.
And I am extremely disappointed that the Secretary of
Health and Human Services, who helped write this budget over
the last 6 months, is not here to do her job. What if the next
Secretary said she couldn't come testify because she didn't
have anything to do with writing the budget? It is the job of
the Secretary to be here, to show respect, not for each of us,
but for the people we are elected to represent under Article 1
of the Constitution of the United States.
Thank you, Mr. Chairman.
Senator Harkin. Thank you, Senator Alexander.
Senator Shaheen.
Senator Shaheen. Thank you, Mr. Chairman.
LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM
Mr. Greenberg, before I get into the meat of my questions,
I do want to just echo what Senator Reed had to say about the
LIHEAP program.
As you know, in the Northeast, we had a very cold winter,
and we have a lot of people in New Hampshire who did not get
the assistance that they really needed through the LIHEAP. So
while I appreciate we have very challenging resource issues, I,
certainly, will be arguing on this committee that we should
increase the amount of funding for LIHEAP.
IMPLEMENTATION OF THE AFFORDABLE CARE ACT
Mr. Love, I am really pleased that despite all of the
challenges with the rollout of healthcare.gov that this past
week we heard that over 40,000 people in New Hampshire had
selected a health insurance plan through the exchange. That is
a significantly greater number than the 19,000 that CMS had
targeted, so we were pleased about that.
I am also pleased that there was recently a bipartisan
compromise in our New Hampshire Legislature that allowed the
Governor and the Legislature to agree to an expansion of
Medicaid in the State.
That will require a waiver, as you know, and I understand
that there are discussions already underway between the State
of New Hampshire and CMS, so I would urge those discussions to
go forward as expeditiously as possible. And I appreciate all
the work that you are doing to try to make that happen.
We have 50,000 residents in New Hampshire who will benefit
from an expansion in Medicaid.
I wonder if you could talk a little bit about the steps
that CMS is taking to continue to improve the implementation of
the healthcare law, specifically with respect to the
healthcare.gov Web site. What steps are you taking to ensure
that problems don't exist moving forward? And can you talk
about the importance of what I believe is the importance of
having a permanent CEO to head up the effort around the
technology and the Web site?
Mr. Love. Thank you, Senator.
Regarding the rollout of healthcare.gov, as you and other
members of the committee have mentioned, we have a number of 8
million that no one I think would have predicted in the early
fall. And there has been an extremely diligent effort, both on
the part of the agency as well as our colleagues elsewhere in
Government, and the private sector, quite frankly, to help us
get up to speed on that. We have made tremendous progress.
What we are very much focused on in the next 6 months--the
end of open enrollment, the first season--is really building on
that infrastructure, particularly as it regards the consumer
experience and interacting with the Web site. That is of
primary importance to us.
There are other aspects of the Web site that the consumer
may not see but are also quite important. We are focused on the
financial management piece of it and various oversight
functions. And we are working just as hard during the down
period as we were during the open enrollment. And we hope to
see a dividend. We hope you will see a dividend to that in the
next open enrollment in the fall.
Regarding your question on a chief executive officer for
our Center for Insurance--CCIIO (Center for Consumer
Information and Insurance Oversight) is our shorthand--but
basically, the component that is central within CMS that has
lead responsibility for that. I know that there are different
management leadership models under consideration. Right now, we
do have an acting director, Dr. Mandy Cohen, who is doing a
great job stepping up since her predecessor left a short while
ago. And we are looking at different management models to bring
the type of leadership effort I think you are considering.
I know the Administrator is consulting both with the
Department and the White House now on what the most rigorous
leadership model for the CCIIO front office will be. I am sure
you will be hearing more about that.
Senator Shaheen. Thank you. I would urge you to make sure
that there is a permanent person in charge of that effort in
the future.
PRESCRIPTION DRUG ABUSE
Dr. Frieden, I am sure you are aware that in northern New
England, we have had an epidemic of heroin use. In New
Hampshire, we had more deaths last year from drug overdoses
than from car accidents, so it is something that we are very
concerned about.
I have done several panels with law enforcement, with
treatment providers, to talk about what might be done to
address this epidemic. And one of the things I heard recently
from a former DEA (Drug Enforcement Administration) agent who
had worked in this field for about two decades was that we
should be doing more to ensure that there are some protocols
around how doctors decide on prescriptions, since that, in too
many cases, has been the avenue through which people got into
drug use.
And I wonder if you could talk about what CDC is doing or
can do to educate providers for appropriate prescription drug
practices.
Dr. Frieden. Thank you very much.
This is, indeed, a huge problem. We have seen a fourfold
increase in deaths from prescription opiates, currently, more
deaths than from heroin and cocaine combined.
And we have also seen devastating impacts on communities,
where there are some communities where it is so rampant that it
is difficult to recruit new businesses in because people can't
pass drug tests.
We see this as an opiate problem. As you point out, many,
perhaps even most, people who currently use heroin started off
with prescription opiates. We have tracked these trends, both
overall and by State. And the numbers are, frankly, shocking.
This is, to a significant extent, a doctor-caused, or
iatrogenic, epidemic. And we do believe it can be reversed by
things like good guidelines.
In fact, enough prescription opiates are given each year to
give every adult in the country 75 opiate pills a year. It is
just way too much. It is 18 billion pills a year. And we find
in some States, as many as one in three people get a
prescription each year.
So what we have focused on for the 2015 request is to be
able to support States with several specific things.
One is strengthening prescription drug monitoring programs.
These are very important, but there isn't one in the country
that is yet real-time, universal, and actively managed. So we
want to get to that key area of tracking prescriptions, and
intervening with both patients and providers for services as
needed, or law enforcement if appropriate.
The second key area is supporting States on a variety of
measures that they can do with insurers, Medicaid, and others.
And the third is specifically the issue of guidelines.
Washington State and some communities have guidelines, but they
aren't well-followed. They aren't well-established. And by
establishing guidelines, then insurers, Medicaid programs,
others can ensure that pain relief, which is very important--
for example, for patients with terminal cancer pain--continues,
but without the great risk that these drugs provide.
Senator Shaheen. Well, thank you very much.
Mr. Chairman, if I can just have one follow-up question. I
know I am over my time.
So how much of the requested $15.6 million for prescription
drug overdose programs is going to be targeted to help
providers become smarter prescription providers?
Dr. Frieden. The overwhelming majority of that would go to
States. And within the States, each State would decide where
they would move the money, where they would invest it.
But the three key components are improving prescription
drug monitoring programs, tracking the system in real-time, and
strengthening prescriber practices and provider behavior.
Senator Shaheen. Thank you very much.
Thank you, Mr. Chairman.
Senator Harkin. Thank you, Senator Shaheen.
Senator Moran, please take the time you desire.
Senator Moran. Mr. Chairman, thank you very much.
First of all, Dr. Frieden, you have invited me to visit the
CDC, and I want to express my gratitude and also express my
sincere interest in accepting the invitation. We will work
toward accomplishing that. I look forward to that visit.
The chairwoman of our full committee, the Senator from
Maryland, talked about the Unaccompanied Alien Children
program. This is an example of a question that I would ask the
Secretary if she were here. If she were here, I would ask this
question: The Unaccompanied Alien Children program is
underfunded by more than half, $1.1 billion. It is my
understanding that the administration will not submit a budget
amendment to address that shortfall. I guess I would ask the
Secretary if that is true.
And I would say, Madam Secretary, if we have to live within
our budget allocations, what HHS programs would you recommend
that we would use to make up for that $1.1 billion?
And again, there is no one here who can help us directly
answer that question.
Further, on ACA risk corridors, I would ask the Secretary
that section 1342 of the Affordable Care Act requires the
Secretary to establish and administer those corridors. Does the
Secretary have the authority to make payments from the risk
corridor fund? And if not, how would the administration pay for
that funding gap?
Again, perhaps someone here could answer their belief as to
whether the authority exists, but I don't think there is
anybody here who could tell us how the administration would
then pay for that gap.
We have had a lot of conversation, mostly in the House,
about the evaluation tap. It was originally implemented
throughout the Department's budget to use for evaluations of
those program activities within the Department. Perhaps,
unfortunately, it is now used--I guess not ``perhaps.''
Unfortunately, it is now used to supplant budget authority.
And I would ask how does the Department of Health and Human
Services justify taking funding from the National Institutes of
Health to fund programs that should receive independent budget
authority.
There has been a request for an increase in that evaluation
tap from 2.5 percent to 3 percent, and, Madam Secretary, how
was it determined that increase in the tap was necessary in
fiscal year 2015? What deliberations took place within HHS, and
within the White House, to decide which agencies are sources
and which are receivers of evaluation tap transfers? And
specifically, why does the Department use what I would say is a
budget gimmick to highlight an increase in NIH funding of $200
million even though NIH is left with only a $58 million
increase above 2014, after accounting for the tap increase?
And finally, an example of what I would ask the Secretary
is regarding the nonrecurring expenses funds. I am trying to
become more knowledgeable about information technology. We have
a hearing later today in the Appropriations Subcommittee on
FSGG.
The nonrecurring expenses fund dollars went to fund the
Affordable Care Act-related information technologies, but the
fund can be used to cover any one-time capital I.T.
acquisition. And I would be interested in knowing what analysis
the Department does before moving unobligated funds into the
nonrecurring expenses fund, and the details of that process for
the subcommittee.
How does HHS decide what I.T. projects merit nonrecurring
expense fund dollars? Does HHS solicit formal or informal
requests from agencies for nonrecurring expense fund-related
projects? What programs would have received funding over the
past 2 years had funding not been siphoned off to fund
implementation of the health insurance exchange?
And then finally, an issue that is in my view so important.
In last year's budget request, there was the $80 million
increase for Alzheimer's disease research. Congress, in our
omnibus bill, we were successful in finding $100 million for an
increase for Alzheimer's disease research.
And why did the Department not include that increase for
Alzheimer's disease research in its 2015 budget proposal?
And perhaps most importantly, will NIH be able to reach the
goal for finding a cure for Alzheimer's by 2025, the stated
goal, without an increase in its research funding?
Mr. Chairman, I thank you for conducting this hearing. I am
sorry that I don't think these folks can answer my question. We
will continue the efforts to try to find those answers.
I was interested in Senator Mikulski's conversation with
Secretary Sebelius. And perhaps we will have that opportunity,
either in a hearing sometime or with the new Secretary, to
explore these issues further.
Thank you.
Senator Harkin. Thank you, Senator Moran.
I just have a couple follow-ups I want to do.
COMMUNITY HEALTH CENTERS
Dr. Wakefield, I want to talk just a little bit about
community health centers. As you know, we are going to face a
funding cliff here if we don't extend the mandatory part of
this budget. So talk to me a little bit about how you envision
this moving ahead to make sure that we have the necessary
funds, so that we don't have that budget cliff. I think it is
2016.
Dr. Wakefield. Sure. Thank you, Senator.
The community health centers program is extremely important
to ensure that individuals across the country have access to
primary healthcare services and preventive healthcare as well.
And the importance of that program has really been
increasing since about 2009 when that infrastructure was seeing
about 17 million patients. As I mentioned in my opening
remarks, as of about 2012, we are seeing about 21 million
patients. And in 2015, we expect we could be seeing as many as
31 million patients in that infrastructure.
So your point about sustainability and stability, to ensure
that individuals and communities across the country have access
to primary healthcare services, is an important one. And we, of
course, are concerned about long-term funding as well.
So in fiscal year 2015, we have $3.6 billion. That is the
last year of funding through the Affordable Care Act for
community health centers, in fiscal year 2015.
Our ask is $1 billion in discretionary for fiscal year
2015, to provide a total of $4.6 billion to fund community
health center programs.
Of that money, Senator, about $1 billion would be applied
for nonrecurring costs. That is, to invest in construction and
renovation. And frankly, from the field, from health centers
across the country, because of this increased demand in numbers
of people who are seeking healthcare services, a lot of them
now with insurance coverage, this will allow those community
health centers to build out and to reconfigure the centers in
order to be able to accommodate that increased number of
patients that are being seen.
So about $1 billion, as I said, in 2015 will be used for
nonrecurring construction funds.
Going forward, then, to replace the Affordable Care Act
funds for fiscal year 2016, 2017, and 2018, we are proposing in
the budget mandatory funding of $2.7 billion per year.
In addition, we would assume that there would be
appropriations made available by the Congress, but that is the
proposal to ensure stability and access to healthcare services
in the subsequent years.
Senator Harkin. Will that $2.7 billion be enough to
alleviate the funding----
Dr. Wakefield. So, Senator, if we were to assume that in
addition to that $2.7 billion, there would be appropriations
that would also be made available in fiscal years 2016, 2017,
and 2018, to support the program.
Senator Harkin. How much?
Dr. Wakefield. That provides baselines to support
operations, and so on.
Senator Harkin. What would that be, about how much a year,
which you anticipate that would be in terms of discretionary
budget?
Dr. Wakefield. Well, I couldn't speak----
Senator Harkin. We would have to come up with that. I am
not going to be here, but he is going to be here.
Dr. Wakefield. So, Senator Moran----
So, Senator, we are looking closely at the out-years
additional needs. What we can count on is that need for $2.7
billion. So we are tracking, for example, the number of
individuals that are receiving care in health centers that are
now coming through the doors with insurance coverage, so that
provides some additional revenue.
Senator Harkin. So you get some funds coming in through the
Affordable Care Act?
Dr. Wakefield. To replace Affordable Care Act, we will have
our mandatory funding of $2.7 million per year. In addition----
Senator Harkin. Are you anticipating money that will come
in because people now have insurance coverage?
Dr. Wakefield. Yes. So people will be coming in with
insurance coverage. So we have that phenomenon. People coming
through the door with insurance coverage, either Medicaid
insurance coverage where it has been expanded, or private
insurance coverage.
But we also know that that is going to be uneven, Senator
Harkin, because there will be some States where Medicaid has
not been expanded and individuals have become aware of
community health centers as a place where they can access
services. No one is turned away. A sliding fee scale is used
for people under 200 percent of poverty.
So we have a little bit of both of those dynamics. And we
will have to look very closely at that for years 2016 and on.
Senator Harkin. Do you anticipate any fall off of
attendance--maybe that is the wrong word--people seeking
medical care from community health centers because they now do
have insurance coverage and they might be going to their
primary care doctor someplace else?
Dr. Wakefield. We don't. We don't expect a decline in
demand for services through community health centers based on a
couple things.
First of all, we can look to the State of Massachusetts
that has enacted healthcare reform a number of years ago. And
even though their rate of uninsured decreased markedly, their
demand for healthcare services through their community health
centers increased markedly. So these are health centers that
are located in underserved communities. They are trusted
sources of care. They have been embedded in those communities
for now, in many cases, a number of years. And frankly, they
provide very high-quality and comprehensive care.
If you go to a health center, you can access oral
healthcare services generally onsite. You can access behavior
of mental health services, generally onsite, in addition to
traditional medical services. So these are comprehensive
healthcare delivery settings that have a strong tie to the
communities that they serve.
So the answer is no. Sorry.
Senator Harkin. Thanks.
HEALTHCARE FRAUD AND ABUSE
Mr. Love, let me just quickly go to you. I mentioned the
healthcare fraud and abuse program. The latest study showed
that for every $1 spent, we got $8.10 recovered. This is the
highest 3-year average return on investment in the 17-year
history of this program.
Now the Budget Control Act included cap adjustments that
encouraged Congress to increase this funding by $898 million
over the past 3 years, an amount that would have saved
taxpayers more than $6.2 billion.
But the President's budget did not request utilizing this
funding. Can you give the subcommittee an idea of what has been
lost over the last 2 years by not taking advantage of the
additional funding encouraged in the Budget Control Act?
Mr. Love. Senator, Mr. Chairman, thanks for the question
area. I cannot answer that specific question, but I can tell
you what the budget is projected going forward, and that, as
you said in your earlier remarks, there was an 8-to-1 return on
investment, which is an excellent investment, indeed. And we
remain very supportive of the fraud, abuse, and program
integrity program.
What the President's fiscal year 2015 budget does do is
request $428 million for the Health Care Fraud and Abuse
Control Fund, HCFAC, which would provide both a dividend for
Medicaid and Medicare. And the projected dividend on that over
10 years is $13.5 billion.
So I think you will see it is, certainly, projected to be
consistent with the 8-to-1 return on investment that you
mentioned earlier.
Senator Harkin. So your budget request increases HCFAC
funding by $428 million? Is that, which you are saying?
Mr. Love. Yes, sir.
Senator Harkin. That is lifting the cap?
Mr. Love. I believe that is discretionary.
Senator Harkin. Yes, lifting the cap on the mandatory side
gives you that $428 million. And with that, you anticipate how
much of a return?
Mr. Love. $13.5 billion return over 10 years.
Senator Harkin. Okay. I got that.
GLOBAL HEALTH SECURITY INITIATIVES
Dr. Frieden, one last thing for you, following up a little
bit on what I started earlier, and that is setting up CDCs in
other countries.
You had a global health initiative, but then the request
zeroes out the money we put in last year, which was $7.5
million.
Again, tell me, how was the $7.5 million utilized? And why
wouldn't we want to continue that effort rather than just
putting it all in the global health initiative?
Dr. Frieden. We certainly do want to continue the effort of
strengthening national public health institutes around the
world.
The current fiscal year, what we are doing is working with
around eight countries to either strengthen or start the
process of creating a national public health institute. Some of
those, it has multiple institutions, binding them together.
Some of them, it is new.
We anticipate working in multiple regions in the world. We
have countries very interested in this area. And it is the kind
of project that we would hope to be able to continue going
forward.
The global health security proposal would also enable us to
strengthen national public health institutes, but not as
directly as the funding in the fiscal year 2014 budget. So I
can't really say more than that, but thank you for that
support.
I will comment that, Senator, if I might, after several
decades, three decades of support for public health, we really
appreciate your support for public health, not only in this
country but around the world.
You, of course, changed our name from the Centers for
Disease Control to the Centers for Disease Control and
Prevention, and we embrace that mission, and we thank you for
your support.
Senator Harkin. I appreciate that. I will follow-up with
you further on the continuation of your effort to help other
countries set up their own CDCs, and basically, to make sure
that they start having coordinated effort.
Again, what I picked up in some of my travels, there were
just so many fragmented parts. And they just don't have a CDC-
like structure to pull it all together.
They do need labs. They need equipment. They need all that.
I understand that, too. But they need to change their
structures.
So I am going to have my staff further inquire about that.
And I am a little disappointed that was not in the budget. I
will get some more information on that as we move ahead in our
decisions on what we want to do on that.
ANTIBIOTIC RESISTANCE
Two other just quick questions: One, tell us again about
the looming crisis that I keep reading about in terms of
antibiotic resistance, what is happening in our country. At
least here, we are losing the ability to fight off certain bugs
because of antibiotic resistance. So what is happening? Where
are we in this?
Dr. Frieden. What we are seeing, Senator, is a steady
increase in the proportion of different bacteria, in
particular, that are resistant to antibiotics.
And earlier, a few months ago, we released the first-ever
report on our national status in terms of antimicrobial
resistance. We found that there are more than 2 million
resistant infections per year, more than 20,000 deaths per year
in the U.S. from resistant infections. Another estimate is more
than $20 billion in expenses.
We highlighted----
Senator Harkin. Do you have something in your budget
request that zeroes in on this?
Dr. Frieden. Yes, we have a specific initiative to expand
our efforts to reverse antimicrobial resistance. It is a $30
million request each year over 5 years. And with that
investment, we think we can cut some of the deadliest resistant
infections in half. We are confident we can deliver that value.
Again, one of them, in particular, that I am very concerned
about, something called CRE. It is a deadly bacteria. It is
spreading in hospitals. It started out in one State, and then
it was in 10, and now it is in virtually every State.
It can be lethal to half of the hospitalized patients who
get it. And I called it a ``nightmare bacteria'' because it can
spread not only from patient to patient, but between different
species of bacteria. So whole classes of bacteria that can
cause routine infections, like urinary tract infections, could
become resistant to virtually all or even all of our available
antibiotics.
And we need to respond quickly. So we would do that by
working intensively with hospitals by setting up regional
centers of excellence and by moving forward as rapidly as
possible, to improve both the detection of persistence and
control of outbreaks, control measures where there are
outbreaks. We have been able to see big reductions where we
have been able to control this using a statewide or
communitywide approach, and prevention measures, which could be
as simple as hand-washing or vaccination, or as complex as more
complex interactions that would reduce the number of resistant
infections.
We recommended that every single hospital in this country
have an antibiotic stewardship program so that they can make
sure that the antibiotics used in the hospitals, where we are
seeing some of the most resistant infections, can be prescribed
appropriately.
Senator Harkin. Thank you.
AFFORDABLE CARE ACT FUNDING
Mr. Love, please take back to CMS for me this: That this is
my last year here, but I am going to be really vigilant in
making sure that CMS follows the law and follows what this
committee prescribes in terms of how the Affordable Care Act
money is used.
And let me cut to the quick on this: That there won't be
any more shifting of money from prevention and wellness
programs into base programs that CMS already has. Okay? It is
just not going to happen. So just please take that back. Let
everybody know.
Mr. Love. I certainly will, Senator. Thank you.
ADDITIONAL COMMITTEE QUESTIONS
Senator Harkin. I appreciate that. Thank you.
Listen, thank you all very, very much. This has been a good
hearing.
Again, please take back to Ms. Tavenner the sympathies of
all of us on the committee. She has been a great administrator,
and this is a tough time for her, and please take that back to
her, our deepest sympathies.
To all of you, thank you again for all of your public
service. You have been great public servants, carrying out your
responsibilities well.
And we will leave the record open for 1 week for other
Senators.
[The following questions were not asked at the hearing, but
were submitted to the Department for response subsequent to the
hearing:]
Questions Submitted to Timothy Love
Questions Submitted by Senator Tom Harkin
health care fraud and abuse control program
Question. The latest HHS report released in March found that for
every $1 spent on fraud and abuse in fiscal year 2013, $8.10 was
recovered. This is the highest 3-year average return on investment
(ROI) in the 17-year history of Health Care Fraud and Abuse Control
Program (HCFAC). The budget Control Act included cap adjustments to
encourage Congress to increase this funding by $898 million over the
past 3 years. I am disappointed that the President's budget did not
request utilizing this funding. Please describe the savings that have
been lost over the last 3 years, and the fraud and abuse that has gone
undetected, by not taking advantage of the additional funding
encouraged in the Budget Control Act?
Answer. The fiscal year 2015 budget supports fraud prevention and
reduction of improper payments, which are top priorities of the
administration. Despite enactment of multiyear discretionary cap
adjustments in the Budget Control Act (BCA), annual appropriations
bills have not provided the full amount of program integrity funding
authorized in that law. Centers for Medicare & Medicaid Services (CMS)
actuaries conservatively project that for every new $1 spent by HHS to
combat healthcare fraud, about $1.50 is saved or avoided. Applying this
rate of return to the $932 million in HCFAC funding that was not
provided between fiscal year 2012 and fiscal year 2014 results in an
estimated $1.4 billion in lost savings. In addition, HCFAC funding has
also been subject to the cumulative effects of rescissions and
sequestration, further affecting CMS' ability to detect fraud and
abuse. Historically, for every $1 spent on healthcare-related fraud and
abuse investigations through HCFAC and other programs in the last 3
years, the Government recovered $8.10. This is the highest 3-year
average return on investment in the 17-year history of the HCFAC
Program. Therefore, the President's budget proposes to build on recent
progress on efforts to reduce fraud, waste, and abuse by increasing
support for the HCFAC program through both mandatory and discretionary
funding streams.
The budget includes $697 million in new HCFAC program funding in
fiscal year 2015: $294 million in base discretionary funding, $25
million in new discretionary funding, and $378 million in proposed new
mandatory funding. Starting in fiscal year 2016, the budget requests
all additional HCFAC funds as mandatory, instead of through the
discretionary cap adjustment included in the Budget Control Act (BCA).
All proposed HCFAC program investments, including gradual growth over
time, are consistent with BCA levels.
Providing additional resources for HCFAC as a dedicated, dependable
source of mandatory funding will allow the Departments of HHS and DOJ
to conduct necessary program integrity activities and make sure that
only accurate payments are made to legitimate providers for appropriate
services to eligible beneficiaries. Providing additional mandatory
funding for HCFAC will also eliminate delays in annual appropriations
that make it difficult for HHS and DOJ to execute budget plans and
achieve targeted results each year. The more stable mandatory program
integrity funding will produce new deficit savings of $2 billion over
10 years.
provider non-discrimination (section 2706)
Question. Section 2706 of the Affordable Care Act, the provider
``non-discrimination'' provision is intended to prohibit health
insurance plans from discriminating against entire classes of licensed
and certified healthcare professionals solely on the basis of the
provider's licensure or certification. Despite the clear intent of this
provision, I believe that the HHS, Treasury and Labor erred when it
released the 2013 FAQ document that subverted the congressional intent
of the section. The fiscal year 2014 Omnibus directed HHS to work with
Labor and Treasury to correct the FAQ to reflect the law and
congressional intent within 30 days of enactment of the bill. Recently
HHS chose to issue a Federal Register notice requesting additional
public comment as to the appropriate interpretation of this provision.
When does HHS plan to correct the FAQ to reflect what congressional
intent is of the provision?
Answer. The comment period for that Federal Register Request for
Information is open until June 10, 2014. After the comment period
closes, I would expect that HHS, together with the Departments of Labor
and Treasury would evaluate the comments and use the public input to
evaluate future rulemaking on that topic.
______
Questions Submitted by Senator Mary L. Landrieu
Question. CMS recently implemented a final rule that changed
payments for speech generating devices (SGDs) so that Medicare
beneficiaries no longer have the option to purchase them, but instead
must rent them. Constituents with diseases like amyotrophic lateral
sclerosis (ALS) and cerebral palsy have expressed concern that Medicare
will not pay the rental fees for the devices if they are admitted to
hospice, a hospital or nursing home. These devices are highly
customized and cannot be provided off-the-shelf. My understanding is
that SGDs are overwhelmingly purchased, upwards of 99 percent of the
time according to recent claims data. Why did you move SGDs into a
rental category when the agency indicated that devices that are
purchased 75 percent of the time should continue to have a purchase
option? And how do you plan to address concerns about beneficiaries
losing access?
Answer. We recognize that patients may use long-term durable
medical equipment (DME) such as SGDs because of chronic conditions or
permanent disabilities. However, the statutory DME benefit is for
equipment used in the home. When the beneficiary is admitted to a
hospital, skilled nursing facility (SNF), or hospice, it is the
responsibility of the institution to furnish this device and any other
DME that a beneficiary needs. CMS is committed to carefully monitoring
beneficiary access using real-time claims data to ensure that
beneficiaries are receiving medically necessary items and services.
Question. As your agency prepares for open enrollment this fall,
what improvements are you making to help certified health insurance
agents and brokers seamlessly enroll and assist consumers into the
health insurance marketplaces? Health Insurance brokers are making sure
consumers understand the nuances of their plans, and they are the only
group of certified individuals who handle both enrollment and service
to policyholders year-round. Specifically, do you plan to establish a
toll-free helpline for agents and brokers, enable their National
Producer Number (NPNs) to be added at any point during the enrollment
process, and list certified agents and brokers on the local help
section of Healthcare.gov?
Answer. Agents and brokers will continue to play a vital role in
enrolling individuals and businesses in coverage, as they do today.
Agents and brokers act as trusted counselors, providing service at the
time of plan selection and enrollment and customer service throughout
the year. CMS provides training for agents and brokers to help them
better assist consumers at purchasing coverage through the federally
facilitated Marketplaces. In the first year, over 52,000 agents and
brokers completed training from CMS.
Agents and brokers continuing their participation in the individual
market federally facilitated Marketplace (FFM) for the 2015 plan year
and future plan years will complete an annual registration renewal
process that includes re-completion of required training and re-
execution of the applicable FFM Agent Broker Agreements. To continue
participation in the FF-SHOPs for the 2015 plan year and future plan
years, agents and brokers will execute the FF-SHOP Agent Broker
Agreement annually, create an FFM user account, complete identity
proofing, and are encouraged to re-complete testing and training.
Agents and brokers who will be participating in the individual market
FFM and/or the FF-SHOP for the first time for the 2015 plan year must
register, create an FFM user account, complete market-specific
training, and execute the applicable FFM Agent Broker Agreements.
In general, the agent or broker's NPN, name, and FFM user ID should
be recorded as part of the consumer's application. This will identify
the agent or broker on the enrollment transaction (called an ``834'')
so the FFM can appropriately track enrollment and the issuer can
compensate the agent or broker based upon the enrollment (as may be
appropriate). However, should an issuer identify a particular
enrollment that should have had an agent/broker associated with it, the
issuer should add the agent or broker to the enrollment internally even
if the agent or broker was not reflected on the 834, in case there is
any follow-up required as a result of the enrollment.
If an agent or broker has a legitimate reason to believe he or she
should be credited for an FFM enrollment, but has not been credited for
it, the agent or broker should contact the respective QHP issuer
directly to discuss the specific situation.
______
Questions Submitted by Senator Richard J. Durbin
meaningful use stage 2
Question. On May 6, 2014, CMS reported to the Health Information
Technology Policy Committee that only 4 hospitals and 50 eligible
professionals had successfully reached Stage 2 of the Medicare and
Medicaid electronic health record (EHR) incentive program commonly
referred to as Meaningful Use. We are now 7 months into the program
year for hospitals and 4 months into the program year for physicians
and other eligible professionals. Further complicating providers'
efforts are the lack of certified EHRs in the inpatient hospital
setting. As of mid-April, only 29 complete EHRs have been certified to
2014 program requirements. CMS has also said the 370 complete EHRs that
were certified for the earlier edition of certified technology may not
be used in 2014, even if providers are still at Stage 1 of the
Meaningful Use program. These performance statistics for Stage 2 are
alarming. What steps are you taking to ensure that providers are able
to safely and effectively transition to Stage 2 of the program?
In addition, while I understand that there is a hardship exceptions
process, this process currently provides relief only from the
significant financial penalties for not attesting in a timely way.
Could the exemption be broadened to include lost incentive dollars once
providers attest to Meaningful Use, even if they attest up to one full
year late?
Answer. HHS has been listening to providers, healthcare
associations, EHR vendors, and its partners in the healthcare industry.
In December 2013, HHS announced that it would engage in rulemaking to
extend Stage 2 of Meaningful Use for 1 year and allow Stage 3 to begin
in 2017. In addition, Office of the National Coordinator for Health
Information Technology (ONC) issued a 2015 Edition EHR Certification
Criteria Proposed Rule as part of its new regulatory approach to
provide more frequent updates to the certification criteria.
By extending Stage 2 until 2017, HHS would have an additional year
of Stage 2 implementation data to help inform any program changes. An
extension also allows CMS and ONC to better align quality performance
measures across Federal programs and to consider effective Stage 3
approaches to advance interoperability and clinical decision support
capabilities that will help drive improved health outcomes.
In response to stakeholder concerns that providers were having
difficulties meeting the requirements of Stage 2, CMS and ONC announced
in February 2013 that additional flexibility would be provided for
payment adjustments and hardship exceptions. For example, eligible
professionals (EPs) may request a hardship exception because the EP is
unable to control the availability of Certified EHR Technology at one
such practice location or a combination of practice locations.
medicaid institutions for mental diseases
Question. Given American Chiropractic Associations (ACAs) emphasis
on patient-centered care and health outcomes, has CMS investigated the
efficacy and long-term cost-effectiveness of residential substance
abuse treatment services for Medicaid eligible recipients?
Answer. The Centers for Medicare & Medicaid Services (CMS) has
identified existing and, in cooperation with our Federal partners, is
developing new resources for States seeking to enhance their efforts to
address the service need of individuals with mental and substance use
disorders. These resources seek to support States in their efforts to
improve benefit design, comply with the Mental Health Parity and Equity
Act, develop community integration strategies and coordinate behavioral
healthcare with primary care and other services. More information can
be found in a Center for Medicaid & CHIP Services Information Bulletin
issued on December 3, 2012 (http://www.medicaid.gov/Federal-Policy-
Guidance/downloads/CIB-12-03-12.pdf). Included as part of the
Informational Bulletin is information related to the variety of current
and new coverage options that States may use to cover behavioral health
services.
packaging rule
Question. In its 2014 Hospital Outpatient Prospective Payment
System Rule, CMS modified its packaging policy. Under Medicare's
previous packaging policy, a drug or biologic that is used 100 percent
of the time, or costs less than $90, may be packaged in a payment to
hospitals to cover healthcare items and services in a procedure. The
revised policy allows packaged payments in cases in which the drug or
biologic is used less than 100 percent of the time or when its cost
exceeds $90. The decision on which treatment to use is at the clinical
discretion of the physician and is incorporated into the single payment
the hospital receives from Medicare.
How will CMS ensure the accuracy of its cost data in the absence of
a requirement that hospitals report what drug or biologic is used
within the package payment? Is CMS planning to conduct audits or
implement a mechanism to ensure hospitals accurately reporting data?
Also, is CMS concerned about the effect this rule will have on
bladder cancer screening and treatment?
Answer. In general, multiple drugs may or may not be used for a
given service and the hospital outpatient prospective payment system
(OPPS) payment for that service reflects the average of all potential
ancillary items and services used to furnish the primary procedure. The
OPPS has never had a requirement that a drug is used 100 percent of the
time with the primary procedure into which the drug payment is
packaged. In the calendar year 2014 OPPS/ambulatory surgery center
(ASC) final rule, for the vast majority of drugs and biologicals, we
continued our traditional methodology for packaging drugs and
biologicals with a per unit cost under a $1 threshold of $90, which is
adjusted each year to reflect changes in nominal prices. We also
finalized packaging all drugs for the following categories of products:
(1) Drugs, biologicals, and radiopharmaceuticals that function as
supplies when used in a diagnostic test or procedure; and (2) drugs and
biologicals that function as supplies when used in a surgical
procedure. Adopting these packaging policies followed our longstanding
policy of packaging radiopharmaceuticals and contrast agents into the
associated imaging test.
In order to help ensure the accuracy of cost data, CMS expects
hospitals to correctly report the items and services provided to
patients according to correct coding principles. CMS provides coding
guidance every year in our annual OPPS/ASC final rule with comment
period and in several sections of our online CMS Manuals. For example,
CMS specifically provides the following coding guidance in the Medicare
Claims Processing Manual, chapter 4, section 10.4 A: ``[I]t is
extremely important that hospitals report all HCPCS codes consistent
with their descriptors; CPT and/or CMS instructions and correct coding
principles, and all charges for all services they furnish, whether
payment for the services is made separately paid or is packaged.''
We are monitoring the effects of our 2014 packaging policies.
However, because these policies became effective January 1, 2014, not
enough time has elapsed with these policies in effect for us to
meaningfully evaluate their effect. We are confident that Medicare
beneficiaries have access to adequate bladder cancer diagnosis and
treatment services and we will continue to examine these services as we
do all other services through our annual rulemaking process.
______
Questions Submitted by Senator Jeanne Shaheen
Question. CMS has used public reporting of hospitals' performance
on certain measures including 30 day outcomes, surgical complications,
and healthcare associated infections to inform the public about a
hospital's performance on these and other important metrics. Public
reporting encourages hospitals to improve their performance and quality
because they know that they are being compared by their potential
patients.
Do you think that public reporting of hospitals' prescription drug
dispensement can help encourage more thoughtful and appropriate
prescribing behavior?
Answer. Under the Hospital Inpatient Quality Reporting (IQR)
program, hospitals report a variety of quality measures, most of which
are publicly displayed on Hospital Compare. These measures encompass a
wide variety of topics, including mortality measures, readmissions
measures, healthcare-associated infection measures, survey measures of
patients' experience of care, and measures of timely and effective
care.
It is possible that a hospital prescription drug dispensement
measure could help encourage appropriate prescribing behavior, but the
details of any such measure would need to be carefully evaluated as
part of the measure consideration process that CMS has adopted. CMS
considers additions to measures for the Hospital IQR program every year
and conducts its measurement activities in a transparent manner, which
involves the solicitation of input from multiple stakeholders. The
processes that have been established to solicit such input throughout
the measure development, selection, and implementation cycle include
posting calls on the CMS Web site for nominations for technical expert
panels; posting proposed or candidate measures on the CMS Web site for
public comment; holding CMS Open Door forums, publicly posting measures
being considered by December 1 each year as part of the pre-rulemaking
process; engaging the National Quality Forum through their Measures
Application Partnership to make recommendations on measures; soliciting
comments through rulemaking on proposed measures; and soliciting
suggestions through rulemaking on potential future measures.
Question. Do you think that providers are prescribing more and
engaging in more testing because they feel a pressure to satisfy their
patients?
Answer. Many different factors can contribute to overprescribing of
medications. CMS has proposed improvements to the Medicare Part D
program to address concerns about overprescribing and other abusive
practices. These improvements include giving CMS the authority to
revoke a physician or eligible professional's Medicare enrollment if
CMS determines that he or she has a pattern or practice of prescribing
that is abusive, represents a threat to the health and safety of
Medicare beneficiaries, or otherwise fails to meet Medicare
requirements. CMS will also be able to revoke a physician or eligible
professional's Medicare enrollment if his or her Drug Enforcement
Administration (DEA) Certificate of Registration is suspended or
revoked, or if the applicable licensing or administrative body for any
State in which he or she practices suspends or revokes his or her
ability to prescribe drugs.
______
Questions Submitted by Senator Jerry Moran
rate stabilization programs
Question. Does the Secretary have the authority to make payments
from the Risk Corridor fund? If not, how will the administration pay
for a possible funding gap?
Answer. Risk corridor payments can be made pursuant to section 1342
of the Affordable Care Act and longstanding CMS user fee authority
provided in appropriations acts.
Question. If the Secretary does have the authority to make payments
from the Risk Corridor fund, how will any surpluses in receipts from
the program be used? Specifically, could a surplus be used for Program
Management activities?
Answer. We intend to implement the risk corridors program in a
budget neutral manner over the 3 years of the program. HHS issued
guidance in April clarifying its plan to hold any excess risk corridor
collections from 1 year to the next to be available to make risk
corridor payments in subsequent years as set out in law and
regulations.
Question. What will happen if the incoming receipts for Risk
Corridor, Risk Adjustment, and Reinsurance programs are less than the
Department's projected estimates?
Answer. If reinsurance collections are not sufficient to fund the
reinsurance payment pool, all payments will be reduced pro-rata to fall
within collections received. The proposed rule entitled, Patient
Protection and Affordable Care Act; Exchange and Insurance Market
Standards for 2015 and Beyond (79 FR 15808 March 21, 2014) proposed
that--in the event that collections are less than projected estimates--
CMS would prioritize reinsurance contributions collected to the
reinsurance payment pool to assure that the pool is sufficient to
provide the premium stabilization benefits intended by the statute.
Under the risk adjustment methodology, risk adjustment charges will
be equal to risk adjustment payments and the program will net to zero.
We anticipate that risk corridors collections will be sufficient to
pay for all risk corridors payments over the life of the 3-year
program. However, in the unlikely event of a shortfall for the 2015
program year, we recognize that the Affordable Care Act requires us to
make full payments to issuers. In that event, we would use other
sources of funding for the risk corridors payments, subject to the
availability of appropriations. We will provide additional specificity
in future guidance or rulemaking as necessary.
Question. When will CMS start making payments under the Risk
Corridor, Risk Adjustment, and Reinsurance programs?
Answer. We anticipate payments for these programs will first be
made in the summer of 2015 for the 2014 plan year.
exchange enrollment
Question. How many previously uninsured Americans have enrolled in
the Exchanges?
Answer. In addition to the more than 8 million people who have
selected plans through the Marketplace during the initial open
enrollment period, Congressional Budget Office (CBO) recently estimated
that 5 million people will have purchased coverage outside of the
Marketplace in Affordable Care Act-compliant plans. Moreover, recent
national surveys indicate that the number of Americans with health
insurance coverage is growing, and the number of 18 to 64 year olds who
are uninsured is declining. For example, Gallup has found an almost 5
percentage point decrease in the uninsured rate for adults (18 and
over) from the third quarter of 2014 to April 2014 (18 percent versus
13 percent, respectively). Similarly, the Urban Institute estimates a
2.7 percentage point decrease in the uninsured rate for adults (18 to
64) between September 2013 and 2014 (corresponding to a 5.4 million
decline in the number of uninsured adults). Meanwhile, the RAND
Corporation estimates a 4.7 percentage point decrease in the uninsured
rate (corresponding to a net decrease of 9.3 million uninsured adults,
ages of 18 to 64) between September 2013 and March 2014.
Question. Since only 28 percent of the new enrollees represent the
young, healthy population, how will the Marketplace avoid the so called
``death spiral'' or significant spikes in premiums in 2015?
Answer. Consistent with expectations, through the end of 2014 open
enrollment, the proportion of young adults (ages 18 to 34) who have
selected a Marketplace plan through the State Based Marketplaces (SBMs)
and Federally-Facilitated Marketplaces (FFMs) has remained strong. We
expect that the robust sign-up numbers we are observing in the
Marketplace's first year--8 million at the close of 2014 open
enrollment--will encourage insurers to compete on price for consumers
during next year's open enrollment period. In addition, provisions of
the Affordable Care Act, including rate review and the medical loss
ratio rule, will help protect consumers against unfair rate hikes.
Question. What is the percentage of enrollees that have actually
paid their premiums to date?
Answer. CMS and the Department have a longstanding focus on
transparency and accuracy. When CMS has accurate and reliable data
regarding premium payments, we will see that this information is
available. However, we do know that some issuers have made public
statements indicating that 80 percent to 90 percent of the people who
have selected a Marketplace plan have made premium payments. It is also
important to note that issuers have the flexibility to determine when
premium payments are due.
exchange cost
Question. How did the Centers for Medicare & Medicaid Services
(CMS) come up with the $1.8 billion estimate necessary to operate the
Marketplace for fiscal year 2015?
Answer. As with all of our budget requests, the fiscal year 2015
Marketplace request represents an assessment of needs based on the
costs of existing contracts, as well as new functions that will be
implemented in fiscal year 2015.
Question. What happens if the Department does not receive the
projected $1.2 billion in Marketplace user fees?
Answer. Millions of Americans have already gained quality,
affordable insurance coverage through the Marketplace, and funding
continued operations is one of my highest priorities. In line with the
2015 President's budget, we expect to collect $1.2 billion in user fees
from issuers participating in the Federal Marketplace in fiscal year
2015. The Department's fiscal year 2015 request is critical to carry
out the Department's responsibilities to fund Marketplace operations.
Question. In fiscal year 2014, the Department estimated $450
million in Marketplace user fees. Did CMS meet that estimate?
Answer. User fees for the federally facilitated Marketplace were
first collected in January 2014 to align with the first month of
Marketplace coverage. We are still working on updating user fee
projections for fiscal year 2014, which will be based on recent
enrollment and premium data gathered from the initial enrollment
period.
state-based exchange replacement costs
Question. Does the Department plan to provide funds to purchase
replacement IT systems for the failed State-based Exchanges like
Oregon? And if so, where will this funding come from?
Answer. CMS is working with States on addressing the implementation
challenges with their State-based Marketplace. CMS will be implementing
contingency plans to smoothly and effectively assume the Marketplace
functions for any States that are unable to demonstrate readiness to
continued operation of their Marketplace.
Question. Will the Department plan to recoup some of these funds
from contractors who failed to deliver a working system?
Answer. We need to determine what went wrong and why (and in States
where things are going right understand that too). In those States
where Federal Government and taxpayer funds were misused, we need to
use all available avenues to get those funds back for the taxpayer.
Finally, we need to make sure that ensure that those who should be
receiving access to quality, affordable healthcare through those States
receive that access.
critical access hospitals
Question. When will the Committee receive the list of Critical
Access Hospitals (CAHs) affected by the 10-mile rule that was requested
in the fiscal year 2014 Omnibus?
Answer. CMS is in the process of obtaining a new software package
that will allow us to produce the list as requested by the committee.
We will work to provide the list to your staff as quickly as possible.
Question. How will the proposals regarding CAHs in the fiscal year
2015 budget request affect access to healthcare for Americans living in
rural communities?
Answer. The proposals in the President's budget are aimed at
preserving beneficiary access while promoting payment efficiency. These
proposals narrowly targeted and designed to improve efficiency while
preserving access to care. CMS does not expect either proposal would
have any significant adverse impact on rural access to care.
Question. How many hospitals will be at risk of losing their
designation based on these CAH proposals?
Answer. Currently, when making a determination of a Critical Access
Hospital's (CAH) satisfying the statutory location requirements
concerning proximity to another CAH or a hospital, CMS starts by using
online driving directions programs (such as Google maps) to calculate
the number of driving miles to other CAHs or hospitals. CMS also
considers any evidence to the contrary that the CAH chooses to submit
before making its determination. Any list would preliminary estimate
only based on the initial policy proposal. A final determination of the
effect on the status of any particular CAH would be determined on a
case-by-case basis and would depend on the legislative language and
implementing regulations.
recovery audit contractors
Question. What is the current status of the new Recovery Audit
Contractors (RACs) contracts? Please provide details on the new
incremental changes that RAC auditors will have to follow under the
terms of the new contracts.
Answer. CMS is currently in the procurement process for the next
round of Recovery Audit Program contracts and plans to award these
contracts this year. In February 2014, CMS announced a number of
changes to the Recovery Audit Program that will take effect with the
new contract awards as a result of stakeholder feedback. CMS believes
that improvements to the RAC program will result in a more effective
and efficient program, including improved accuracy, less provider
burden, and more program transparency.
Question. When will the Department's Working Group on the RAC
program propose its recommendations?
Answer. The Department has formed an intra-agency workgroup with
representatives from CMS, Office of Medicare Hearings and Appeals
(OMHA), and the Departmental Appeals Board (DAB) tasked with developing
recommendations to improve the Medicare appeals process and address the
significant backlog of appealed claims. We are working diligently to
identify short- and long-term solutions to address the backlog.
Question. What is the plan to address the current multiyear backlog
at the Office of Medicare Hearings and Appeals?
Answer. The Department has formed an intra-agency workgroup with
representatives from CMS, OMHA, and the DAB tasked with developing
recommendations to improve the Medicare appeals process and address the
significant backlog of appealed claims. We are working diligently to
identify short- and long-term solutions to address the backlog.
community health centers
Question. This is the last year of mandatory funding for Community
Health Centers. How has the Department planned for the so-called
funding cliff for Community Health Centers? How will the Department
prioritize its current budget in the event that no additional mandatory
dollars are provided?
Answer. As you know, the Affordable Care Act appropriated $11
billion over 5 years in mandatory funding for community health centers,
with $1.5 billion available to support major construction and
renovation at health centers, and the remaining $9.5 billion available
to support ongoing health center operations, establish new health
center sites in medically underserved areas, and expand primary care
health services at existing health center sites. While the Department
has submitted proposals in the past to mitigate the impact of the
declining mandatory funding, Congress included language in the fiscal
year 2013 and fiscal year 2014 appropriations bills directing HHS to
obligate all funding available for each respective fiscal year.
The fiscal year 2015 President's budget includes a proposal to
extend mandatory funding for health centers at $2.7 billion annually
over fiscal years 2016-2018, in addition to a discretionary investment.
This funding level is projected to support continued operations for
over 1,300 health centers with nearly 9,500 primary care sites.
The President has not yet submitted a discretionary budget for
fiscal year 2016, the year the mandatory Health Center funds will
expire. If funding for the Health Center Program is significantly lower
in fiscal year 2016 compared to the previous year a complex procedure
of grant level reductions, and possibly terminations, could occur. This
could result in numerous health center sites closing, and a reduction
in patients served by health centers.
Question. Why did the fiscal year 2015 budget proposal not attempt
to offset the funding cliff with discretionary funding?
Answer. The budget includes a proposal to continue mandatory
funding for health centers in fiscal years 2016, 2017, and 2018 at $2.7
billion per year, for a total investment of $8.1 billion. The President
has not yet submitted a discretionary budget for fiscal year 2016, the
year the mandatory Health Center funds will expire.
______
Questions Submitted by Senator Richard C. Shelby
heathcare.gov backend systems
Question. What is the status of the Affordable Care Act's (ACA)
appeals system? Has the backlog been resolved? Where are the funds
coming from to pay for the computer based infrastructure used to review
these claims?
Answer. Consumers applying for health coverage in the Marketplace
receive an eligibility determination that informs them whether or not
they are qualified to purchase coverage through the Marketplace or
receive financial assistance. Consumers who disagree with the
determination may request an appeal.
CMS first attempts to resolve the appeal directly with the consumer
through informal resolution, which involves contacting the consumer as
expeditiously as possible to work through the consumer's concerns. This
approach has worked particularly well for consumers who filed appeals
early in the open enrollment period, before system errors were
corrected. Many of these consumers have since been able to successfully
enroll in a qualified health plan and have withdrawn their appeals. CMS
prioritizes medically urgent appeals, and as a result, is working to
resolve those appeals as quickly as possible. CMS is now holding
hearings for those cases that are not otherwise resolved through an
informal process.
Question. Provide an update on how much of the healthcare.gov
backend remains incomplete including the automatic payment system. What
are the current problems with completing this task and the timeline for
resolving the issues?
Answer. As CMS has said, the automated payment and reporting system
between issuers and CMS is not complete or fully tested. CMS has an
interim process for paying issuers that are owed Marketplace financial
assistance in the form of Advanced Premium Tax Credits (APTC) or Center
for Scientific Review (CSR) payments. Under this interim process,
issuers who are owed payments submit initial, aggregate information on
a monthly basis in order to receive Marketplace financial assistance
payments. This data includes preliminary total effectuated enrollments,
enrollees receiving Marketplace financial assistance, and the estimated
amount owed to the issuer, all of which are subject to change and
unconfirmed by CMS. On a monthly basis, CMS compares the effectuated
enrollment counts submitted by the issuers to the enrollment counts
generated from the FFM for individual market issuers. These data and
payments will be further reconciled once the automated payment and
reporting system is in place. The automatic payment system is a
priority for CMS.
navigators
Question. How many Navigators have been hired?
Answer. HHS does not directly hire Navigators. The Affordable Care
Act requires that each Marketplace, including the federally facilitated
and State Partnership Marketplaces, establish a program under which it
awards grants to Navigators. In August 2013, CMS, as operator of the
federally facilitated and State Partnership Marketplaces, awarded
Navigator grants to 105 grantees to provide Navigator services to
consumers in those Marketplaces in 2013-2014. The CMS Navigator
grantees represent a broad and diverse segment of stakeholders. Each
Navigator grantee is responsible for determining staffing levels that
would be appropriate for meeting the terms and conditions of their
grants. Over the course of Open Enrollment, more than 28,000 in-person
assisters, including Navigators, were trained, and they reached more
than 2.4 million consumers through events, outreach activities, and
storefront locations.
Question. With the ACA enrollment period closed, have these people
been laid off (i.e. are they temporary employees)? If not, what will
the Navigators be doing until the next enrollment period?
Answer. Staffing levels and deployment are determined by CMS
Navigator grantees in a manner that best enables the grantee to fulfill
the terms and conditions of the Navigator grant.
Question. How much funding from fiscal year 2014 will be allocated
to the Navigators' program?
Answer. The Funding Opportunity Announcement for Navigators in the
federally facilitated and State Partnership Marketplaces for 2014-2015
has not yet been released.
Question. How much funding do you expect to allocate to the
Navigators' program in fiscal year 2015?
Answer. Funding decisions related to the Navigator program in the
federally facilitated and State Partnership Marketplaces for fiscal
year 2015 have not yet been made.
______
Questions Submitted by Senator John Boozman
Question. According to title XVIII of the Social Security Act, in
order for a hospital to continue to participate in the Medicare
program, it must meet all of the statutory provisions of section
1861(e) of this Act. This section defines a hospital as an institution
that `` . . . is primarily engaged in providing, by or under the
supervision of physicians, to inpatients . . . diagnostic services and
therapeutic services.''
With no statutory or regulatory definition of ``primarily engaged''
in reference to inpatients treated at hospitals, what criteria and/or
specific recognized quantitative method(s) is CMS using to determine
whether a hospital meets the statutory provisions of 1861(e) of the
Social Security Act?
Answer. CMS has not yet identified any quantitative method, such as
percentage of services or ratio of inpatient-to-outpatient services,
which could solely be used to determine whether a facility is primarily
engaged in furnishing services to inpatients. CMS has heard from
stakeholders that a fixed standard might exclude certain rural
hospitals. Therefore, CMS continues to interpret the phrase ``primarily
engaged'' on a case-by-case basis to consider the facts and
circumstances of each facility.
Question. In Arkansas, safety net hospitals have been subject to
overly aggressive contractors denying an overwhelming number of claims
based on minor technicalities or the contractor's own inaccuracies. Are
you aware of this issue? If so, what is being done to address and/or
correct these situations?
Answer. CMS uses the Recovery Auditors to perform medical review to
identify and correct Medicare improper payments primarily on a post
payment basis. CMS uses the vulnerabilities identified by the Recovery
Auditors to implement actions that will prevent future improper
payments nationwide. Since full implementation in fiscal year 2010
through the first quarter of fiscal year 2014, the Recovery Auditors
have returned over $7.4 billion to the Medicare Trust Fund.
To ensure the accuracy of the Recovery Auditor's claim
determinations, CMS uses an independent validation contractor to review
a monthly random sample of claims on which the Recovery Auditors has
made an improper payment determination. The Recovery Audit Validation
Contractor (RVC) establishes an annual accuracy score for each Recovery
Auditor. The RVC employs policy experts and clinicians, and presents
CMS with an independent decision regarding each sample. The accuracy
score represents how often the Recovery Auditors were accurately
determining overpayments or underpayments based on the validation
contractor's review. In fiscal year 2012, all Recovery Auditors had a
cumulative accuracy score of 92 percent or higher.
CMS is currently in the procurement process for the next round of
Recovery Audit Program contracts and plans to award these contracts
this year. In February 2014, CMS announced a number of changes to the
Recovery Audit Program that will take effect with the new contract
awards as a result of stakeholder feedback. CMS believes that
improvements to the RAC program will result in a more effective and
efficient program, including improved accuracy, less provider burden,
and more program transparency.
Question. What does CMS do when an overly aggressive contractor
review threatens the financial solvency of a longstanding Medicare
provider? Specifically, do you assist in the navigation of the appeals
process, and do you encourage attempts to be creative to achieve an
alternative resolution?
Answer. Providers who disagree with a Recovery Auditor improper
payment determination may utilize the multilevel administrative appeals
process. Recovery Audit appeals follow the same appeal process as other
Medicare claim determinations.
However, CMS is sensitive to the concerns of the provider and
supplier communities and continues to work with these communities to
reduce the burden of the review process. The CMS has imposed additional
documentation request limits on the number of medical records a
Recovery Auditor may request in a 45-day timeframe. The limits
establish continuity and help providers prepare for potential audits,
as well as encourage the Recovery Auditors to select only those claims
with the highest risk of improper payment. The limits and the
acceptance of electronic health records help to minimize the time
necessary to respond to Recovery Auditor requests and offers another
alternative for providers to safely and quickly transport the
documentation. The CMS understands that additional staffing is often
required to address Recovery Auditor correspondence and it is
constantly working to ensure providers can respond to requests without
affecting beneficiary care.
Each Recovery Auditor has a customer service center with
representatives available to address provider concerns. They are
required to have a quality assurance program to ensure that all
customers receive professional and knowledgeable assistance with timely
follow-up when necessary. Personnel are required to return telephone
calls within 1 day, respond to electronic inquiries within 2 days, and
respond to written requests within 30 days. The Medicare Administrative
Contractors (MACs) are also available to address any Recovery Audit
Program questions dealing with claims adjustment, recoupment, and
appeals. If a provider is experiencing financial hardship, the MAC may
be able to approve an extended repayment plan for the provider.
CMS works across the agency to minimize provider burden. These
efforts include ensuring that claims reviewed by one entity are not
reviewed by another contractor again, unless there is a concern of
potential fraud. CMS also works to ensure that multiple review entities
such as Recovery Auditors, Medicare Administrative Contractors, and
Zone Program Integrity Contractors are not reviewing the same providers
and the same topics at the same time. CMS is exploring additional
options to help providers navigate through the audit process.
Initiatives include enhancing CMS Web sites with consolidated
contractor information, standardizing documentation request letters,
and standardizing medical review timeframes. The CMS understands that
some providers utilize additional staffing to help manage the
requirements of the Recovery Audit Program and is constantly working to
streamline program operations as much as possible.
Question. Are you aware that Recovery Audit Contractor (RAC)
contractors are denying claims based on minor documentation
technicalities, which is explicitly prohibited by the RAC Statement of
Work? If so, how are you striving to correct this problem?
Answer. CMS regularly evaluates the Recovery Auditors' performance
and adherence to the requirements in their Statement of Work. Staff
members go on location to observe medical reviewers, IT systems, and
customer service areas. When onsite visits are not possible, CMS
conducts desk audits on claims to confirm that all aspects of the
review process were completed correctly and accounted for in the Data
Warehouse. Regular meetings with claims processing contractors,
provider groups, and other stakeholders are also monitored for
additional contractor oversight. If there are any findings in these
evaluations, CMS notifies the Recovery Auditor and requires a
corrective action plan. The results of these regular evaluations are
consolidated annually in the Contractor Performance Assessment Rating
System (CPARS) for an overall performance rating for the year. These
results are available to all Federal agencies. CMS believes that
regular contractor oversight is essential to the success of the
Recovery Audit Program. In addition, CMS uses the Recovery Audit
Validation Contractor mentioned in the response to the first question
to ensure Recovery Auditors are identifying accurate improper payments
based on Medicare policy.
Question. Does CMS expect its contractors to agree to meet in-
person with providers who have been the subject of an aggressive review
of claims and a significant number of inappropriate denials?
Answer. After notification of an improper payment, providers may
request a discussion with the Recovery Auditors regarding their claim
determinations. The discussion period offers providers the opportunity
to discuss concerns about the determination with the Recovery Auditor
Medical Director and submit additional documentation relevant to the
determination to substantiate their claims. It also allows the Recovery
Auditors to review the additional information without the provider
having to file an appeal. If the Recovery Auditor reverses its claim
determination, it will stop the claim from being adjusted, or work with
the MAC to reverse the adjustment if it has already occurred.
Each Recovery Auditor has a customer service center with
representatives available to address provider concerns. They are
required to have a quality assurance program to ensure that all
customers receive professional and knowledgeable assistance with timely
follow-up when necessary. Personnel are required to return telephone
calls within 1 day, respond to electronic inquiries within 2 days, and
respond to written requests within 30 days. The MACs are also available
to address any Recovery Audit Program questions dealing with claims
adjustment, recoupment, and appeals.
CMS is exploring additional options to help providers navigate
through the audit process. Initiatives include enhancing CMS Web sites
with consolidated contractor information, standardizing documentation
request letters, and standardizing medical review timeframes. The CMS
understands that some providers utilize additional staffing to help
manage the requirements of the Recovery Audit Program and is constantly
working to streamline program operations as much as possible.
Question. In the recently released fiscal year 2012 Recovery
Auditor Report, CMS reports data as of the first level of appeal. What
does CMS do to assess the accuracy of data cited by contractors?
Answer. The fiscal year 2012 Recovery Auditor Report, in Appendix L
includes information on the number of appeals at the first 4 levels of
appeals, including the (1) Medicare Administrative Contractor, (2)
Qualified Independent Contractors, (3) Administrative Law Judge (within
the Office of Medicare Hearings and Appeals, an agency independent of
CMS), and (4) the Departmental Appeals Board. The data reported in the
Report to Congress is gathered by CMS with assistance from the Office
of Medicare Hearings and Appeals and the Departmental Appeals Board.
All collections and appeals data cited in the Report to Congress is CMS
data and not contingent on Recovery Auditor data.
To ensure the accuracy of the Recovery Auditor's claim
determinations, CMS uses an independent validation contractor to review
a monthly random sample of claims on which the Recovery Auditors has
made an improper payment determination. The Recovery Audit Validation
Contractor (RVC) establishes an annual accuracy score for each Recovery
Auditor. The RVC employs policy experts and clinicians, and presents
CMS with an independent decision regarding the sample. The accuracy
score represents how often the Recovery Auditors were accurately
determining overpayments or underpayments based on the validation
contractor's review. In fiscal year 2012, all Recovery Auditors had a
cumulative accuracy score of 92 percent or higher.
Question. CMS announced in February that it will require RACs to
adjust the Additional Documentation Requests (ADRs) to levels in line
with the provider's denial rate, allowing providers with low denial
rates to have lower ADR limits and providers with high denial rates to
have higher limits. Although it is yet to be determined whether this
change will alleviate provider burden as there is disagreement over the
accuracy of RAC denial rates, I would urge the Agency to continue to
pursue changes that ensure the RAC program targets improper payments
while taking into consideration the overall burden on providers. Does
the Agency have further plans to require such flexibility and
reasonableness in the RAC program?
Answer. CMS is currently in the procurement process for the next
round of Recovery Audit Program contracts and plans to award these
contracts this year. In February 2014, CMS announced a number of
changes to the Recovery Audit Program that will take effect with the
new contract awards as a result of stakeholder feedback. CMS believes
that improvements to the RAC program will result in a more effective
and efficient program, including improved accuracy, less provider
burden, and more program transparency.
______
Questions Submitted to Mark H. Greenberg
Question Submitted by Senator Richard J. Durbin
head start
Question. In fiscal year 2014, Congress restored the 5.27 percent
reduction Head Start grantees received in fiscal year 2013 due to
sequestration with the expectation that grantees would use the funds to
restore services to pre-sequestration levels. In some cases, especially
in rural Illinois, restoration of services to exactly match pre-
sequestration enrollment slots or other service levels may be
impossible or no longer the best use of funds due to reduction in
population or other changing needs of the community. How is the
Department working with local grantees to provide flexibility to ensure
the much needed restored resources are being used to best serve the
local community?
Answer. The Office of Head Start (OHS) communicated to grantees the
expectation that they use the 5.27 percent Congress appropriated to
restore the number of funded enrollment slots, the number of days or
weeks in the program year, or the other cuts programs made to absorb
the reduction. We asked grantees to work with their Regional Office if
there are circumstances that make full restoration of services or slots
challenging. As the Senator noted, there are situations where it is no
longer possible or the best use of funds to restore exactly what was
cut. For example, some grantees no longer have access to the facility
where they provided center-based care prior to sequestration or the
needs of the community have changed, such as declining population or
expanded pre-school services through other providers. In these cases,
Regional Offices are working with grantees to explore other service
enhancements to meet the needs of the community. If the grantee can
only restore a portion of the slots that were cut, for example,
Regional Offices engage in discussions on extending the hours or days
of service as an alternative.
______
Questions Submitted by Senator Jerry Moran
head start
Question. How will the Administration on Children and Families
ensure that Early Head Start-Child Care Partnership funding reaches
rural States like Kansas?
Answer. We anticipate a robust nationwide competition, including
rural States and communities. Funding is available within each State
based on the number of young children in poverty and HHS hopes to fund
high-quality applications from all 50 States.
unaccompanied alien children program
Question. The budget request did not provide an increase for the
Unaccompanied Alien Children (UAC) program, knowing that the number of
children coming into the country illegally would increase this year.
Therefore, what HHS programs do you suggest we reduce to address this
shortfall?
Answer. The fiscal year 2015 budget requested $868 million for the
UAC program, consistent with the level provided in the fiscal year 2014
enacted bill, given the high degree of uncertainty around the program's
future needs. However, the budget also proposed over $2.2 billion in
discretionary program terminations and reductions at the Department. We
appreciate the additional funding provided in the fiscal year 2015 bill
reported out by the subcommittee as well as the enhanced authority to
draw on other resources in the Department as needed.
Question. After appropriating a $510 million increase in the fiscal
year 2014 Omnibus for the UAC program, the subcommittee requested that
HHS coordinate with the Departments of State, Homeland Security, and
Justice in an effort to develop strategies for managing the rising cost
of HHS' program. What proposals have been developed to reduce funding
increases for this program in the future?
Answer. HHS has been coordinating with State, DHS, DOJ, and OMB on
strategies to stem the flow of UAC, reduce the length of stay, and
otherwise reduce costs. HHS efforts, in coordination with other
Departments, have already reduced length of stay (from 75 days to 35
days) and costs, producing a 56 percent reduction in per capita shelter
costs from 2011 to 2014.
The Departments have also identified several strategies that are
currently under consideration for feasibility of implementation. These
strategies include:
--Modified approach to children with non-parent relatives--to not
treat some children that are apprehended at the border with a
non-parent relative as a UAC, and to develop alternate
procedures for children apprehended throughout the interior of
the U.S., if residing with a relative at the time of
apprehension.
--Modified approach to youth with serious criminal offenses, for whom
release to a parent or sponsor is not appropriate.
--Speeding up voluntary departure.
--Developing improved transportation services--DHS and HHS are
exploring whether an integrated transportation system could
reduce costs while maintaining sufficient protections for
children.
--Developing a shared services model.
--DHS and HHS are exploring a plan for a co-located site, which may
yield savings.
evaluation tap
Question. How was it determined that an increase in the Evaluation
Tap was necessary for fiscal year 2015?
Answer. The Public Health Service (PHS) Evaluation Set-Aside is
authorized by section 241 of the PHS Act, which has been amended in
appropriations bills, to fund activities across HHS like AHRQ and CDC's
National Center for Health Statistics. These funds are used to support
critical public health and evaluation activities across HHS. Congress
sets both the tap percentage and the usage of funds for the purposes
specified in law. The fiscal year 2015 President's budget proposes an
increase of the PHS Evaluation Set-Aside from 2.5 percent to 3 percent,
consistent with the approach taken in the fiscal year 2014 President's
budget, and transparently reports how this funding would be used, both
in program level totals and in appropriations language.
Question. Please explain what deliberations take place within HHS
and with the White House when deciding which agencies are to be the
sources and receivers of Evaluation Tap transfers.
Answer. The PHS Act Set-Aside is authorized by section 241 of the
PHS Act, which has been amended in appropriations bills and allows HHS
to assess a percentage of PHS Act authorized program funding to support
activities across the Department. Historically, activities are excluded
from the set-aside because they are not PHS Act authorized, they
support program management, or they have been consciously excluded by
Congress (e.g., the SAMHSA block grants). The Department examines
sources and receivers during the annual budget process and Congress
sets both the tap percentage and the usage of funds for the purposes
specified in law.
Question. Why does the Department use a budget gimmick to highlight
an increase of $200 million for NIH, even though NIH is left with only
a $58 million increase above fiscal year 2014 after accounting for the
tap increase?
Answer. The Public Health Service Evaluation Set-Aside plays a
critical role supporting key public health programs and Congress sets
both the tap percentage and the usage of funds for the purposes
specified in law. As with most of the Department's other public health
agencies, NIH contributes its mathematical share of resources to the
PHS Evaluation Fund.
______
Question Submitted by Senator Richard C. Shelby
children's hospital graduate medical education & new workforce
initiative
Question. The new Children's Hospital Graduate Medical Education
(GME) program sets-aside $100 million for children's hospitals.
Children's hospitals were funded at $265 million in fiscal year 2014.
Why is the Children's GME program targeted for such a significant
reduction?
Currently, the Children's GME is distributed by a formula-based
payment. Within the new $530 million workforce initiative, only $100
million will be distributed to children's hospitals using the current
formula. Children's hospitals along with all teaching hospitals will be
eligible to compete for the remaining $430 million. How will children's
hospitals continue to train physicians when they will only receive a
small percentage of their prior formula-based payments and are not
successful in the new competition?
The National Health Service Corps and Targeted Support for GME
programs are described with a focus on increasing the number of
physicians in rural and other underserved areas. How will HHS
accomplish this objective?
Answer. The Children's Hospital Graduate Medical Education (CHGME)
Program will be integrated into the new, competitive community-based
Targeted Support for Graduate Medical Education Program which will
expand residency slots, with a focus on ambulatory and preventive care
in order to advance the goal of higher value healthcare that reduces
long-term costs. To support the transition of CHGME into the new
program, the budget includes $100 million of mandatory funding per year
for 2 years to support the Children's Hospital GME Program to be
allocated using the existing formula. In addition, these hospitals will
be able to apply for the competitive funding to support pediatric
residency training through the new Targeted Support for Graduate
Medical Education Program.
The Targeted Support for Graduate Medical Education Program will
continue to support graduate medical education in children's hospitals.
The program includes a $100 million set-aside for 2 years to be
distributed to children's hospitals using the current CHGME formula and
they can compete for additional funding. While HRSA can't estimate the
number of FTEs supported in Children's Hospitals in the TSGME program
until a FOA is released and awards are made, HRSA supports efforts to
train providers who treat children outside of the hospital setting, as
well as current service delivery to children.
--NHSC, through both scholarship and loan repayment programs,
supported 540 pediatricians, pediatric nurse practitioners,
pediatric dentists, and child psychiatrists to serve in HPSAs
(as of September 2013).
--Currently, there are nearly 100 students, residents, and health
providers specializing in the health of children and preparing
to go into practice and are receiving support from these
programs.
--HRSA also funds the PC Residency Expansion program, which currently
supports 14 pediatric residencies to increase the number of
resident positions for 5 years, from 2010-2015, adding well
over 100 new pediatricians to the workforce.
--And also relevant to access to care for children, in 2012, health
centers treated more than 6.6 million patients under the age of
18; in fact, nearly 32 percent of all health center patients
are children.
The Targeted Support for Graduate Medical Education Program will
focus specifically on key priorities for workforce development and
transforming the healthcare delivery system. For example, the program
will focus on increasing training opportunities in community-based
settings, including in rural and underserved areas. Applicants will
need to demonstrate that they provide diverse training experiences that
will help ensure that we are training future physicians in the settings
where we know patients get the bulk of their care, as well as being
trained in the models of healthcare delivery that are most effective.
This will help ensure that HRSA funds residencies that are likely to
produce primary care practitioners who would work in rural and
underserved areas, where the need is the greatest.
In fiscal year 2015, HRSA expects to fund over 10,000 new National
Health Services Corps loan repayment awards in order to build and
sustain a field strength of 15,000 primary care providers across the
country, serving the primary care needs of more than 16 million
patients in high-need rural, urban, and frontier areas across the
United States. In fiscal year 2013, 100 percent of all new National
Health Services Corps loan repayment awards were made to those serving
in health professional shortage areas (HPSAs) of highest need (scores
of 14 or higher) and nearly half of National Health Services Corps
clinicians are serving at rural sites.
A 2012 retention assessment survey found that 55 percent of
National Health Service Corps clinicians continue to practice in
underserved areas 10 years after completing their service commitment.
Another recent study completed in fiscal year 2013 showed 85 percent of
those who had fulfilled their service commitment remained in service to
the underserved in the short-term. Short-term is defined as up to 2
years after their service completion.
HRSA continues to provide support to clinicians who practice in
underserved areas. For example, HRSA has several social media outreach
efforts to keep clinicians apprised of program updates and events, as
well as networks to provide additional local resources for clinicians
serving in underserved communities.
______
Questions Submitted to Thomas R. Frieden, M.D., M.P.H
Questions Submitted by Senator Tom Harkin
prescription drug overdose
Question. Our country is facing a major public health problem
regarding the increasing use, and abuse, of prescription painkillers.
In the past two decades, prescriptions for opioid painkillers in the
U.S. nearly tripled to over 200 million per year. Just last month, a
study reported that one in five women on Medicaid used prescription
opioids during pregnancy. How will the funding you requested in the
President's budget address the prescribing patterns of doctors
regarding opioid painkillers?
Answer. Prescription opioid overdoses quadrupled in the United
States between 1999 and 2010. During this same time period, the amount
of prescription opioids prescribed in the United States also
quadrupled. Centers for Disease Control and Prevention (CDC) identified
two factors that account for a large percentage of prescription opioid
overdoses: (1) patients receiving opioids from multiple prescribers
and/or pharmacies and (2) increased number of prescriptions for high
daily doses of opioids. As the Nation's public health agency, CDC
focuses on prevention, and prevention of this epidemic includes
addressing the prescribing practices that fuel prescription drug abuse,
addiction, and overdose.
The President's budget request reflects CDC's focus on prescribing.
The initiative will deliver the resources and expertise to funded
States to address prescribing practices that are driving this epidemic.
The $15.6 million proposed would expand the existing Core Violence and
Injury Prevention Program (Core VIPP) funds to support State health
department injury programs to (1) strengthen their ability to track and
monitor prescribing and overdose trends, (2) build out effective
insurance strategies to identify and stop inappropriate prescribing,
and (3) enhance prescription drug monitoring programs (PDMPs) to equip
doctors and pharmacists with the information they need to protect their
patients.
Sixteen of the currently funded 20 States currently use this
funding to address problem prescribing in important and innovative
ways. For example, States are improving or evaluating Medicaid patient
review and restriction programs, protecting patients at the highest
risk for overdose, integrating PDMP with electronic health record
systems, or using PDMP data to identify doctors who may be prescribing
inappropriately.
linkages with clinical care
Question. In the fiscal year 2014 Omnibus, Congress provided CDC
with funding to make big new investments in heart disease, diabetes,
and community chronic disease prevention this year. Given all the
changes in the healthcare system, please describe how these resources
will help link public health and clinical care to prevent and control
chronic disease and promote health in our communities.
Answer. CDC provides scientific leadership and technical expertise
to State, local, tribes/tribal organizations, and U.S. territories to
assist them in building capacity to develop and implement chronic
disease prevention and health promotion programs that have measureable
impact. CDC is focused on implementing cross-cutting strategies to
address school health, nutrition and physical activity risk factors,
obesity, diabetes, heart disease and stroke: (1) conducting
epidemiology and surveillance, (2) implementing environmental
approaches, (3) expanding health system interventions, and (4)
enhancing community-clinical linkages.
With fiscal year 2014 funds from the Prevention and Public Health
Fund, CDC will implement Funding Opportunity Announcement (FOA) DP14-
1422, PPHF 2014: State and Local Public Health Actions to Prevent
Obesity, Diabetes, and Heart Disease and Stroke. CDC is supporting
implementation of population-wide approaches to prevent obesity,
diabetes, and heart disease and stroke and reduce health disparities.
In addition, these new investments target priority population subgroups
with uncontrolled high blood pressure and those at high risk for type 2
diabetes that experience racial/ethnic or socioeconomic disparities,
including inadequate access to care, poor quality of care, or low
income. This competitive FOA to States and large cities has two
components, both of which are designed to address heart disease,
stroke, and diabetes. Through these efforts, CDC builds on and expands
the work funded in ``FOA 13-1305-State Public Health Actions to Prevent
and Control Diabetes, Heart Disease, Obesity, and Associated Risk
Factors and Promote School Health''.
To specifically address linkages with clinical care, CDC is
implementing key interventions such as:
--Implementing systems to facilitate identification of patients with
undiagnosed hypertension and people with pre-diabetes.
--Increasing partnerships to facilitate bi-directional referral
between community resources and health systems, including
evidence-based lifestyle change programs.
--Improving the delivery and use of clinical services by increasing
implementation of quality improvement processes in health
systems (e.g., fully utilizing electronic health records).
--Working to increase the use of team based care in health systems
(e.g., increasing the use of self-measured blood pressure
monitoring in conjunction with clinical support).
--Increasing the use of community health workers (e.g., patient
navigators) in the community to promote linkages between health
systems and community resources for adults with high blood
pressure and adults with pre-diabetes or at high risk for type
2 diabetes and to support self-management of chronic diseases
and related risk factors.
Such interventions have been shown to result in measurable impacts
on heart disease, stroke, and other chronic conditions. The
interventions build on the lessons learned implementing coordinated
models intended to maximize CDC's investment in the work of State and
local departments of health. Using additional non-PPHF funds, CDC will
work with awardees to operationalize community health needs assessments
(CHNAs) as a critical tool in improving health and a tangible
opportunity to link communities and health systems, including nonprofit
hospitals. Throughout the course of this funding and beyond, CDC will
continue to monitor and evaluate longer term outcomes associated with
better connections between the public health and the health sector that
result from these investments.
______
Questions Submitted by Senator Richard J. Durbin
biomedical research
Question. Many Americans think of the Center for Disease Control
and Prevention (CDC) as a reactive agency that works to contain and
manage viral epidemics and other public health threats--and it does--
but the agency also conducts important proactive research work.
What areas of biomedical research are being conducted by CDC? Has
past research led to any significant health safeguards? How would CDC
invest a steady increase in funding to expand and supplement this
research? The fiscal year 2015 budget request cuts CDC funding by more
than $200 million. What research functions will CDC have to suspend as
a result of this decrease?
Answer. CDC has many unique roles that span the research continuum,
as well as a primary role in applying the knowledge gained through
research in addressing health threats and making Americans healthier.
CDC research provides people the information they need to make
healthier choices; provides clinicians with vaccines to protect
children against deadly diseases; and gives health systems the tools
they need to control healthcare-associated infections. CDC's unique
applied research role is in solving real-world problems, and in taking
what we learn and know based on research and putting it to work in
clinics and communities around the world.
As the Nation's public health protection agency, CDC funds and
engages in a wide range of research, from laboratory investigations to
epidemiologic analyses to prevention effectiveness research to clinical
trials. A few examples of research conducted by CDC include the
following:
--Through new fiscal year 2014 funding, CDC is increasing its
investment in Advanced Molecular Detection technology to use
molecular sequencing tools and better develop bioinformatics
capacity. These technologies can more rapidly deliver a greater
level of detailed information on infectious pathogens, thereby
more quickly identifying and responding to outbreaks, better
understanding and controlling antibiotic resistance, and better
developing targeted prevention measures.
--CDC is the source of much of our knowledge about the population's
health, from rigorous surveys and scientific studies. For
example, CDC's National Health and Nutrition Examination Survey
(NHANES) takes measures of nutritional biochemistries,
nutrients, toxic chemicals, and other direct biomedical
measures to assess the Nation's health. From this and other
data from CDC surveys, scientists at CDC and elsewhere analyze
the relationship between health risk factors and health
outcomes.
--CDC's laboratories serve as key elements of our Nation's defense
against outbreaks, but also generate new knowledge that
advances the biomedical sciences. As an example, tobacco
laboratories measure addictive and toxic substances in tobacco
products and smoke, as well as in the urine and blood of
persons who use tobacco or are exposed to secondhand smoke.
Similarly, the deadly 1918 influenza virus was safely
reconstructed in secure CDC laboratories, using genetic
fragments, allowing scientists to better understand influenza
genetics and be more prepared to detect new, deadly flu
strains.
--CDC tracks antibiotic resistance, having last year released the
first-ever national report on the burden and threats posed by
antibiotic-resistant infections. CDC not only tracks these
threats, but also assesses and categorizes their hazard level,
provides recommendations on preventing the spread of
resistance, and addresses gaps in our current knowledge of
antibiotic resistance.
--CDC has developed a portable and effective light trap to kill
mosquitoes and other insect vectors of disease. This trap is
being used throughout the world.
--Nutrition and chronic disease laboratories develop new or improved
methods for measuring nutritional and dietary bioactive
compounds to conduct the most comprehensive assessment of the
Nation's nutritional status, improve laboratory measurements to
detect micronutrient deficiencies in the United States and
developing countries, and operate reference laboratories that
ensure the accuracy of clinical measurements for cardiovascular
and other selected chronic diseases.
Question. Has past research led to any significant health
safeguards?
Answer. CDC's biomedical and other research has consistently
supported the protection and improvement of the public's health. New
scientific discoveries lead to the development and refinement of
clinical guidelines, health policies, and community programs. CDC
identifies new pathogens, and develops new diagnostic tests for their
identification by laboratories across the country and the world.
Moreover, CDC continually tracks the health of the Nation and the
emergence of new health threats, providing recommendations for action
and guiding funding decisions elsewhere.
--CDC has contributed significantly to the roughly 63 percent
decrease in new domestic tuberculosis (TB) cases between 1992
and 2012. Since its inception in 1997, CDC's Tuberculosis
Trials Consortium has brought together a number of U.S.
research institutions and clinical trials sites around the
world to develop new TB treatment and prevention strategies. In
2009, CDC's TB laboratory developed and implemented the
Molecular Detection of Drug Resistance Service, a national
clinical referral service providing rapid confirmation of
multidrug-resistant and extensively drug resistant TB. CDC also
develops TB prevention and treatment guidelines, such as the
recent release of guidelines for the use and safety monitoring
of Bedaquiline Fumarate, the newest drug for the treatment of
multidrug-resistant TB.
--CDC's influenza laboratories work to develop vaccines and track
changes in the circulation of influenza viruses. These
laboratories test influenza viruses from around the world to
detect antigenic change, which provides information for
pandemic preparedness and vaccine composition decisions.
Additionally, they produce seed strains for influenza vaccine
development, test the immunogenicity (ability to provide an
immune response) of influenza vaccines among humans, and test
transmissibility of newly emergent influenza viruses in animal
models.
--CDC health data collection drives health funding allocations. For
instance, CDC provides HIV surveillance data to the HRSA Ryan
White HIV/AIDS Program. Since fiscal year 2007, HRSA has used
total counts of living cases of HIV and living cases of AIDS in
the Ryan White HIV/AIDS Treatment Program Parts A and B
allocation formulae. By providing these data to HRSA, CDC and
HRSA are collaborating to ensure that the HIV care and
treatment funds are rationally distributed according to the
Ryan White program legislation.
--Chemical threat agents and toxins laboratories support the public
health response to emergencies with around-the-clock laboratory
capability to identify human exposure to 150 chemical threat
agents within 36 hours. This laboratory system provides support
to and proficiency testing for State, local, and territorial
public health laboratories to maximize national capacity for
response to chemical incidents, and develop unique laboratory
methods for measuring toxins for diagnosing botulism, anthrax,
and ricin poisoning rapidly and accurately.
Question. How would CDC invest a steady increase in funding to
expand and supplement this research?
Answer. CDC research is directed to solving real-world problems.
Sustained increased funding for research would allow to CDC to steadily
expand investments in current priorities areas, while also allowing for
funding to address emerging health threats. The fiscal year 2015
President's budget includes funding increases for key areas of
research, such as:
--Antibiotic Resistance.--CDC is proposing to establish a robust
national network to deal with this rapidly growing threat to
our Nation and the world. Additional funding will enable better
detection of the deadliest antibiotic resistance threats and
protect patients and communities, saving lives and healthcare
costs.
--Global Health Security.--All our health security threats are
amplified by the globalization of travel and the food supply.
MERS is a recent example. CDC will work in partnership with
other countries, U.S. Government partners, and global
organizations to accelerate progress toward a world safe and
secure from infectious disease threats. An important element of
this proposal is to establish a global laboratory network
capable of detecting all public health emergencies of
international concern.
--Surveillance, Epidemiology, and Public Health Informatics.--The
budget request expands CDC's capacity to monitor key health
indicators, purchase 12 months of electronic birth records
enhanced data, phase in electronic death and birth records, and
increase funding for public health systems research.
Question. The fiscal year 2015 budget request cuts CDC funding by
more than $200 million. What research functions will CDC have to
suspend as a result of this decrease?
Answer. The President's budget request proposes strategic new
investments and identifies targeted reductions that will allow CDC to
advance its core public health mission in the most cost-effective
manner. In a limited resource environment, the request includes
elimination of CDC funding for Occupational Safety and Health Education
Research Centers, as well as for the Agricultural, Forestry, and
Fishing Sector of the National Occupational Research Agenda. CDC
reductions focused primarily on eliminating duplicative, less
effective, and lower priority programs in order to fund priorities and
address urgent public health threats, such as global health security
and antimicrobial resistance.
tobacco and e-cigarettes
Question. Smoking causes nearly one in every five deaths in the
United States and costs the country $193 billion each year in
healthcare expenses and lost productivity. An estimated 43.8 million
American adults smoke cigarettes, and about 3,800 young people under
the age of 18 smoke their first cigarette every day. Congress created
the Prevention and Public Health Fund, a dedicated funding stream for
crucial investments in prevention for a healthier America, to begin
addressing these and other public health challenges. The Fund provides
an opportunity to reverse decades of increasing healthcare costs
attributable to growing rates of obesity, chronic disease, and other
preventable illness.
Please summarize investments made through the Prevention and Public
Health Fund (PPHF) to promote tobacco prevention and control. What
measurable economic and health benefits have resulted from those
investments?
A portion of the fund went toward the Centers for Disease Control
and Prevention Tips from Former Smokers campaign. Please summarize the
status of this initiative and health and economic benefits of this
campaign. If Prevention and Public Health Funds dollars are reallocated
toward nonpublic health prevention initiatives, how would that
reallocation of funds impact tobacco control and prevention efforts and
the returns on those investments?
The use and sale of e-cigarettes in the United States has grown
significantly over the past decade. According to a recent CDC report,
the number of calls to poison centers involving e-cigarette liquids
rose from one per month in September 2010 to 215 per month in February
2014. More than half of the calls to poison centers due to e-cigarettes
involved young children under age 5, and about 42 percent of the poison
calls involved people age 20 and older.
Please summarize CDC's current and planned research on the public
health effects of e-cigarettes?
Answer. PPHF-funded tobacco prevention initiatives such as Tips
from Former Smokers and quitline support are having substantial impact.
Without these investments we would expect to see substantially fewer
Americans who have quit smoking.
Tips From Former Smokers.--The Tips from Former Smokers Campaign is
currently in its third year, and will return to the airwaves with new
ads in summer 2014. CDC estimates that so far, Tips has led millions of
Americans to make a quit attempt, and hundreds of thousands to quit
permanently. Because of the strong evidence of effectiveness of the
Tips campaign, the 2014 Surgeon General's Report recommended ``the
following action should be implemented: Counteracting industry
marketing by sustaining high impact national media campaigns like the
CDC's Tips from Former Smokers campaign and FDA's youth prevention
campaigns at a high frequency level and exposure for 12 months a year
for a decade or more.''
On average, annual funding levels have sustained the Tips campaign
between 3 and 4 months of each year, and represent less than 3 days of
tobacco industry spending on promotion and marketing. Nevertheless, at
current levels the funds are having a substantial impact. At a cost of
less than $200 per life year saved, Tips is also a highly cost-
effective strategy. In contrast, most clinical and preventive
interventions cost thousands of dollars per year of life saved.
Quitline Support.--PPHF funds also allowed CDC to dramatically
expand the reach of State tobacco cessation quitlines through the Tips
from Former Smokers national tobacco education campaign. PPHF funds
supported both the campaign and State quitline capacity to handle the
increased calls generated by the campaign. During the 2012 and 2013
Tips campaigns, which aired for a combined total of 28 weeks, there
were a total of 718,042 calls to 1-800-QUIT-NOW, a portal which routes
callers to their State quitlines. This represents 359,055 additional
calls beyond baseline levels.
Community Investments.--In addition, PPHF-funded community
investments addressing tobacco use (as well as nutrition and physical
activity) have had substantial impact and reach. For example:
--As a result of the CDC's chronic disease community investments
funded through recovery act funds, an estimated 27.4 million
Americans now have increased protections from deadly secondhand
smoke exposure in workplaces, restaurants, bars, schools,
multi-unit housing complexes, campuses, and recreation areas.
--As of December 2013, the chronic disease community investments
funded through Prevention and Public Health Funds are estimated
to have provided 15.6 million new people with access to smoke-
free or tobacco-free interventions.
Question.--The use and sale of e-cigarettes in the United States
has grown significantly over the past decade. According to a recent CDC
report, the number of calls to poison centers involving e-cigarette
liquids rose from one per month in September 2010 to 215 per month in
February 2014. More than half of the calls to poison centers due to e-
cigarettes involved young children under age 5, and about 42 percent of
the poison calls involved people age 20 and older.
Please summarize CDC's current and planned research on the public
health effects of e-cigarettes?
Answer. Through surveillance analysis and updates, original
research, and coordination with HHS agencies, CDC is conducting
cutting-edge research to capture the public health effects of e-
cigarettes.
Surveillance Analyses and Updates.--CDC's Office on Smoking and
Health (OSH) is in the process of analyzing available e-cigarette data
and updating key surveillance systems to incorporate questions about e-
cigarette use, including CDC's National Adult Tobacco Survey, National
Youth Tobacco Survey, and the Global Adult and Youth Tobacco Surveys.
--Additionally, CDC is working with partners, other Federal agencies,
and States to incorporate e-cigarette questions into existing
surveillance systems, including the National Health Interview
Survey (NHIS), National Health and Nutrition Examination Survey
(NHANES), Behavioral Risk Factor Survey (BRFS), Youth Risk
Behavior Survey (YRBS), Pregnancy Risk Assessment Monitoring
System (PRAMS), FDA's Population Assessment of Tobacco and
Health (PATH), SAMHSA's National Survey on Drug Use and Health
(NSDUH), and State Youth (YTS) and Adult (ATS) Tobacco Surveys.
--Finally, CDC is leveraging opportunities to collect data on e-
cigarettes from rapid response sources, such as HealthStyles
and YouthStyles surveys.
Research.--CDC is developing a series of research projects to
address significant knowledge gaps related to e-cigarettes.
--A request for proposal (RFP) has been announced to support a
contract for research to measure the effects of secondhand
exposure to e-cigarette aerosol. The CDC study aims to simulate
and examine real-life exposure to secondhand aerosol from e-
cigarettes by conducting an observational pilot research study
looking primarily at biomarkers of exposure to nicotine in
research participants exposed to secondhand e-cigarette
aerosol. CDC anticipates making the award this summer.
--CDC's Tobacco Laboratory is collaborating with the FDA on studies
that address three main categories of e-cigarettes: cigarette
look-alikes, pencil size e-cigarettes (these use nicotine
liquid) and tank e-cigarettes (large, often with voltage
adjustment and use nicotine liquid). These studies will
measure: (1) harmful and potentially harmful constituents of e-
cigarette aerosol and nicotine liquid, (2) addictive compounds
in e-cigarette aerosol and liquid, and (3) biomarkers of these
harmful and addictive constituents in blood and urine of users
and people exposed to e-cigarette aerosol. CDC is also working
on standardized smoking machine measurement protocols so
measurements of constituents in e-cigarette aerosol can be
reliably compared between different laboratories.
--CDC, in coordination with FDA's Center for Tobacco Products, is
conducting a more in-depth analysis to build upon the MMWR
published on e-cigarette exposures called to poison centers.
The additional analyses will compare the health effects and
demographics of reported e-cigarette exposures to other
nicotine-delivery methods such as nicotine patches, lozenges,
and gums.
--Formative research is being conducted with adult smokers and former
smokers 18-54 years old to understand reasons for use of
noncombustible tobacco products (e.g., e-cigarettes, chewing
tobacco, snus) in combination with combustible tobacco products
(e.g. cigarettes, little cigars).
--In partnership with FDA, CDC is performing in-depth research with
pregnant women and women planning a pregnancy to assess their
understanding of risks associated with using electronic
cigarettes and other nicotine-containing products during
pregnancy.
--Among youth and adults, CDC is also examining the impact of
exposure to e-cigarette advertising on intention to use e-
cigarettes or other tobacco products.
--Through a survey administered by the American College of
Obstetricians and Gynecologists, CDC is examining screening
practices, knowledge and attitudes of obstetricians toward the
use of electronic cigarettes and other nicotine containing
tobacco products during pregnancy.
Coordination.--CDC's Office on Smoking and Health works closely
with HHS agencies to coordinate research priorities, including, for
example:
--CDC and the National Cancer Institute (NCI), with the North
American Quitline Consortium, are assessing current quitline
experiences regarding e-cigarettes to inform future messaging
and tracking.
--CDC and FDA co-authored recent updates on youth use of e-cigarettes
(September 2013) and e-cigarette related calls to poison
centers (April 2014).
--CDC and FDA are working together to analyze data from the National
Adult Tobacco Survey (NATS) and the National Youth Tobacco
Survey (NYTS) on the impact of e-cigarette use on cessation and
on youth and young adult intentions to smoke conventional
cigarettes.
______
Questions Submitted by Senator Jeanne Shaheen
Question. The National Asthma Control Program helps millions of
Americans control their disease. In the United States today nearly 26
million people have asthma, including 7 million children. This is
concerning to me since New Hampshire's asthma prevalence rates are
higher than the national average.
The CDC has requested level funding of $27.4 million for the
National Asthma Control Program, which appears to only fund preventive
work in 20 States. However, it is my understanding that this program
was always envisioned to be nationwide. Is CDC committed to ensuring
that every State has a comprehensive approach to asthma control? How
much funding would it take to get a quality program in every State?
Answer. CDC's National Asthma Control program is committed to
advancing knowledge on asthma interventions with the strongest evidence
of effectiveness. Comprehensive asthma care entails providing a
seamless alignment of the full array of services across the public
health and healthcare sectors so that people with asthma receive all,
not just some, of the services they need. Providing comprehensive care
at a population level requires a stepwise approach. The first step is
to ensure the availability of and access to guidelines-based medical
management and pharmacotherapy for all people with asthma. Then, for
the segment of people whose asthma remains poorly controlled,
additional next steps provide or link them with progressively more
individualized services (e.g., intensive self-management education,
environmental trigger reduction services, and other environmental
management strategies).
CDC reduced the number of awards in order to increase the average
award to States ($331,000 in fiscal year 2013 to $650,000 in fiscal
year 2014). Additionally, CDC restructured the awards using a
population-based model to ensure that funding was allocated based on
need. Funding comprehensive care to a subset of States based on need is
CDC's current approach.
Question. I am deeply troubled that 1 in 10 kids have asthma
nationwide and it is a growing contributor to health disparities. What
can we do to reverse this startling trend?
Answer. CDC recognizes that asthma prevalence is increasing
nationwide and is a significant contributor to health disparities.
Today, African-Americans are 2-3 times more likely to die from asthma
than any other racial or ethnic group. CDC has a strong network of
funded State asthma programs and partners and an established
surveillance role in public health. States use the information we
collect to target vulnerable populations and implement comprehensive,
evidence-based asthma interventions.
Asthma carries with it a significant economic burden. In 2007,
asthma cost about $56 billion in medical cost, lost school and work
days, and early deaths. Medicaid spends over $10 billion per year
treating asthma. While we don't know what causes asthma, we do know
that attacks are sometimes triggered by allergens, exercise,
occupational hazards, tobacco smoke, air pollution, and airway
infections.
CDC's National Asthma Control program works with States to reduce
the burden of asthma across the country. While the overall number of
people with asthma has risen, trends show that more people with asthma
are living with their disease under control. For example, we have seen
the hospitalization rate decline by 14 percent in States receiving CDC
asthma funds (2000-2007).
Other progress in addressing asthma:
--1.7 million fewer people had asthma attacks in 2009
--Over 1,000 fewer people died in 2010
--Children missed 4.2 million fewer school days because of asthma in
2008
CDC's asthma grantees have also reduced healthcare costs. In
Connecticut, the ``Putting on AIRS Program,'' a home based program
focusing on self-management and elimination of asthma triggers,
reported significant progress:
--85 percent decline in emergency department visits
--67 percent decline in asthma-related physician visits
--62 percent decline in missed days of school and work
--Net savings of $26,720 per patient after 6 months
In Michigan, the asthma program worked with the Asthma Network of
West Michigan and Priority Health, the largest payer in western
Michigan, to reduce healthcare costs and improve asthma outcomes:
--44.4 percent decline in emergency department visits among private
members
--24.4 percent decline in emergency department visits among Medicaid
members
--For every $1 invested in home visits, environmental assessments and
trigger reduction, it has recouped $2.10 in reduced costs due
to uncontrolled asthma.
These are just a few examples of how CDC is working to reverse
trends.
Question. I believe the National Diabetes Prevention Program holds
great promise to reduce the burden of diabetes and I am anxious to see
the program implemented in even more communities in New Hampshire and
across the country. I was pleased to see that the President's budget
includes a request for $10 for the program.
--Given the incredible promise of the National Diabetes Prevention
Program to reduce the number of individuals with prediabetes
that develop type 2 diabetes, can you share with us the
agency's plan for expanding the number of program sites and
individuals participating in fiscal year 2015?
--Currently there are 79 million people with prediabetes. Does the
agency have an estimate of the resources needed for the
National Diabetes Prevention Program to confront the human and
economic impact of the disease beyond 2015?
Answer. New estimates from CDC indicate more than 86 million adults
in the U.S. have prediabetes, an increase from the previous estimate of
79 million in 2010. With an fiscal year 2015 appropriation request of
$10 million (level with the 2014 appropriation), CDC's National
Diabetes Prevention Program grantees will expand locations, target
populations, settings, number of sites, number of participants, and
number of lifestyle coaches, class offerings, and insurance
reimbursement. Selected grantee activities include:
--The Black Women's Health Imperative will expand its program sites
to New Orleans and Baton Rouge, Louisiana, where they have
identified specific prediabetes health disparities.
--Y of the U.S.A. (Y) plans to increase the number of sites offering
the lifestyle change program from 11 to 46.
--The National Association of Chronic Disease Directors (NACDD) has
secured coverage of the lifestyle interventions for the Thomas
Jefferson Health System medical school, medical center, and
Accountable Care Organization clients.
In fiscal year 2015, CDC plans to increase the number of
organizations applying for CDC recognition through promotion of the
Diabetes Prevention Recognition Program (DPRP). To date, 508
organizations have applied for recognition, serving approximately
10,200 participants. CDC is revising its DPRP standards to incorporate
recognition of virtual lifestyle change programs. Initiating this type
of program virtually will significantly increase the availability of
lifestyle interventions in communities where no physical programs exist
or for those who would prefer to engage at home.
CDC is partnering with a national medical organization to educate
their constituency and increase referral and uptake of the intervention
for their patients with prediabetes. Furthermore, CDC will continue
educating employers and public/private payers across the U.S. about the
benefits and cost-savings of offering the evidence-based lifestyle
change program as a covered health benefit for employees and for
reimbursing organizations who deliver the intervention.
Additionally, with fiscal year 2014 funds from the Prevention and
Public Health Fund, CDC will implement Funding Opportunity Announcement
(FOA) DP14-1422, PPHF 2014: State and Local Public Health Actions to
Prevent Obesity, Diabetes, and Heart Disease and Stroke. These new
investments target priority population subgroups with uncontrolled high
blood pressure and those at high risk for type 2 diabetes that
experience disparities, including racial/ethnic or socioeconomic
disparities, inadequate access to care, poor quality of care, or low
income. This funding will support environmental and system approaches
to promote health, support and reinforce healthful behaviors, and build
support for lifestyle improvements. Diabetes primary prevention
strategies include:
--Working with a network of partners and local organizations to build
support for evidence-based lifestyle change (e.g., National
Diabetes Prevention Program);
--Implementing evidence-based engagement strategies (e.g. tailored
communications) to build support for lifestyle change; and
--Increasing coverage for evidence-based lifestyle change programs by
working with employers and other network partners.
Question. Currently there are 79 million people with prediabetes.
Does the agency have an estimate of the resources needed for the
National Diabetes Prevention Program to confront the human and economic
impact of the disease beyond 2015?
Answer. CDC is currently in the early stages of formulating an
fiscal year 2016 budget request and, therefore, does not have an
estimate at this time for funding needs in fiscal year 2016 or beyond.
Question. Studies show that gestational diabetes is a growing
problem and affects up to 18 percent of all pregnancies in the United
States. The same studies show that gestational diabetes puts women and
their children at a higher risk of developing type 2 diabetes later in
life and is associated with more health problems for both mother and
child during pregnancy and childbirth.
Can you talk about steps the CDC is taking to understand, monitor
and help providers understand and test for gestational diabetes?
Answer. CDC agrees that gestational diabetes is a prevalent and
growing public health problem, and considerable work has been conducted
to demonstrate that the obesity epidemic has contributed to the problem
of gestational diabetes. However, we do not believe that testing for
gestational diabetes is an issue; virtually all women who obtain
prenatal care are tested. Work funded by other HHS agencies (NIH's
NICHD) has demonstrated that treating even mild gestational diabetes
has benefits for mothers and their offspring. CDC is mainly concerned
with the impact of gestational diabetes on the future health of women
who had a pregnancy affected by gestational diabetes. These women and
their children are at substantial risk of developing Type 2 diabetes as
they move through their life course. Short-term follow-up of these
women may not be adequate; as a result, CDC has:
--Partnered with national organizations including the National
Association of Chronic Disease Directors (NACDD) and the
Council for State and Territorial Epidemiologists (CSTE) to
facilitate information exchange among members and to provide
new information about gestational diabetes. Their reach
includes over 500 State and local health departments,
healthcare organizations, community health centers, WIC
programs, nonprofit agencies, and private providers.
--Worked with clinical partners to emphasize the need for postpartum
testing of women who had a pregnancy affected by gestational
diabetes
--Funded a pilot study (Balance after Baby) to determine how best to
structure an intervention for recently pregnant women who had a
pregnancy affected by gestational diabetes so that they might
optimize their weight, physical activity and nutritional status
and prevent or delay the onset of Type 2 diabetes. We are
considering expansion of this pilot study.
--Recommended that all women with a Gestational Diabetes Mellitus
(GDM) affected pregnancies be screened for diabetes at their
postpartum visit (about 6-8 weeks after delivery); currently
postpartum screening rates are very low. As a result, CDC
funded a clinical study (Comparison of Glucose Tolerance
Testing Immediately Postpartum and at 6 Weeks in Women with
Gestational Diabetes Mellitus) to determine if women with GDM
could be accurately screened for diabetes during their delivery
hospitalization instead of waiting 6-8 weeks for their
postpartum visit. If screening at the delivery hospitalization
is comparable to the 6-8 week screen, it increases the ability
to identify women who are at risk for diabetes and adverse
health outcomes.
______
Questions Submitted by Senator Jerry Moran
prescription drug overdose
Question. The Centers for Disease Control and Prevention's (CDC's)
budget requests $15.6 million for a new Prescription Drug Overdose
initiative. Instead of focusing funds specifically to address this
problem, the budget requests an increase to the Core Violence and
Injury Prevention Program, which is a much broader injury prevention
program. Why did CDC not design a program to specifically address this
problem in the States where the burden is highest?
Answer. CORE VIPP is an existing system that has shown evidence of
success in preventing injuries and protecting residents in the States
in which the program has been implemented. Of the 20 currently funded
States, 16 have already identified PDO as a priority and have been
working on this topic with existing resources. Additionally, 10 of the
highest PDO burden States are already funded through Core VIPP. The
Core VIPP mechanism allows CDC to target specific activities to address
this critical public health epidemic while also supporting State health
departments' overall ability to collect data, use those data to act,
and collaborate across sectors to address the highest burden injury and
violence prevention issues. Through the expansion of Core VIPP, CDC can
direct resources to the States who need it most (i.e., those with the
highest burden) and those who to demonstrate their readiness to advance
multiple, complementary approaches--insurance innovations, prevention
programs, and enhanced State-focused analysis. CDC strives to
capitalize on existing mechanisms to better coordinate State efforts
and reduce administrative burden on States.
The request of $15.6 million in the fiscal year 2015 President's
budget will support PDO work (via Core VIPP) at the State level, in two
ways:
--Provide base injury prevention funding to a number of States that
are not currently part of the Core VIPP program, with an
emphasis on States with the highest burden of PDO. The goal is
to build a State's basic ability for injury prevention in order
to have a foundation for PDO-specific activities. Each of these
States will be required to include PDO as one of their injury
prevention priorities.
--The majority of the funding will be used for a set of Core VIPP
States to expand and intensify their PDO prevention activities.
This funding will be competed among existing and new Core VIPP
States, with an emphasis on States with the highest burden of
PDO and those States most prepared to conduct PDO prevention
activities.
alzheimer's disease research
Question. Last year, the budget requested an $80 million increase
for Alzheimer's disease research. Congress provided $100 million in the
fiscal year 2014 Omnibus. Why did the Department not include an
increase for Alzheimer's disease research in the fiscal year 2015
budget proposal?
Answer. Unlike the one-time funds provided for Alzheimer's research
by the NIH Director in fiscal year 2012 and fiscal year 2013, the
additional $100 million appropriated dollars are added to the base, and
upcoming budgets for Alzheimer's research will be estimated from this
increased base. The estimated total NIH-wide support for Alzheimer's
disease in fiscal year 2014 and again in fiscal year 2015 is $566
million. This amount is an estimate that could potentially increase, or
decrease depending on peer review results. Most of the efforts for
implementation of the National Alzheimer's Project Act and the
development of the National Plan to Address Alzheimer's Disease (AD)
are led by the National Institute on Aging (NIA). NIA has awarded
several major new grants supporting translational and clinical research
aimed at the disease; they are among the first projects to be developed
with direction from the 2012 AD Research Summit, and focus on
identifying, characterizing, and validating novel therapeutic targets
and identifying possible ways to stop disease progression.
This brain disease is being aggressively targeted on multiple
fronts. For example, NIH recently launched the Accelerating Medicines
Partnership (AMP), an unprecedented partnership with the Food and Drug
Administration, a number of biopharmaceutical companies, and several
nonprofit organizations that will use cutting-edge scientific
approaches to sift through a long list of potential therapeutic targets
and biomarkers, and choose those most promising for further
development. This public-private partnership will initially focus on
three disease areas, including Alzheimer's disease. This truly
innovative and collaborative approach should speed up the development
of new treatments and cures for multiple conditions and diseases.
Another way NIH-funded scientists are accelerating the development and
application of innovative technologies toward major advances in
Alzheimer's disease is with the Brain Research through Advancing
Innovative Neurotechnologies (BRAIN) Initiative. NIH is a major player
in this pioneering, multi-agency venture that will enable the creation
of new tools to examine the activity of billions of nerve cells,
networks, and pathways in real time. By measuring activity at the scale
of circuits and networks in living organisms, researchers can begin to
decode sensory experience and, potentially, even memory, emotion, and
thought. The BRAIN Initiative will provide a foundational platform that
has the potential to spawn remarkable opportunities in basic and
applied research for several brain disorders.
Question. Will NIH reach the goal of finding a cure for Alzheimer's
by 2025 without an increase in its research funding?
Answer. While it is still impossible to predict with certainty when
an effective treatment or preventive intervention will be available,
the infusion of new Federal funds to Alzheimer's research in the past
several years has already energized the field, accelerated the pace of
discovery, and facilitated the support of research projects that may
not otherwise have been funded.
In particular, the field is benefiting from the inclusion of an
additional $100 million in the NIH's fiscal year 2014 budget
appropriation which will be applied to high-priority research on
Alzheimer's disease. The National Institute on Aging (NIA), an NIH
Institute and lead Federal agency for research on Alzheimer's disease,
will manage the bulk of the projects awarded with these funds. Unlike
the one-time funds provided for Alzheimer's research by the NIH
Director in fiscal year 2012 and fiscal year 2013, these additional
appropriated dollars are added to the NIA's base, and upcoming NIA
budgets will be estimated from this increased base. NIA is
strategically distributing these funds among single-year and multiyear
projects to maintain a stream of new competing dollars to support high-
quality, peer-reviewed research on aging and Alzheimer's disease in
future years.
This recent increase in funding comes at an opportune time, and we
have more reason than ever to be optimistic about the possibility of an
effective treatment or preventive intervention for Alzheimer's. Recent
breakthroughs in biomedical imaging are enabling us to identify and
track the earliest pathological stages of the disease process in the
living human brain, long before clinical symptoms appear. These
discoveries, in addition to discovery of other early biomarkers of the
Alzheimer's disease process, have opened a ``window of opportunity''
for us to target and potentially reverse the disease's underlying
pathology before cognitive, behavioral, and emotional symptoms appear.
NIH has begun to launch its first such clinical trials in
presymptomatic individuals. For example, in one study, researchers are
investigating whether an antibody treatment, crenezumab, which is
designed to bind to, and possibly clear away, abnormal amounts of
amyloid protein in the brains of people with Alzheimer's, can prevent
decline in cognitive function among members of a unique and large
family population in Colombia sharing a genetic mutation known to
produce early-onset disease. We anticipate initial results from this
groundbreaking study by 2017. Another study, the A4 Trial, will test an
amyloid-clearing drug in the pre-symptomatic stage of the disease, in
symptom-free older volunteers who have had positron emission tomography
brain images that show abnormal levels of amyloid accumulation.
Positive results from these or similar studies would provide important
``proof of concept'' that targeting preclinical disease is an effective
strategy, and would represent a major step forward in our efforts
against Alzheimer's disease.
NIH also supports more than 35 Alzheimer's disease clinical trials,
including a number of studies of interventions to slow disease
progression among individuals who are already showing symptoms. Over 40
compounds are currently under study to stimulate and advance research
on the discovery and development of new preventive and therapeutic
interventions for AD, mild cognitive impairment, and age-related
cognitive decline.
______
Questions Submitted by Senator Richard C. Shelby
strategic national stockpile
Question. The budget proposes, for a second year, to reduce funding
for the Strategic National Stockpile. This reduction could result in
fewer people receiving treatment during an influenza pandemic and fewer
people receiving post-exposure treatment following exposure to anthrax.
The proposed reduction is more than an efficiency cut; it affects our
capability to respond in the event of a terrorist attack. If this cut
is sustained, how does HHS expect the Federal Government to adequately
respond should there be a bioterrorist attack or disease epidemic?
Answer. Through collaboration on the Public Health Emergency
Medical Countermeasures Enterprise (PHEMCE) governance process, CDC and
other HHS agencies coordinate priorities and activities for future
fiscal years to utilize all available resources to safeguard the health
of U.S. populations. CDC will prioritize replacement of expiring items
that rank the highest on formulary priorities, based on an annual
review of the SNS and result in efficiencies form improved procurement.
duplication
Question. In the Government Accountability's Office's annual report
on duplication, it highlighted that it takes 10 different offices at
the Department of Health and Human Services to run programs addressing
AIDS in minority communities, that autism research is spread over 11
different agencies, and that there are 45 early learning and child care
programs funded by the Federal Government. How is your Department
addressing this issue?
Answer. The Department of Health and Human Services (HHS) mission
is to provide the building blocks that Americans need to live healthy,
successful lives. HHS programs span from infant home visiting to the
largest healthcare provider for seniors. In addition to the breadth of
HHS' mission, several of the programs identified in the report have
unique aspects to them, which warrant tailored approaches.
Specifically for AIDS in minority communities, HHS does not support
consolidating the Minority AIDS Initiative (MAI) into core HIV/AIDS
funding at this time. MAI is distinct from other HIV/AIDS programs and
funding as it focuses specifically on the elimination of racial and
ethnic disparities in HIV/AIDS prevention, care and treatment, and
outreach and education in the United States. HHS continues to
deliberate strategies to more efficiently administer MAI and reduce
duplicative requirements for grantees, while ensuring that the
Department is being responsive to the needs of racial and ethnic
minority communities and populations disproportionately impacted by the
HIV/AIDS epidemic.
For autism research, the Government Accountability Office (GAO)
report cites that ``84 percent of the autism research projects funded
by Federal agencies were potentially duplicative.'' HHS believes that
this statement is misleading or could be easily misconstrued. It is
important to recognize the difference between appropriately addressing
complex problems using multiple strategies and funding redundant or
duplicative projects. We do not believe that research is necessarily
duplicative if two agencies fund the same broad objectives in a
strategic plan. Although GAO's report acknowledges that duplication is
necessary in science for the sake of replication or corroborating
results, it does not appreciate the full extent of the necessity of
replication and the extensive policies in place at HHS and other
Federal agencies to prevent redundant projects. HHS recognizes that
scientific endeavors and the path of research discovery are not linear
undertakings and often require verification and validation efforts.
HHS is concerned about the GAO report's implication that it is
wasteful when more than one funding agency addresses an objective or
aim of the Strategic Plan for Autism Research. It must be recognized
that the goals and objectives of the Strategic Plan represent complex
scientific questions that require a multidisciplinary approach, with
multiple scientific strategies. For example, to develop effective
interventions for autism spectrum disorder (ASD) that will address the
full range of symptoms and degrees of disability found in the ASD
population, research studies on multiple intervention types, such as
behavioral, pharmacological, educational, and occupational, may need to
be undertaken simultaneously to facilitate rapid progress that benefits
individual with varying needs. Based on the urgent need to address
rapidly the health and services issues that are the most pressing in
the community, it is not only appropriate, it is critical that multiple
agencies address the complex questions related to understanding the
neurobiology of ASD and identifying efficacious strategies for use
across the lifespan.
HHS is supportive of and committed to the call for greater
coordination among Federal research funding agencies and actively
engages in efforts to minimize risk of research duplication in all
activities. HHS agrees that there should be continued vigilance and
coordination to avoid unnecessary duplication across research projects.
HHS has robust procedures in place for avoiding duplication before
grant and contract awards are made and to keep the funding
decisionmaking process fair and equitable. In addition, the internal
NIH Autism Coordinating Committee (NIH ACC) and the Interagency Autism
Coordinating Committee (IACC) provide opportunities for monitoring and
collaboration within NIH and across Federal agencies. These policies
and coordinating bodies have served HHS well in terms of identifying
and preventing unwarranted duplication prior to making funding
decisions. We will continue to monitor the internal NIH ACC procedures,
as well as participation on the IACC, to make full use of these
opportunities.
As part of the HHS Strategic Plan, HHS commits to collaboration
across State, local, tribal, urban Indian, nongovernmental, and private
sector partners to support early childhood initiatives. The most recent
GAO report released in April 2014 (2014 Annual Report: Additional
Opportunities to Reduce Fragmentation, Overlap, and Duplication and
Achieve Other Financial Benefits) did not include Early Learning in the
11 areas that were suggested to take action to address evidence of
fragmentation, overlap, or duplication.
______
Questions Submitted by Senator Lindsey Graham
Question. Last month the CDC published the latest prevalence study
on the rates of autism. The report focused on children born in the year
2002, and found a 30 percent increase in the rates of autism in just 2
years--finding that 1 in 68 children born in 2002 is likely on the
autism spectrum.
The previous study had included the State of South Carolina and
found an overall rate of 1 in 90 children born in 2000 on the autism
spectrum with 1 in 55 boys. This latest report does not include South
Carolina data. Why not? Can I presume that the rates of autism in South
Carolina have also increased 30 percent?
Answer. South Carolina was not able to provide suitable data in
time to be included in the CDC's 2014 report on autism. CDC is working
with the South Carolina Autism and Developmental Disabilities
Monitoring (ADDM) site to finalize their 2010 data; it would not be
appropriate to speculate or compare SC to the ADDM 2010 published
findings.
Question. There is great concern among the autism community that
the CDC continues to take 4 years to publish the data on 8 year olds.
The agency should be able to obtain and publish data more quickly. What
are you doing to improve your turn around time on the data evaluation?
Answer. CDC's Autism and Developmental Disabilities Monitoring
(ADDM) Network method for tracking autism has advantages and
disadvantages. CDC's ADDM Network collects and analyzes in-depth data
to understand what is happening in communities across the United
States, rather than simply counting the number of children with autism.
The ADDM Network does not rely on parents' or providers' reporting of
autism diagnoses; the network collects detailed information on symptoms
that are consistent with a diagnosis of autism, as documented in tens
of thousands of children's health and education records. This method
allows us to:
--identify children with diagnosed and undiagnosed autism,
--cover a very large and diverse population base,
--track changes over time,
--examine whether certain groups of children are more likely to be
diagnosed with autism than others with similar symptoms,
--analyze the age when children are being identified, and
--demonstrate what progress is being made to identify children
earlier.
CDC's ADDM Network is continuously working to maximize our tracking
system's efficiency. First, we recently rolled out a new Web-based data
collection system that is helping us collect, manage and review data
more efficiently. Second, many of the community sources from which we
collect data have moved to electronic records. This switch might also
help us collect and review data more quickly. Lastly, we are piloting
new electronic data mining techniques that hold potential for
streamlining record review in the future.
Question. Last month the CDC published the latest prevalence study
on the rates of autism. The report focused children born in the year
2002 and found a 30 percent increase in the rates of autism in just 2
years--finding that 1 in 68 children born in 2002 is likely on the
autism spectrum.
There is concern in the autism community that you are not requiring
each of the State grantees to obtain education data, so that you are
making apples to apples' comparison from State to State. Two of the
States included in this year's published study do not have the
education data, which your report States decreases the prevalence rate.
If the two States are removed, then the rate of autism goes from 1 in
68 to 1 in 58. Can you insure that going forward all grantees obtain
educational data so we are getting the most accurate picture?
Answer. CDC currently cannot ensure that all grantees will have
access to educational data going forward. Decisions about whether CDC's
Autism and Developmental Disabilities Monitoring (ADDM) Network sites
have access to educational data are made at the local level and are
subject to change. CDC has and will continue to encourage ADDM Network
surveillance sites to work closely with their local communities to
obtain access to as many sources of information on children with autism
as possible. CDC is assessing ways to maximize information sources in
the new ADDM Funding Opportunity Announcement in 2014.
______
Questions Submitted by Senator Mark Kirk
Question. NIH and NCI provide all kinds of grants to researchers to
provide support for investigator-initiated projects. These grants are
integral to researcher's ability to pursue academic careers. I have
heard from several constituents that many young, promising MD/Ph.D.
investigators are leaving their training programs to go into private
practice- abandoning their scientific scholarship because there isn't
funding to support their labs. This is a general problem, but I'm
particularly concerned about the field of radiation oncology. I
understand that when the NCI did a review of its grants, it determined
that about 5 percent of NCI's budget was going to fund radiation
oncology grants/projects. I'm not sure what the right number would be,
but 5 percent seems awful small given that radiation oncologists treat
roughly two-thirds of all cancer patients. Does 5 percent seem small to
you? And are you willing to review your internal processes to make sure
that there aren't any problems in the way radiation oncology proposals
are reviewed that is leading to such a low funding rate?
Answer. NCI's primary goals are to support and conduct a broad
spectrum of cancer research. The research NCI oversees uses a wide
variety of approaches and funding mechanisms, with several goals:
improving our understanding of the causes and biological mechanisms of
a large variety of cancers; preventing cancers; detecting and
diagnosing all types of cancers; and treating cancers, as well as the
symptoms and sequelae of cancers, more effectively. NCI's research
projects and programs include studies of the basic aspects of cancer
biology at the molecular and cellular levels: investigations of how
cancer cells and processes affect, and are affected by, the cellular
environment in which they exist, and applications of these discoveries
toward successful detection, diagnosis, treatment, prevention, and
control of cancers of all types.
All research efforts supported by NCI are subjected to rigorous
review for quality and purpose by expert peer reviewers, program staff,
and advisory groups. Decisions about individual research projects
selected for funding are made for a limited period of time, based on a
series of rigorous evaluations performed by scientific peers, NCI
divisional program staff, and NCI Scientific Program Leaders, and then
subjected to final approval by the National Cancer Advisory Board and
the NCI Director. An emphasis on scientific merit is maintained
throughout the review process. All of these efforts are monitored
annually through written progress reports and subjected to competitive
peer review or terminated on a regular basis, generally between 2 to 5
years. Similar processes are used to oversee the representation of
various types and costs of research in our portfolio.
Radiation therapy plays a critical role in NCI's portfolio of
cancer clinical trials. It is incorporated as a standard part of the
treatment plans for patients with stage III squamous and
adenocarcinomas of the lung, limited stage small cell lung cancer, as
well as esophageal, breast, brain, and rectal cancers. Investigational
questions related to new radiation therapy techniques as well as how to
best combine radiation therapy with systemic therapies and surgery
comprise a major part of the portfolio of studies carried out by the
NCI's National Clinical Trials Network (NCTN). The majority of the
trials conducted by one of the adult clinical trials groups, NRG
Oncology, focus on studies to improve the use of radiation therapy. In
addition to NRG, the Alliance, the Children's Oncology Group, the
Pediatric Brain Tumor Consortium, and the ECOG-ACRIN Cancer Research
Group also have active studies that incorporate radiation therapy. This
portfolio of trials is monitored by an NCI oversight committee, the
Clinical Trials and Translational Research Advisory Committee. The
overall quality control for radiation therapy clinical studies
supported by the NCI is also directly supported by a grant to fund a
core quality control group responsible for overseeing these activities
across the NCTN. NCI currently supports 50 national trials that
incorporate radiation therapy as a component of the investigational
program under examination. In addition to the substantive resources
provided for radiation therapy-related clinical trials, NCI supports
basic research into radiation therapy and radiobiology. In fiscal year
2013, funding for this basic research was approximately $56 million.
This, of course, is complemented by $107 million per year in funding
for studies of critical DNA repair mechanisms that are of major
interest and relevance to understanding the mechanism(s) of action of
radiation therapy.
Question. Stroke is the leading cause of disability for adults in
the United States and the 4th leading cause of death. Recent studies
show that 1 of 6 veterans returning from war zones and 1 of 4 stroke
survivors have symptoms of PTSD. Knowing these statistics what cross-
coordinating efforts, if any, are happening within NIH, DOD and the VA?
Answer. The high rate of PTSD among military servicemembers and
veterans is of major concern to NIH. The National Institute of Mental
Health (NIMH) is working with the Department of Defense (DOD), U.S.
Department of Veterans Affairs (VA), and academic clinicians and
researchers to focus on the mental health needs of military service
personnel, as well as veterans and their families. A cross-agency
priority goal (CAPG) of the DOD, VA, and HHS to improve mental health
outcomes for Service Members, Veterans, and their families will help
speed the progress of research efforts related to PTSD, suicide
prevention, and common co-occurring conditions (e.g., traumatic brain
injury (TBI) and substance abuse). The CAPG will be supported through
specific cross-agency priority actions that will be accomplished over
the next 3 years. Another example of collaborative efforts across
agencies to address military mental health issues is the Army Study to
Assess Risk and Resilience in Servicemembers (Army STARRS) project, a
partnership between NIMH and the Department of the Army to provide the
Army with actionable data to help them drive down the suicide rate, and
to address associated problems, such as PTSD, among soldiers. In
addition, as a result of a 2012 Executive Order, DOD, VA, HHS
(including NIH), and the Department of Education developed a National
Research Action Plan, which provides a comprehensive approach to
accelerating research on traumatic brain injury and PTSD.
While PTSD most commonly develops after exposure to a terrifying
event or ordeal, it also occurs in individuals who have suffered an
acute life-threatening illness, e.g., stroke survivors. An NIH-
supported study estimated that 1 in 4 survivors of a stroke or
transient ischemic attack (TIA) develop significant PTSD symptoms. More
than one-third of stroke survivors suffer post-stroke depression. Post-
stroke depression can interfere with daily functioning, inhibit quality
of life, and if not treated and managed appropriately, can slow
rehabilitation and lead to further disability. NIH-funded research is
addressing ways to treat post-stroke depression, including
psychosocial/behavioral interventions, in addition to novel
rehabilitation protocols that improve motor function as well as reduce
depression in stroke survivors. NIH-funded studies are also
investigating ways to identify patients who will benefit most from
these therapies, and more generally, trying to understand the
mechanisms by which behavioral factors contribute to outcome and
recovery from stroke. The new National Institute of Neurological
Disorders and Stroke (NINDS) StrokeNet, composed of 25 acute and
rehabilitation stroke centers, is dedicated to testing new means of
improving quality of life in stroke survivors which must include
attention to post-stroke depression and PTSD.
NIH will continue to look for ways to collaborate with other
agencies as appropriate to help uncover connections between conditions
such as PTSD, stroke, and depression.
Question. Viral hepatitis is the leading cause of liver cancer--one
of the most lethal, expensive and fastest growing cancers in America.
More than 5.3 million people in the U.S. are living with hepatitis B
(HBV) and/or hepatitis C (HCV) and as many as 75 percent of them are
undiagnosed. With the lack of an adequate, comprehensive surveillance
system, these estimates are only the tip of the iceberg. Viral
hepatitis kills 15,000 people each year and is the leading non-AIDS
cause of death in people living with HIV. These epidemics are
particularly alarming given the rising rates of new infections and high
rates of chronic infection among disproportionately impacted racial and
ethnic populations. Additionally, recent alarming epidemiologic reports
indicate a rise in HCV infection among young people throughout the
country. Further, the baby boomer population (those born 1945-1965)
currently accounts for two out of every three cases of chronic HCV. As
these Americans continue to age, they are likely to develop
complications from HCV and require costly medical interventions that
can be avoided if they are tested earlier and provided with treatment
options. Can you highlight the problems facing our country with viral
hepatitis and the urgent need to address these two diseases and what
could happen if we do not act?
Answer. Viral hepatitis is an urgent public health problem in the
United States.
Hepatitis B (HBV).--There have been dramatic decreases in the
number of new acute infections among children, resulting from universal
infant immunization recommendations, and today most new infections are
among adults. However, an estimated 1.2 million persons in the United
States have chronic hepatitis B infection, and 25 percent will die of
HBV-associated complications in the absence of medical interventions.
Preventing perinatal infections by screening pregnant women and
vaccinating infants upon birth also remains a priority.
Hepatitis C (HCV).--Recent data indicate that no more than 50
percent of HCV-infected persons in the United States have been tested
for HCV. Of those tested, 32-38 percent are referred for care, 7-11
percent are treated, and 5-6 percent achieve virologic cure. These low
proportions reflect gaps in health-care delivery at every stage of the
HCV continuum of care. Consequently HCV-related disease, healthcare
costs, and mortality are increasing. Implementation of CDC and USPSTF
recommendations for birth-year based HCV testing linked to HCV care and
treatment can avert an estimated 121,000 deaths (Smith BD et al.
Recommendations for the Identification of Chronic Hepatitis C Virus
Infection Among Persons Born During 1945-1965. MMWR. 61(RR04);1-18. See
Table 3 with Source: Rein DB et al. The Cost-Effectiveness of Birth-
Cohort Screening for Hepatitis C Antibody in U.S. Primary Care
Settings. Ann Intern Med. 2012;156(4):263-270. Modified and reprinted
in MMWR with permission from Annals of Internal Medicine.). CDC is
working to improve the continuum of hepatitis C testing, care, and
treatment; and will leverage the use of newly FDA-licensed safe and
curative therapies for new prevention opportunities.
CDC plays a key role in implementing the HHS Action Plan for the
Prevention, Care and Treatment of Viral Hepatitis. The plan sets out
ambitious goals and a path forward to confront viral hepatitis. Its
goals are to increase the proportion of those who are aware of their
Hepatitis B or Hepatitis C infections; reduce new Hepatitis C
infections; and, eliminate mother to child transmission of Hepatitis B.
Question. Given the release of U.S. Preventive Services Task Force
(USPSTF) grade ``B'' recommendation for HCV screening for baby boomers
and individuals at risk, do you feel you have the resources to
implement that recommendation and educate Medicare beneficiaries and
healthcare providers about hepatitis C and its disproportionate impact
on baby boomers?
Answer. Currently, only a small proportion of the baby boomer
cohort is eligible for Medicare. The cohort will steadily age into
Medicare eligibility over the next 15 years.
Recent evidence from CDC demonstration projects indicates that a
substantial number of people who are either currently Medicare-eligible
or will become eligible over the upcoming decade can receive
recommended HCV testing in nonprimary care settings. Therefore,
Medicare beneficiaries receiving screening and in the near future can
significantly increase the proportion of people who are aware of their
infection.
However, while screening those who are or will soon be Medicare
beneficiaries is vitally important, it is also important to screen the
rest of the birth cohort now, so that all who are infected can be
screened for alcohol use, and receive care and treatment (including
hepatitis A and B vaccination, as medically appropriate).
Implementation of new CDC and USPSTF recommendations for HCV
testing can save over 120,000 lives.
In fiscal year 2012, CDC received Prevention and Public Health
Funds to support demonstration sites for hepatitis B and hepatitis C
testing to identify persons with undiagnosed infection, and for
linkages to care when appropriate. Nine sites were selected to do
hepatitis B testing, and 24 sites to do hepatitis C testing. Evaluation
of these sites is ongoing, but preliminary data indicate that over
45,000 tests were completed in the first year of the initiative,
yielding important lessons learned that can be implemented elsewhere.
CDC was able to provide continuation funding to almost all of the sites
in fiscal year 2013, and substantial gains in the total number of
completed tests are expected in the second year.
In 2014, CDC will support the development and evaluation of new
viral hepatitis prevention programs in three jurisdictions. These viral
hepatitis prevention programs aim to establish the platform needed to
reduce new infections, improve systems of care, and combat hepatitis-
related health disparities; activities will include but not be limited
to education on hepatitis C.
Question. Viral hepatitis is the leading cause of liver cancer--one
of the most lethal, expensive and fastest growing cancers in America.
More than 5.3 million people in the U.S. are living with hepatitis B
(HBV) and/or hepatitis C (HCV) and as many as 75 percent of them are
undiagnosed. With the lack of an adequate, comprehensive surveillance
system, these estimates are only the tip of the iceberg. Viral
hepatitis kills 15,000 people each year. These epidemics are
particularly alarming given the rising rates of new infections and high
rates of chronic infection among disproportionately impacted racial and
ethnic populations. Additionally, recent alarming epidemiologic reports
indicate a rise in HCV infection among young people throughout the
country. Some jurisdictions have noted that the number of people ages
15 to 29 being diagnosed with HCV infection now exceeds the number of
people diagnosed in all other age groups combined. Further, the baby
boomer population (those born 1945-1965) currently accounts for two out
of every three cases of chronic HCV. As these Americans continue to
age, they are likely to develop complications from HCV and require
costly medical interventions that can be avoided if they are tested
earlier and provided with treatment options. It is estimated that this
epidemic will increase costs by billions of dollars--from $30 billion
in 2009 to over $85 billion in 2024--to private insurers and public
systems of health such as Medicare and Medicaid, and account for
additional billions lost due to decreased productivity from the
millions of workers suffering from chronic HBV and HCV. Over the last 2
years, CDC and the U.S. Preventive Services Task Force (USPSTF) have
begun to align their recommendations for hepatitis screening,
recommending one-time testing of baby boomers and screening vulnerable
groups for HCV. In April, the Department of Health and Human Services
(HHS) renewed the Action Plan for the Prevention, Care and Treatment of
Viral Hepatitis which provides clear and attainable goals to increase
the number of individuals diagnosed with viral hepatitis and reduce
transmission of the viruses. The Action Plan identifies discrete
activities for HHS and other Federal agencies to break the silence of
this epidemic. Will the agency continue to focus cross agency attention
on addressing the viral hepatitis epidemic and implementing the Action
Plan?
Answer. On April 3, 2014, HHS released the 3-year update of the
Action Plan for the Prevention, Care and Treatment of Viral Hepatitis,
which provides a framework around which both Federal and non-Federal
stakeholders from many sectors can engage to strengthen the Nation's
response to viral hepatitis and work to improve viral hepatitis
prevention, screening, and treatment through 2016.
This update is the culmination of efforts across the Department of
Health and Human Services as well as at the Departments of Justice,
Housing and Urban Development, and Veterans Affairs who have worked to
develop this framework for focused activity by both Federal and non-
Federal stakeholders. Federal colleagues have identified more than 150
important actions their agencies and offices will undertake between
2014 and 2016 across six priority areas.
--Educating Providers and Communities to Reduce Viral Hepatitis-
related Health Disparities (Confront viral hepatitis by
breaking the silence).
--Improving Testing, Care, and Treatment to Prevent Liver Disease and
Cancer (Take full advantage of existing tools).
--Strengthening Surveillance to Detect Viral Hepatitis Transmission
and Disease (Collect accurate and timely information to get the
job done).
--Eliminating Transmission of Vaccine-Preventable Viral Hepatitis
(Take full advantage of vaccines that can prevent hepatitis A
and B).
--Reducing Viral Hepatitis Associated with Drug Use (Stop the spread
of viral hepatitis associated with drug use).
--Protecting Patients and Workers From Health Care-Associated Viral
Hepatitis (Quality healthcare is safe healthcare).
In shaping these actions, HHS sought substantial input from non-
Federal partners and stakeholders through public webinars and a formal
Request for Information (RFI) published in the Federal Register. In
fact, a notable feature of the updated plan is a more explicit
recognition that achieving the goals of this national plan will require
the time, talent, and energy of a broad mix of partners from across all
sectors of society, both governmental and nongovernmental. As such, the
updated plan includes a listing of potential opportunities for non-
Federal stakeholders to promote successful implementation.
Finally, to maximize cross-agency and cross-departmental effort in
support of the updated Viral Hepatitis Action Plan, the Office of HIV/
AIDS and Infectious Disease Policy, in the Office of the Assistant
Secretary for Health, actively coordinates a Viral Hepatitis
Implementation Group (VHIG) composed of senior leaders from HHS, VA,
DOJ/BOP, HUD and ONDCP. The VHIG meets on a regular basis to share
progress, discuss challenges and highlight new opportunities.
Question. There are a number of cancers, and stomach cancer is a
prominent example, where there is both dismal survival rates and also a
shortage of ongoing research. The vast majority of stomach cancer is
diagnosed at metastatic stages, for which there are, at present, no
cures. Stomach cancer treatments have made little progress in the past
decade and are quite limited. The investment that the NCI is making in
a number of cancers through The Cancer Genome Atlas has the potential
to catalyze research in stomach and other cancers. But for cancers,
like stomach cancer, with less-developed research infrastructures, how
can we be confident that research to pursue the findings of the TCGA
will occur?
Answer. While NCI has made significant progress in preventing,
detecting, and treating many cancers, gastric cancer is one of several
types that are not well understood and remain difficult to treat. For
such areas, NCI has a variety of tools at its disposal to stimulate
research in specific areas. Meetings of NCI and extramural experts to
conduct ``horizon scanning'' for scientific opportunities on a variety
of cancers occur as part of NCI's standard practices. In fact, NCI
invited a group of international experts in gastric and esophageal
cancer to participate in a workshop in May 2011. In addition to
discussing the basic biology, epidemiology and clinical research, they
also focused on different patterns of gastric cancer observed in other
countries. One result of the workshop was the initiation of a pilot
project for obtaining pre-treatment gastric tumor specimens. (NCI has
also recently convened workshops for hepatic, lung, and pancreatic
cancers.)
Initiatives, such as The Cancer Genome Atlas (TCGA), that provide
new insights into a wide range of cancer types can greatly accelerate
progress in many common and rare cancer types, such as gastric cancer,
and generate prime research opportunities. The genomic sequence data
from TCGA's gastric cancer samples are already freely available to
qualified researchers for further study. (NCI has developed websites
that allow researchers to search for genetic alterations in any cancer
studied by TCGA and will continue to support these cancer genomics
portals to promote the widest possible utilization of these data.) The
first 295 gastric cancer samples have been evaluated, and a report is
expected to be published early this summer. The report shows that the
current classification of gastric cancer subtypes by appearance under
the microscope is imprecise and can be refined by analysis of tumor
genomes. Some of the genetic abnormalities are characteristic of
particular gastric cancer subtypes and might be amenable to therapeutic
intervention. Additionally, several of the mutations found in gastric
cancer are also present in other cancers studied by TCGA and other
projects. NCI vigorously supports research into therapeutic strategies
to target the abnormal molecular pathways that are caused by mutations
that occur in one or many tumor types.
The work that is expected to follow up findings from TCGA does not
require specific research methods or equipment for each type of cancer,
but it does require certain specific resources: tumor samples,
appropriate experimental models for each disease, and investigators
motivated by new opportunities to work on that disease. Suitable
laboratory models are important for testing candidate drugs or
immunotherapies for their ability to block abnormal molecular pathways
and prevent tumor growth. Human cancer cell lines are the mainstay of
this kind of research, but the currently available cell lines do not
model all of the diverse subtypes of cancer, including gastric cancers,
and do not possess all of the recurrent mutations that drive the
malignant process. NCI is addressing this infrastructural deficiency by
using biopsies of various kinds of human cancers to create a large
number of new cancer models with newly available methods (e.g., so-
called ``organoid'' cultures and ``conditionally reprogrammed'' cells).
When successful, NCI will distribute these new cancer models broadly to
cancer researchers to help develop diagnostic and treatment strategies
tailored to specific subtypes of cancer and to specific molecular
abnormalities. To that end, NCI is soliciting applications to support
pilot projects at NCI-designated cancer centers for the development and
characterization of cell lines derived from human cancer specimens.
These models could also help clarify cellular mechanisms that drive
tumor progression and generate hypotheses about ways to interrupt those
processes. Letters of intent have been received from several potential
applicants, and at least one plans to develop models for gastric
cancer.
Question. How can the NCI assist stomach cancer researchers and
researchers of other cancers with deficiencies in foundational
knowledge in developing successful RO1 grant applications that can have
an impact for patients battling stomach cancer?
Answer. NCI can and does foster opportunities to study gastric
(stomach) cancer in several ways:
--by providing new information of the type illustrated by The Cancer
Genome Atlas and discussed in response to the previous question
(this kind of new information suggests new ideas and
opportunities for research, often addressed to diseases that
were previously difficult to study);
--by offering an array of funding opportunities (including team
awards), and not only RO1 grants;
--by supporting the training of talented individuals who might
develop an interest in gastric cancer through individual
fellowships, institutional training awards, and career
development awards; and
--by highlighting NCI's concerns about the slow progress against this
disease through the organization of workshops and public
discussion of public health needs and research opportunities.
In addition, NCI program managers are available to provide guidance
to investigators who seek help in finding the most appropriate funding
mechanisms to support proposed work on gastric cancer and other types
of cancers.
______
Questions Submitted to Mary K. Wakefield
Questions Submitted by Senator Tom Harkin
community health centers
Question. The Health Centers program received mandatory funding
under the ACA, a critical investment that the National Association of
Community Health Centers (CHCs) estimates created over 550 new health
clinics and expanded capacity at thousands of existing sites. This
investment needs to be extended, or the mandatory funding will expire
in fiscal year 2016 and health centers will face a massive funding
cliff. I have expressed support for fixing this issue by continuing
mandatory funding, an approach supported in the President's budget. If
funding was not extended, please provide the administration estimate on
how that would impact the CHC program in fiscal year 2016. Please
include how much base funding for existing health centers will be
reduced, the number of clinics that will close, and the loss in patient
capacity.
Answer. The budget includes a proposal to continue mandatory
funding for health centers in fiscal years 2016, 2017, and 2018 at $2.7
billion per year, for a total investment of $8.1 billion. This
investment is part of a total budget that includes more than $400
billion in specified health savings over 10 years. The President has
not yet submitted a discretionary budget for fiscal year 2016, the year
the mandatory Health Center funds will expire. If funding for the
Health Center Program is significantly lowered in fiscal year 2016
compared to the previous year a complex procedure of grant level
reductions, and possibly terminations, could occur. This could result
in numerous health center sites closing, and a reduction in patients
served by health centers.
ryan white hiv/aids program
Question. The President's budget proposes to consolidate Part D of
the Ryan White HIV/AIDS program into Part C of the program. Part D
provides family-centered primary medical care for women, infants,
children, and youth with HIV/AIDS. These services include case
management for HIV-infected pregnant women and HIV-infected children
and youth.
Has Health Resources and Services Administration (HRSA) conducted
an assessment of Part C programs to determine whether Part C programs
are prepared and have the infrastructure to provide primary and
specialty care to these populations? How many Part C grantees have
pediatric providers and are currently equipped to provide primary and
specialty medical care and support services to infants, children and
youth?
Answer. In 2014, 67 percent of Part D programs funded by the Ryan
White HIV/AIDS Program are dually funded by the Part C program. The
consolidated program will continue to provide increased access to
allowable services under Part C that meet the needs of the Part D
community. All applicants to the fiscal year 2015 Part C Funding
Opportunity Announcement will be required to demonstrate how they will
provide care and treatment for the most vulnerable populations,
including women, infants, children and youth. The assessment of an
applicant's capacity to provide the services proposed in their grant
applicant is a key area of focus for the objective grant review
committee. The consolidation will expand the focus on women, infants,
children, and youth across all of the funded grantees and will increase
points of access for the population. In addition, the consolidation
will result in increased efficiencies, reduced duplication of effort
and reporting/administrative burden among currently co-funded grantees,
and allow more funding to be available for direct patient care
services.
Question. What are HRSA's plans to ensure a seamless transition of
services, including case management services, and to ensure that women,
infants, children and youth are not lost to care, including plans to
provide technical assistance to current and future grantees?
Answer. Since 67 percent of Part D grantees are currently also Part
C grantees, HRSA expects that transition will be manageable. Continuing
to reduce mother-to-child transmission of HIV remains a priority. The
President's budget will result in more Part C programs providing women,
infants, children and youth-focused services, which will result in
increased access to proven medical care for these populations across
the country. The Ryan White HIV/AIDS Program provides extensive
technical assistance opportunities to both current and future Ryan
White HIV/AIDS Program grantees through our Technical Assistance
Resources, Guidance, Education & Training (TARGET) Center, AIDS
Education and Training Centers (AETCs), our national cooperative
agreements, and during pre-application technical assistance calls when
the new Funding Opportunity Announcement is released. In addition, one-
on-one technical assistance from the HRSA staff will be available to
assist grantees receiving new funding under Part C to ensure that the
Program's most vulnerable populations, which include women, infants,
children and youth, are not lost to care and treatment.
Question. What impact will the proposed consolidation have on Part
C grantees needing to seek a waiver from the 75/25 core medical
services requirement in order to provide case management services to
Part D populations?
Answer. HRSA takes seriously the responsibility to ensure that all
of the needs of individuals living with HIV/AIDS are met. Under the
President's budget, all Part D programs that meet the Part C Program
eligibility for grant funding are encouraged to apply for Part C
funding. Eligible Part C grantees, and grantees awarded Part C funding
through the fiscal year 2015 Funding Opportunity Announcement, would
need to meet the legislative requirements in Part C regarding use of
funds. This will result in more Part C programs providing women,
infants, children, youth focused services, which means increased access
to proven medical care for these populations across the country. HRSA
will ensure that Part C grantees meet the needs of these populations
through grant monitoring and technical assistance.
the 340 b drug discount program
Question. The President's budget requests $17 million for the
Office of Pharmacy Affairs (OPA) to improve program integrity and
administration of the 340B Federal drug discount program. Congress
provided $10 million in the fiscal year 2014 Omnibus, an increase of $6
million over fiscal year 2013, for program integrity consistent with
existing requirements and recommendations from the Office of the
Inspector General and the Government Accountability Office. Please
provide an fiscal year 2014 implementation plan for the program
integrity effort and describe what has been accomplished to date with
the increase in funding. How is HRSA prioritizing its program oversight
activities?
Answer. The $6 million of additional funding provided in the
Omnibus Appropriations Act for fiscal year 2014 have enabled HRSA to
develop a robust strategy to more effectively oversee the covered
entities and manufacturers that participate in our program. Please find
a detailed outline of our areas of investment that follows.
Manufacturer Compliance
--We are devoting resources to implement provisions of the Affordable
Care Act (ACA) to prevent overcharges to 340B covered entities.
--The resources will upgrade our current internal-facing pricing
database, providing a secure access mechanism for covered
entities and the capacity for HRSA's Office of Pharmacy Affairs
to conduct ceiling price verification.
--The contract will be awarded this summer and upgrades will be
complete in 2015.
--Work has begun to finalize rulemaking on Civil Monetary Penalties
for manufacturers and Administrative Dispute Resolution.
Covered Entity and Manufacturer Compliance
--We are investing in a new compliance management system that will
create a sophisticated tracking system for all covered entities
and manufacturers participating in the 340B program.
--We have designed a system overview for proposal, and the contract
for building the system will be awarded this summer. Full
implementation is expected in fiscal year 2015.
Covered Entity Compliance
--Five additional auditors, and one audit coordinator, will be hired
in order to increase the number of program audits conducted.
The resulting increase in audits will be seen in fiscal year
2015 when hiring is complete and new staff have been trained.
Overall Program Integrity
--We are have hired 2 staff and plan to hire 6 additional staff in
the Office of Pharmacy Affairs to manage and analyze
information from expanded program integrity efforts. This
includes Program Integrity Specialists, Data Analysts, and an
individual devoted to technical assistance and education. Staff
will review audits and other compliance related activities,
develop policy, manage and analyze data, and continue work on
implementing 340B ACA provisions.
______
Questions Submitted by Senator Richard J. Durbin
mental health
Question. According to USDA, 50 million people live in rural
America. This rural population is disproportionately affected by mental
health disorders with higher levels of depression, along with domestic
violence, and child abuse than their urban peers.
Unfortunately many families in rural American find themselves cut
off from mental health services, because of geographic and cultural
barriers. As of January 2013, there are 3,800 Mental Health
Professional Shortage Areas nationwide, as defined by HRSA. More than
85 percent of MHPSAs are in rural areas. As a result of the scarcity of
mental health professionals, primary care providers in rural
communities typically have a larger role in mental healthcare than
their urban peers.
Studies have shown that stigma is a significant concern for many in
rural America. People suffering from a mental disorder are less likely
to seek treatment if they fear being recognized.
In light of this stark data, what steps is the agency taking to
increase the mental health workforce in rural settings? What steps is
HRSA taking to better integrate mental health and primary healthcare in
rural hospitals and FQHCs? What steps does HRSA propose for further
addressing the scarcity of mental providers in rural settings?
Answer. The National Health Service Corps (NHSC) is one of the
Administration's most effective tools for getting healthcare providers
to the areas where they are needed most, with half of all NHSC
clinicians serving in community health centers. In fiscal year 2013,
nearly one in three clinicians (2,854 as of September 2013) in the NHSC
was a behavioral and mental health professional, which includes
psychiatrists, health service psychologists, clinical social workers,
licensed professional counselors, marriage and family therapists,
psychiatric physician assistants, and psychiatric nurse specialists.
All NHSC behavioral and mental health practitioners serve in high-need,
underserved areas that have a mental Health Professional Shortage Area
(HPSA) designation.
The fiscal year 2015 President's budget also includes a $3.96
billion increase in funding for the National Health Service Corps over
6 years, the largest increase in the program's history. This increase
will build and sustain an annual field strength of 15,000 and create
incentives for providers to practice in the areas of the country that
need them most. Since 2010, based on historical data, over 27 percent
of the total field strength has been behavioral and mental health
practitioners.
In addition, HRSA is implementing programs that help train
additional behavioral health providers. The Mental and Behavioral
Health Education and Training (MBHET) Program supports accredited
graduate schools and programs of social work and accredited doctoral
psychology schools, programs and pre-degree internship organizations to
increase the number of behavioral health providers serving the
medically underserved populations, including rural areas. It is
estimated that over 2,900 individuals will be trained as a result of
these activities.
In fiscal year 2014, HRSA partnered with SAMHSA to expand the
behavioral health workforce as part of the President's plan to prevent
gun violence. The initiative will include $35 million to expand
training for roughly 3,500 behavioral health professionals and
paraprofessionals, including master's level social workers,
psychologists and marriage and family therapists, as well as various
behavioral health paraprofessionals. The program will include an
emphasis on training to address the needs of children, adolescents, and
transition-age youth (ages 16-25) and their families. The President's
fiscal year 2015 budget includes a request to continue to fund this
effort.
HRSA's Graduate Psychology Education Program supports clinical
training programs for doctoral-level psychology students to address the
behavioral health needs of vulnerable and underserved populations. In
Academic Year 2012-2013, the most recent data available over a third of
the individuals supported in this program are from rural or
disadvantaged backgrounds. In addition, more than half of individuals
who received a financial award and completed their training reported
that they were currently employed or pursuing further training in a
Medically Underserved Community.
Further, in January, the Vice President announced a $50 million
Funding Opportunity Announcement to expand access to behavioral health
services at approximately 200 existing health centers nationwide.
Health centers will be able to use these new funds, made available
through the Affordable Care Act, for efforts such as hiring new mental
health and substance use disorder professionals, adding mental health
and substance use disorder services, and employing team-based models of
care. All current health center grantees, nearly half of which serve
rural areas, were eligible to apply for this funding.
oral health
Question. According to HRSA, 108 million Americans currently lack
access to dental coverage. In fact, a large number of people with
dental insurance coverage lack access to dental care. The U.S. has
141,800 working dentists and 174,100 dental hygienists. However,
according to HRSA data, there are 4,230 dental health professional
shortage areas nationwide with 49 million people living in them.
More than 16 million children in the United States go without
seeing a dentist each year. Particularly vulnerable are children living
in rural areas. Although the Children's Health Insurance Program (CHIP)
provides comprehensive oral health coverage, dental care is the
greatest unmet health need among children. More concerning, many
dentists refuse to treat Medicaid beneficiaries, citing low
reimbursement rates and administrative burdens.
In 2009, HRSA embarked on an Oral Health Initiative, which included
a series of Institute of Medicine reports. Based on this work, what has
the agency done to implement the recommendations from the Initiative to
close the coverage gap?
States with the highest Medicaid reimbursement rates still have
children enrolled in Medicaid who aren't able to access adequate oral
healthcare. What is the agency's position on expanding the number of
mid-level professionals to provide care in underserved areas?
Answer. HRSA has used the IOM reports to advance its work to expand
access to oral healthcare. In 2012, HRSA/MCHB launched the Perinatal &
Infant Oral Health National Initiative in tandem with the release of
the MCHB-funded document: Oral Health Care During Pregnancy: A National
Consensus Statement. This effort responds to three of the IOM
committee's Organizing Principles for an HHS Oral Health Initiative:
reduce oral health disparities (#4), explore new models for . . .
delivery of care (#5), and promote collaboration among private and
public stakeholders (#8). Concrete examples of success will include:
increased utilization of preventive dental care by pregnant women,
establishment of a dental home for infants by age one, reduced
prevalence of early childhood caries (ECC), and reduced dental
expenditures. In 2013, HRSA initiated the first phase of this
initiative, funding the Perinatal and Infant Oral Health Quality
Improvement Pilot grant program. The outcome will put into practice and
continuously assess a statewide approach that responds to the
comprehensive oral health needs of pregnant women and infants most at
risk. In 2014, HRSA will award funding to establish the Perinatal and
Infant Oral Health Quality Improvement National Learning Network. This
learning network will coordinate the development and testing of an
evidence-informed strategic framework that can inform statewide
healthcare systems transformation. Knowledge gained will comprise the
National Strategic Framework for Improving Perinatal and Infant Oral
Health through Systems Change.
HRSA also entered into a cooperative agreement with the National
Network for Oral Health Access to provide specialized training and
technical assistance to HRSA awardees around increasing access to
primary oral healthcare services for underserved and vulnerable
populations. In February 2014, HRSA issued a report on the Integration
of Oral Health and Primary Care Practice (http://www.hrsa.gov/
publichealth/clinical/oralhealth/primarycare/
integrationoforalhealth.pdf) as part of an initiative that strives to
improve access for early detection and preventive interventions by
expanding oral health clinical competency of primary care clinicians,
leading to improved oral health. Furthermore, HRSA is supporting a
pilot project to demonstrate implementation of a core set of clinical
competencies for primary care clinicians in three Community Health
Centers. The IOM reports have also informed work on an HHS Oral Health
Strategic Framework by the HHS Oral Health Coordinating Committee.
HRSA is also deploying its programs to increase access to oral
health services. In the National Health Service Corps, the numbers of
oral health providers (dentists and registered dental hygienists), have
nearly tripled since 2008, increasing from approximately 480 to 1,300
in 2013. As of the end of fiscal year 2013, 164 dentists, committed to
work in underserved areas, are currently in the training pipeline,
being supported by the NHSC Scholarship Program.
HRSA's oral health workforce training programs providing financial
support to over 390 students, residents and fellows participating in
degree, residency or fellowship programs in dentistry, public health
and/or dental hygiene. In Academic Year 2012-2013, these programs
trained over 2,600 oral health students and 517 primary care dental
residents.
The State Oral Health Workforce Improvement Program provides grants
to States to implement innovative programs to address their dental
workforce needs in a manner that is appropriate to the States'
individual needs. As part of this program States have used HRSA funds
for dentist recruitment and retention efforts, expanded training in
community settings, increased preventive services such as dental
sealant and fluoride programs, and expansion of clinical services in
underserved areas.
HRSA has provided funding to support curriculum development for
dental therapists and development of community prevention programs
using expanded practice dental hygienists.
HRSA grantees have undertaken activities related to the use of
alternative oral health providers with the goal of expanding the number
of oral health providers and increasing access to oral health services.
postpartum depression
Question. Maternal depression is often unrecognized and untreated
because pregnant and postpartum women are not universally screened for
depression. Estimates of depression during pregnancy range between 14
and 23 percent. Rates of postpartum depression in the first year range
from 5 to 25 percent.
What is the assessment of HHS on the adequacy of current research
into the causes of postpartum depression? Does HHS have a position on
the value of universal screening as a meaningful goal and will the
agency work with the Congress to encourage it? What is HHS doing to
increase access to mental health services for low-income mothers?
Answer. HHS supports numerous efforts to address the problem of
depression among pregnant and postpartum women in the areas of
research, prevention, screening, and care. In the U.S., we know that
approximately 12 percent of recent mothers (2009) who had a birth in
the past 2-9 months reported postpartum depression. We also know that
postpartum depression disproportionately affects mothers with less
education and with lower incomes, as well as American Indian/Alaska
Native mothers.
Research has shown that risk factors or possible causes of
postpartum depression include previous depressive episodes, stressful
life events, and low social support. HHS, through the National
Institutes of Health, is conducting research examining the
epidemiologic characteristics of severe postpartum depression, the
effects of the high levels of stress hormones experienced by pregnant
women living in poverty, the effects of postpartum depression on
infants, and effective treatments for this type of depression.
Regarding universal screening for postpartum depression, the
Department, has reviewed healthcare research and found the following:
--perinatal depression is one of the most common complications of the
perinatal period;
--validated screening tools exist that demonstrate high levels of
both sensitivity and specificity (at least for major
depression); and
--screening and intervention demonstrate better outcomes for women
experiencing perinatal depression.
However, the agency does not recommend universal screening at this
time due to an insufficient evidence base for how and when to screen
and intervene, especially as it relates to non-White women. Further
study in these areas is needed.
HHS is also supporting a number of programs to increase access to
mental health services for low-income and disadvantaged mothers,
especially in the area of screening and care for pregnant and
postpartum women. HRSA supports the Maternal, Infant and Early
Childhood Home Visiting Program, which provides voluntary, evidence
based home visiting services for low income pregnant and postpartum
women and their families in all 50 States, DC and territories. All home
visitors assess maternal depression with valid depression screening
tools, and they provide referrals to community mental health services
as available and as needed. The program has established a new
collaborative this year that focuses on optimizing the management of
maternal depression. HRSA also supports the Healthy Start program,
which focuses on reducing infant mortality and improving perinatal
outcomes in areas of high need throughout the country. All Healthy
Start grantees screen their clients for perinatal depression before,
during, and after pregnancy. Screening is repeated throughout the
pregnancy, with screening frequency dependent upon the woman. If the
woman is found to need services related to depression, she is referred
for appropriate care. Healthy Start has also developed perinatal
screening booklets and materials for materials in English and Spanish,
which have been widely disseminated.
Finally, SAMHSA supports Project LAUNCH (Linking Actions for Unmet
Needs in Children's Health) which seeks to promote the wellness of
young children from birth to 8 years by addressing the physical,
social, emotional, cognitive, and behavioral aspects of their
development. One area in which Project LAUNCH focuses is on the
strengths and challenges within the family system, including parental
depression. SAMHSA is also preparing to launch a toolkit on maternal
depression for family service providers that includes basic information
about maternal depression, tips, resources and strategies for talking
with women about depression, screening for depression and referral to
mental health services.
______
Questions Submitted by Senator Jeanne Shaheen
Question. HRSA invests a great deal of resources on doctors in
training and also for continuing medical education. What can HRSA do to
help educate providers about appropriate narcotic prescription drug
dispensement and how to avoid excess prescribing?
Answer. HRSA supported training is not specifically focused on
training in prescribing narcotic medications for pain management;
however, this topic is addressed as part of training curricula for many
health disciplines. Through the National Health Service Corps (NHSC)
program, HRSA will seek to increase education about appropriate
narcotic prescription drug dispensement to NHSC providers through
various available media, including webinars, newsletters and social
media.
Question. As you know, the United States has the lowest ratio of
primary care providers in the Organization for Economic Cooperation and
Development countries. American medical students often choose
specialist training over primary care training.
How can we incentivize medical students to choose primary care
specialties?
Answer. The administration recognizes that primary care is the
foundation of the healthcare delivery system today, and it will play an
even greater role in the future.
HRSA funds several programs that aim to encourage physicians to
select a primary care specialty. Through the National Health Service
Corps (NHSC) programs, students and clinicians receive scholarship or
loan repayment awards in return for a commitment to provide primary
health services in underserved areas (HPSAs) for at least 2 years. In
fiscal year 2013, 100 percent of all new NHSC loan repayment awards
were made to those serving in HPSAs of highest need (scores of 14 or
higher) and nearly half of NHSC clinicians are serving at rural sites.
In fiscal year 2015, HRSA expects to fund over 10,000 new NHSC loan
repayment awards in order to build and sustain a field strength of
15,000 primary care providers across the country, serving the primary
care needs of more than 16 million patients in high-need rural, urban,
and frontier areas across the United States. In fiscal year 2012, the
NHSC launched the Student to Service Loan Repayment Pilot Program which
provides loan repayment awards to medical students in their last year
of school as an incentive to pursue residency training in a primary
care specialty. To date, 147 medical students have participated in this
pilot program. In fiscal year 2015, the NHSC expects to award 100 new
Student to Service Loan Repayment awards.
In addition to the recruitment of providers, the NHSC also works to
retain primary care providers in underserved areas after their service
commitment is completed to further leverage the Federal investment and
to build more integrated and sustainable systems of care. A 2012
retention assessment survey found that 55 percent of NHSC clinicians
continue to practice in underserved areas 10 years after completing
their service commitment. Another recent study completed in fiscal year
2013 showed 85 percent of those who had fulfilled their service
commitment remained in service to the underserved in the short-term.
Short-term is defined as up to 2 years after their service completion.
The Primary Care Training Enhancement (PCTE) program strengthens
primary care by supporting innovation in primary care curriculum
development, education and practice (i.e. Patient-Centered Medical
Homes, team-based care, etc.) as well as expanding training
opportunities by funding primary care residency positions. In Academic
Year 2012-2013, the PCTE program trained a total of 23,830 physician
and physician assistant students, medical residents, and fellows. Of
those individuals trained, approximately 532 received direct financial
support.
In addition, in fiscal year 2012, HRSA modified the Scholarships
for Disadvantaged Students Program to better support the primary care
workforce by giving priority to applicants who could demonstrate a 15
percent or better rate of graduates practicing in primary care. The
program provides funding to eligible health professions schools to
support scholarships for financially needy students from disadvantaged
backgrounds.
The President's fiscal year 2015 budget includes a new Targeted
Support for Graduate Medical Education program that will train 13,000
new physicians over 10 years. This new Targeted Support for Graduate
Medical Education Program will expand residency slots, with a focus on
ambulatory and preventive care in order to advance the ACA's goals of
higher value healthcare that reduces long-term costs. Successful
applicants will need to demonstrate that their training of residents
addresses key workforce objectives, such as: training and retaining
residents in primary care and providing comprehensive primary care that
includes oral health, behavioral health, prevention and population
health.
Question. How do you ensure that funding for primary care training
will not only go to large tertiary care teaching hospitals but also the
smaller clinics and community hospitals that make up the backbone or
primary care?
Answer. HRSA actively seeks to expand primary care training in
community-based, ambulatory settings. The Affordable Care Act created
the Teaching Health Center Graduate Medical Education Program to help
move primary care training into community-based settings. The 5-year
investment in this program is expected to support the community-based
training of over 600 new primary care physician and dental residents by
2015. The program supports community-based training sites in 30
Federally Qualified Health Centers (FQHCs) and FQHC look-alikes, 2 Area
Health Education Centers, 2 Native American Health Authorities, 1
Community Mental Health Clinic and 4 additional community-based
entities.
To build on the success of the Teaching Health Center Graduate
Medical Education program, the President's fiscal year 2015 budget
proposes a new initiative to expand residency training and build the
health workforce needed for a changing healthcare system. The Targeted
Support for Graduate Medical Education Program will focus specifically
on key priorities for workforce development and transforming the
healthcare delivery system. The program will fund new residency slots
using a competitive approach in which applicants demonstrate how their
training of residents addresses key workforce objectives, such training
in new models of care that are interprofessional.
Unlike Medicare GME, which is only paid to hospitals, this funding
will be available to consortia of teaching hospitals and other
community-based healthcare entities, as well as to consortia of
community-based healthcare entities. Consortia partners would partner
to deliver a broad range of training experiences in different settings
to strengthen experiential training in ambulatory care settings where
the vast majority of the public receive care.
Question. The Office for the Advancement of Telehealth (OAT)
administers grants to incorporate telehealth in underserved and rural
communities. What is HRSA doing to help States like New Hampshire with
a many rural communities benefit from telemedicine access?
Answer. The Telehealth Network Grant Program (TNGP) helps
communities build the human, technical, and financial capacity to
develop sustainable telehealth programs. These networks can be used to
deliver quality healthcare to medically underserved populations in
rural and frontier communities and also to provide information and
training to healthcare providers in remote areas. Currently the Office
for the Advancement of Telehealth (OAT) funds 20 TNGP grantees,
including Mary Hitchcock Memorial Hospital located in Lebanon, New
Hampshire.
Additionally, OAT funds the Telehealth Resource Center Grant
Program (TRC), which provides funding to 14 centers of excellence that
assist healthcare organizations, healthcare networks, and healthcare
providers in the implementation of cost-effective telehealth programs
to serve rural and medically underserved areas and populations. The
Northeast Telehealth Resource Center provides technical assistance to
rural communities in New England (including New Hampshire), and New
York.
______
Questions Submitted by Senator Jerry Moran
prevention and public health fund
Question. What is the overall strategy in determining what HHS
programs are funded with the Prevention and Public Health Fund (PPHF)?
What internal departmental discussions take place to determine
which agencies are recipients from and which agencies are donors to the
Fund?
Answer. Funding decisions for the Prevention Fund were made using
the same formulation process used to develop the annual Federal budget
and was decided in conjunction with other annual budget decisions. HHS
works with public health, programmatic, and scientific experts in
agencies across the department to identify effective and proven
strategies that will improve health outcomes, promote prevention, and
aim to reduce the cost of healthcare. Funds allocated to agencies are
directly appropriated to HHS and are not based on contributions from
agencies.
nonrecurring expenses fund
Question. What analyses does the Department do before moving
unobligated funds into the Nonrecurring Expenses Fund? Please detail
this process.
Answer. Prior to moving unobligated funds into the Nonrecurring
Expenses Fund (NEF), the Department of Health and Human Services (HHS)
works closely with the program offices in determining which funds are
eligible. HHS is restricted in the types of Federal funds that may be
transferred to the NEF. Funds must be expired and unobligated, meaning
the funding is not available for current year obligations and is not
obligated to a vendor or grantee. However, statutory requirements (31
U.S.C. 1551-1558) require expired unobligated balances be used for
routine adjustments to previously recorded obligations, meaning not all
expired unobligated funds may be transferred to the NEF. As an account
nears its time of cancellation, HHS is able to identify with more
accuracy the amounts eligible to transfer. These unobligated balances
would otherwise cancel or return to the Department of the Treasury if
not transferred to the NEF. In addition, HHS may only obligate funds
after notifying the Committees on Appropriations in the House of
Representatives and the Senate of the planned use.
Question. How does HHS decide what information technology (IT)
projects merit Nonrecurring Expenses Fund dollars?
Answer. HHS has used the NEF to fund critical capital acquisition
projects necessary for the operation of the Department. NEF funded
projects have reduced the financial impacts on current year funds, thus
ensuring appropriations support key programs targeted by Congress. When
the Department considers funding a project with NEF funds, the HHS
Office of the Chief Information Officer and subject matter experts
conduct a thorough review of each project to confirm that each project
is eligible to receive NEF funding consistent with HHS legal authority,
regulations, and policies.
Question. Does HHS solicit formal or informal requests from
agencies for Non-recurring Expenses Fund-related projects? Please
provide details on what each HHS agency requested.
Answer. The Department of Health and Human Services (HHS) does work
with components to determine investments made through use of the
Nonrecurring Expenses Fund (NEF). As part of the budget development
process, HHS examines the needs across the agency seeking to balance
funds availability, project timing, and optimal use of the fund sources
available. Determining eligibility on a specific project is a fluid
process with multiple stages including internal review, subject matter
expert review, and approval by the Office of Management and Budget. In
the fiscal year 2015 Congressional Justification to the Committees on
Appropriations, HHS listed potential project investments, specifically
financial system modernization and information technology
infrastructure investments.
Question. What programs would have received funding over the past 2
years had funding not been siphoned off to fund the implementation of
the health insurance Exchanges?
Answer. The NEF has funded a number of critical capital acquisition
projects identified by the Department other than the implementation of
the health insurance Marketplace, including the beginning work on
financial system modernization, enabling HHS to upgrade its core
financial platform for both functionality and security reasons,
critical Cybersecurity infrastructure upgrades, and the initial stages
for acquisition of an electronic case processing system in the Office
of Medicare Hearings and Appeals. This system will aide in the
processing of appeals and secure documents that are currently stored in
paper files.
information technology
Question. Describe the role of the department's Chief Information
Officer in the oversight of IT purchases. How is this person involved
in the decision to make an IT purchase, determine its scope, oversee
its contract, and oversee the product's continued operation and
maintenance?
Answer. HHS is a federated environment where IT purchase decisions
are made at the Operating Division (OpDiv) level. To improve
departmentwide visibility, the HHS Office of the Chief Information
Officer (OCIO) chartered the HHS Domain Governance Office which
provides oversight for IT acquisitions across the Department of Health
and Human Services. The Domain Governance Office requires that OpDivs
within HHS share IT acquisition and project forecasts through the
Annual Procurement Forecast System. The HHS Chief Information Officer
is a member of the IT Steering Committee, which reviews planned
acquisitions and projects to direct strategy and to prioritize
investments.
Question. Describe the existing authorities, organizational
structure, and reporting relationship of your department Chief
Information Officer. Note and explain any variance from that prescribed
in the Information Technology Management Reform Act of 1996 (The
Clinger-Cohen Act) for the above.
Answer. The Department level Chief Information Officer (CIO)
provides varying levels of oversight to HHS's OpDivs in regard to the
Clinger-Cohen Act. Many of the authorities are delegated to the OpDiv
CIOs, such as governance, program training and management since the
OpDiv CIOs have a direct line of sight into their investments. Since
the HHS CIO operates in a decentralized funding structure, the office
is working towards efforts to increase its ability to strategically
manage the Department's IT portfolio via the three Domains of the IT
Steering Committee: Administrative, Health and Human Services, and
Scientific Research. There is also an HHS CIO Council in order to
provide transparency and communications throughout HHS.
Question. What formal or informal mechanisms exist in your
department to ensure coordination and alignment within the CXO
community (i.e., the Chief Information Officer, the Chief Acquisition
Officer, the Chief Finance Officer, the Chief Human Capital Officer,
and so on)? How does that alignment flow down to department
subcomponents?
Answer. The IT Steering Committees (ITSCs) that were recently
chartered include membership from the Chief Financial Officer (CFO) and
Chief Acquisition Officer (CAO). Additionally, the Deputy CFO has a
Financial Governance Board that includes representation from the Chief
Information Officer (CIO), CAO, Chief of Budget, and the Chief Human
Capital Officer. The ITSC charter is built upon information from the
Senior Procurement Executive regarding use and analysis of the Annual
Procurement Forecast in order to leverage HHS's buying power
proactively. The CIO has also been proactively engaging with the Chief
Human Capital Officer in transformative processes used to hire IT
professionals.
Question. How much of the department's budget goes to
Demonstration, Modernization, and Enhancement of IT systems as opposed
to supporting existing and ongoing programs and infrastructure? How has
this changed in the last 5 years?
Answer. In fiscal year 2014, 12.4 percent of HHS's total IT budget
will go to Development, Modernization, and Enhancement (DME) of IT
Systems. When Grants to States and Local IT investments are excluded
(representing 40 percent of the total HHS fiscal year 2014 IT budget),
the DME portion rises to 20.2 percent. In each case, the trend over the
past 5 years has been downward from a high of 22 percent in fiscal year
2010. An off-trend spike to 24.6 percent (30.8 percent without grants)
in fiscal year 2011 represents DME activity related to implementation
of the Patient Protection and Affordable Care Act.
Question. Where and how are you taking advantage of this
administration's ``shared services'' initiative? How do you identify
and utilize existing capabilities elsewhere in government or industry
as opposed to recreating them internally?
Answer. HHS used the administration's ``shared services''
initiative to institutionalize shared services requirements across the
Department. A dedicated workgroup under the purview of the Enterprise
Architecture Review Board developed HHS's Shared Services Strategy
which illustrates the long-term strategy and sets the foundations to
successfully develop, deploy, and use shared services at HHS. To
promote the identification and reuse of services, HHS documented and
published the Shared Services Catalog (available to all HHS employees
through the intranet). This catalog contains a list of services
available to use across HHS or within a specific Operating Division
(OpDiv). Additionally, HHS contributed a list of cross-Agency services
to Uncle Sam's List so other Agencies can reuse HHS's services. A
publicly available summary of the Shared Services Strategy can be found
here: http://www.hhs.gov/ocio/ea/sharedservices.html.
HHS continues to leverage cloud computing technologies, through
carefully assessing technical, security, and contractual requirements
to ensure seamless integration to avoid disruption of current services
and the mission that we provide for the American public.
Question. Provide short summaries of three recent IT program
successes, projects that were delivered on time, within budget, and
delivered the promised functionality and benefits to the end user. How
does your department define ``success'' in IT program management?
Answer. Human Resources IT (HRIT).--The HRIT Shared Service project
is in progress and has gone through the Enterprise Project Life Cycle
(EPLC) with the approval to proceed to the final phase of
implementation. The implemented solution is expected to provide HHS
with a true end-to-end hire to retire solution that improves data
integrity by eliminating errors caused by using three separate
platforms (HR, Time & Labor, Pay). The project is expected to be fully
implemented on time and within budget.
HRIT will strengthen internal controls and support the
administration's PortfolioStat initiative which seeks opportunities to
shift to commodity IT, leverage technology, procurement, and best
practices across the whole of government, and build on existing
investments. By implementing HRIT as a shared service, HHS is poised to
achieve:
--reduction of manual data calls;
--implementation of a single data entry, multiple use model;
--elimination of manual data reconciliation processes;
--reduction in the number of handoffs to effect routine HR actions.
Personal Identity Verification (PIV) Implementation.--HHS
identified operational improvements to the Department Identity,
Credential, and Access Management (ICAM) program in order to reduce
costs and enhance security. The ICAM program reviewed the proposed
design for the enhancements in the HHS Access Management System (AMS)
to simplify the efforts by applications to integrate with the
Department-wide Single Sign-On system. HHS has a mature capability to
allow user access to the HHS network with a PIV badge issued at Level
of Assurance (LOA 4). HHS also has the capability to accept PIV or
Common Access Card (CAC) credentials from other Federal agencies/
departments for access to applications that are integrated with the HHS
Access Management System for Single Sign-On services. At this time
there are 18 Enterprise systems and 5 Operational Division specific
systems integrated with AMS.
HHS LMS SABA 7.2 Upgrade.--The HHS Learning Portal, also referred
to as the LMS (Learning Management System), is utilized by the
Department of Health and Human Services (HHS) to provide a single
standardized training recording system for all of HHS. The LMS is
currently used by approximately 80,000 HHS employees and 20,000
contractors. The LMS software is provided by Saba and is hosted by
General Strategies (GS). GS also provides technical and consulting
support to HHS for the LMS and associated technologies. HHS took
advantage of new technology in SABA version 7.2 with a major upgrade
that enabled the LMS application to run more efficiently and allow
employees to have a more enjoyable user experience.
Defining IT Program Management Success at HHS.--Success at HHS in
IT Program Management is supported by the HHS Enterprise Performance
Life Cycle (EPLC) established in 2008. It is an essential part of our
IT management and governance. The process provides a framework for
planning, managing and monitoring projects to ensure our projects are
sufficiently resourced, well managed and achieve their objectives. In
addition, the EPLC ensures compliance with a variety of IT management
mandates, including: security, privacy, records management, and
accessibility. All HHS IT projects are required to follow the EPLC.
The Department's ongoing commitment to the alignment between IT and
business processes, organization structure, and strategy has
strengthened Program Management at HHS. At the highest levels, this
alignment is achieved through proper integration of enterprise
architecture, business architecture (business need), process design,
organization design, and performance metrics to provide value and
support the mission of HHS.
Question. What ``best practices'' have emerged and been adopted
from these recent IT program successes? What have proven to be the most
significant barriers encountered to more common or frequent IT program
successes?
Answer. Best Practices.--The Department will be offering an IT
Project Management Training contract for all Operating Divisions to
enhance the technical skill set of our project management community.
HHS has also taken an active approach to advertise and reuse
services that are shared between Government agencies, citizens, and
industry at one or more levels. HHS has developed a catalog of inter-
agency, intra-agency, and intra-OPDIV services that can be shared
within HHS and with all Federal agencies as seen in our Shared Services
Catalog. Currently, HHS offers 170 services within specific OPDIVs,
across HHS, and to other Federal agencies.
HHS also utilizes CIO Council Meetings as a forum within which best
practices are collaboratively shared between the participating HHS
Operational Divisions.
Significant Barriers.--Some of the most significant barriers to IT
program success are ensuring that secured and trusted information is
constantly updated and monitored to align with the rapidly changing
technology environments. The lengthy acquisition process itself can be
a barrier to IT success given the rapid pace at which technologies
continually evolve. Other notable barriers include a risk adverse
culture, lack of accountability, and shared risk.
Lastly, one of the Department's most valuable resources is our
Federal workforce--hiring people with the right skill sets for the job.
The HHS OCIO has previously relied strongly on contract support to
supplement our Federal workforce. OCIO is in the process of hiring
Federal staff to fulfill the needs within areas of Enterprise
Architecture, capital planning and project management. The hiring of
these candidates will allow us to build a reliable, talented and
innovative workforce within the agency that can help accelerate the
goals of HHS.
Question. Describe the progress being made in your department on
the transition to new, cutting-edge technologies and applications such
as cloud, mobility, social networking, and so on. What progress has
been made in the CloudFirst and ShareFirst initiatives?
Answer. HHS continues to make progress in transitioning to new,
cutting-edge technologies and applications departmentwide. HHS has
operationalized and integrated a departmentwide Federal Risk and
Authorization Management Program (FedRAMP) security authorization
process and is actively using FedRAMP. HHS is developing cloud based
use cases that will enable other programs to implement and manage cloud
computing systems in accordance with best practices and Federal
standards, to improve the transition to a cloud environment.
Question. How does your department implement acquisition strategies
that involve each of the following: early collaboration with industry;
RFP's with performance measures that tie to strategic performance
objectives; and risk mitigation throughout the life of the contract?
Answer. Within the OCIO's office, the Vendor Management office
provides outreach and serves as a conduit to industry and the CIO's
principal office to connect those vendors who provide products and
services that meet the needs and requirements for projects that are
underway or in the planning stage.
Each departmentwide RFP is developed based on the requirements and
needs of the Operating Divisions. Service Level Agreements and other
performance measures are included to ensure these requirements are met
in the most efficient and effective manner possible.
Question. According to the Office of Personnel Management, 46
percent of the more than 80,000 Federal IT workers are 50 years of age
or older, and more than 10 percent are 60 or older. Just 4 percent of
the Federal IT workforce is under 30 years of age. Does your department
have such demographic imbalances? How is it addressing them? Does this
create specific challenges for attracting and maintaining a workforce
with skills in cutting edge technologies? What initiatives are underway
to build your technology workforce's capabilities?
Answer. OCIO completed an organizational assessment in March 2014
to update vision, goals, core principles and strategic mapping of OCIO
goals which included efforts to position the IT workforce to readily
meet new and complex challenges. OCIO is engaging the workforce through
a series of communications efforts to include quarterly Town Halls,
monthly Brown Bag discussions with the CIO and promotion of close
engagements and frequent communications between managers and employees.
Communication efforts also include OCIO branding to reflect the one-
team focus in response to OCIO customers. An IT Community Workforce
Plan is under development which will allow us to:
--identify IT goals and external workforce trends;
--identify impact on IT Talent;
--establish the resulting talent needs;
--identify gaps in our IT competencies; and
--describe how IT is to attract high-quality talent and build the
best IT team.
Question. What information does your department collect on its IT
and program management workforce? Please include, for example, details
about current staffing versus future needs, development of the talent
pipeline, special hiring authorities, and known knowledge gaps.
Answer. HHS has a CIO Workplan that sets goals for each OpDiv. The
overall goal is to create and administer a comprehensive plan that
aligns with the Information Resource Management Strategic Plan and day-
to-day work of HHS IT employees that motivates them to achieve their
best. One of the goals for 2014 is to develop an IT Community Workforce
Development Plan to:
--provide challenging projects to work;
--ensure skills stay current with training;
--hold employees accountable to deliver; and
--reward top performers.
The OCIO is developing an IT workforce plan and establishing an
OCIO led working group to prioritize goals and implement this activity
by expanding opportunities for leadership, training, and workforce
development. We will position the IT workforce to meet new and complex
challenges by promoting collaboration and enabling free flow of
information to others who can use it to advance public health and human
services. Additionally, OCIO is actively sponsoring student interns to
engage new IT professionals in government services through the Pathways
program and the Student Volunteer Program.
______
Questions Submitted by Senator Richard C. Shelby
area health education centers
Question. The Area Health Education Centers (AHEC) program received
a $1.8 million increase in fiscal year 2014. Please provide an
explanation on how these funds were used, including a rationale for the
allocation between the Infrastructure Development Grants and the Point
of Service and Maintenance Grants. In the response, please include a
comparison of the funding allocation to the past 2 fiscal years.
Answer. HRSA is currently exploring options for fiscal year 2014 to
support the AHEC program with available resources. The options may
include increasing funding to current AHEC grantees to the amount
requested in their fiscal year 2012 grant proposals, or supporting new
AHEC centers.
Use of the funds will be consistent with past years, and with the
requirements of the fiscal year 2012 funding opportunity announcement
of the program. Recognizing that Infrastructure Development (ID)
grantees need additional funding support, the fiscal year 2012 AHEC
Program funding opportunity announcement distinguished between the ID
and Point of Service Maintenance and Enhancement (POSME) phases of the
program. These phases were treated as two separate options with
distinct funding levels in the grant competition. AHEC ID applicants
were able to request for up to $250,000 for each center, and AHEC POSME
applicants were able to request up to $102,000 per AHEC center.
The grant competition and review processes for each of the phases
also play a factor in how funding is allocated within program. No
formula or targeted ratio of funding is utilized in making decisions
for how much funding is allocated to grantees applying for the two
phases. The proposals and funding requests of the grantees and the
merit evidenced through their separate objective reviews guide
decisionmaking for which grantees should receive an award, and at what
amount. Applications for both phases of the program received an
objective and independent peer review performed by a committee of
experts who assessed the technical merit of each grant application. In
the case of this program, the objective review committee also made a
specific recommendation for each application as applicable to approve
or disapprove any new center(s) requested. Last, based on the advice of
the objective review committee, the HRSA was responsible for final
selection of grantees and allocating funding as able per the grantee's
requests, and in making these decisions consideration was given to the
Sense of the Congress per section 751 of the Public Health Service Act
``that every State have an area health education center program in
effect under this section.''
Question. Why has HRSA held back funding for building approved
centers when grantees included these in their budget when they were
awarded multicenter grants?
Answer. While the fiscal year 2013 enacted budget for the AHEC
program did include an increase in funding for the AHEC program,
sequestration significantly reduced available funding, and there was
not sufficient funding for new activity within the AHEC program to
support all of the new centers that had been proposed to be added in
fiscal year 2013. Accordingly, funding for existing AHEC activity was
prioritized and no new AHEC centers were funded in fiscal year 2013.
Note that, in anticipation of budgetary constraints, the Notices of
Award for all fiscal year 2012 grantees informed them of the fact that
funding for new center(s) would depend on future appropriation levels.
Specifically, the Notices of Award Stated if the fiscal year 2013
appropriation level for the AHEC program is the same or less than the
fiscal year 2012 appropriation level, the additional new center(s) may
not be funded.
Senator Harkin. And I would just say publicly, my good
friend from Kansas, that Ms. Burwell is testifying tomorrow
before my other committee, the authorizing committee.
Hopefully, we will get her through and get her in place soon.
I will, as the chairman, give her some time. Working with
my ranking member here, I hope that sometime after she gets
settled and gets fully briefed up, that we will have her up
here to talk about implementation.
SUBCOMMITTEE RECESS
Senator Moran. Mr. Chairman, thank you very much. I welcome
that. I have requested an appointment with the nominee and
expect to have that within the next few days. I look forward to
getting acquainted with her.
The point I would make is that this kind of hearing that we
just had today is valuable, but it ought not be in lieu of a
Secretary. We ought to do this kind of thing on an ongoing
basis, and I welcome the opportunity to work with you to
accomplish that.
Senator Harkin. Thank you very much, Senator Moran.
Thank you all very much. And with that, the committee will
stand adjourned.
[Whereupon, at 11:40 a.m., Wednesday, May 7, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]