Labor, Health and Human Services, Education Appropriations for 2022, Part 5 (House Hearing)
Summary
Part 5 of the hearings "Departments of Labor, Health and Human Services, Education, and Related Agencies Appropriations for 2022" before the Subcommittee on Labor, Health and Human Services, Education, and Related Agencies of the Committee on Appropriations, chaired by Rosa L. DeLauro. The part lists hearings on Covid-19 and the Childcare Crises, U.S. Health Infrastructure, protections for meatpacking, poultry, and agricultural workers, Covid-19 and the Mental Health and Substance Use Crises, and the Maternal Health Crises. The first hearing, on February 19, 2021, heard from Melissa Boteach of the National Women's Law Center, Georgia Goldburn of Hope Child Development Center, Theresa Hawley of the Office of Illinois Governor JB Pritzker and Katharine Stevens of the American Enterprise Institute.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
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“Labor, Health and Human Services, Education Appropriations for 2022, Part 5 (House Hearing).”
Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/house-hearing-117th-congress-departments-of-labor-health-and-human-ser-18d154c255/
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[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2022
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
_____
SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND
RELATED AGENCIES
ROSA L. DeLAURO, Connecticut, Chair
LUCILLE ROYBAL-ALLARD, California TOM COLE, Oklahoma
BARBARA LEE, California ANDY HARRIS, Maryland
MARK POCAN, Wisconsin CHUCK FLEISCHMANN, Tennessee
KATHERINE M. CLARK, Massachusetts JAIME HERRERA BEUTLER, Washington
LOIS FRANKEL, Florida JOHN R. MOOLENAAR, Michigan
CHERI BUSTOS, Illinois BEN CLINE, Virginia
BONNIE WATSON COLEMAN, New Jersey
BRENDA L. LAWRENCE, Michigan
JOSH HARDER, California
NOTE: Under committee rules, Ms. DeLauro, as chair of the full
committee, and Ms. Granger, as ranking minority member of the full
committee, are authorized to sit as members of all subcommittees.
Stephen Steigleder, Jennifer Cama, Jaclyn Kilroy, Jared Bass,
Philip Tizzani, Laurie Mignone, Rebecca Salay, and Trish Castaneda
Subcommittee Staff
______
PART 5
Page
Covid-19 and the Childcare Crises..... 1
Ready or Not: U.S. Health Infrastructure 79
Health and Safety Protections for
Meatpacking, Poultry, and Agricultural
Workers................................. 159
Covid-19 and the Mental Health and
Substance Use Crises....................
239
Addressing the Maternal Health Crises 315
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Appropriations
U.S. GOVERNMENT PUBLISHING OFFICE
46-638 WASHINGTON : 2022
COMMITTEE ON APPROPRIATIONS
----------
ROSA L. DeLAURO, Connecticut, Chair
MARCY KAPTUR, Ohio KAY GRANGER, Texas
DAVID E. PRICE, North Carolina HAROLD ROGERS, Kentucky
LUCILLE ROYBAL-ALLARD, California ROBERT B. ADERHOLT, Alabama
SANFORD D. BISHOP, Jr., Georgia MICHAEL K. SIMPSON, Idaho
BARBARA LEE, California JOHN R. CARTER, Texas
BETTY McCOLLUM, Minnesota KEN CALVERT, California
TIM RYAN, Ohio TOM COLE, Oklahoma
C. A. DUTCH RUPPERSBERGER, Maryland MARIO DIAZ-BALART, Florida
DEBBIE WASSERMAN SCHULTZ, Florida STEVE WOMACK, Arkansas
HENRY CUELLAR, Texas JEFF FORTENBERRY, Nebraska
CHELLIE PINGREE, Maine CHUCK FLEISCHMANN, Tennessee
MIKE QUIGLEY, Illinois JAIME HERRERA BEUTLER, Washington
DEREK KILMER, Washington DAVID P. JOYCE, Ohio
MATT CARTWRIGHT, Pennsylvania ANDY HARRIS, Maryland
GRACE MENG, New York MARK E. AMODEI, Nevada
MARK POCAN, Wisconsin CHRIS STEWART, Utah
KATHERINE M. CLARK, Massachusetts STEVEN M. PALAZZO, Mississippi
PETE AGUILAR, California DAVID G. VALADAO, California
LOIS FRANKEL, Florida DAN NEWHOUSE, Washington
CHERI BUSTOS, Illinois JOHN R. MOOLENAAR, Michigan
BONNIE WATSON COLEMAN, New Jersey JOHN H. RUTHERFORD, Florida
BRENDA L. LAWRENCE, Michigan BEN CLINE, Virginia
NORMA J. TORRES, California GUY RESCHENTHALER, Pennsylvania
CHARLIE CRIST, Florida MIKE GARCIA, California
ANN KIRKPATRICK, Arizona ASHLEY HINSON, Iowa
ED CASE, Hawaii TONY GONZALES, Texas
ADRIANO ESPAILLAT, New York
JOSH HARDER, California
JENNIFER WEXTON, Virginia
DAVID J. TRONE, Maryland
LAUREN UNDERWOOD, Illinois
SUSIE LEE, Nevada
Robin Juliano, Clerk and Staff Director
(ii)
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED
AGENCIES APPROPRIATIONS FOR 2022
Friday, February 19, 2021.
COVID-19 AND THE CHILDCARE CRISIS
WITNESSES
MELISSA BOTEACH, VICE PRESIDENT, INCOME SECURITY AND CHILDCARE/EARLY
LEARNING, NATIONAL WOMEN'S LAW CENTER
GEORGIA GOLDBURN, DIRECTOR, HOPE CHILD DEVELOPMENT CENTER
THERESA HAWLEY, FIRST ASSISTANT DEPUTY GOVERNOR, EDUCATION, OFFICE OF
ILLINOIS GOVERNOR JB PRITZKER
KATHARINE STEVENS, VISITING SCHOLAR, AMERICAN ENTERPRISE INSTITUTE
The Chair. This hearing will come to order. In the absence
of a gavel, I am banging on the table here. So there we go.
Some housekeeping things first here. As the hearing is
fully virtual, we need to address some of these issues.
For today's meeting, the chair or staff designated by the
chair may mute participants' microphones when they are not
under recognition for the purposes of eliminating inadvertent
background noise. Members are responsible for muting and un-
muting themselves. If I notice that you have not unmuted
yourself, I will ask you if you would like the staff to unmute
you. If you indicate approval by nodding, staff will unmute
your microphone.
I remind all members and witnesses that the 5-minute clock
still applies. If there is a technology issue, we will move to
the next member until the issue is resolved. You will retain
the balance of your time. You will notice a clock on your
screen that will show how much time is remaining. At 1 minute
remaining, the clock will turn yellow. At 30 seconds remaining,
I will gently tap the gavel to remind members that their time
is almost expired. When your time is expired, the clock will
turn red. I will recognize the next member.
In terms of the speaking order, we will begin with the
chair and ranking member. Then members present at the time the
hearing is called to order will be recognized and will be
recognized in the order of seniority, and, finally, members not
present at the time the hearing is called to order.
Finally, House rules require me to remind you that we have
set up an email address to which members can send anything they
wish to submit in writing at any of our hearings or markups.
That email address has been provided in advance to your staff.
With that, I want to acknowledge Ranking Member Cole and
all of our colleagues joining us as we come together to discuss
the COVID-19 pandemic and the childcare crisis. Let me also
welcome our witnesses this morning: Melissa Boteach, vice
president, income security and childcare/early learning,
National Women's Law Center; Georgia Goldburn, director, Hope
Child Development Center; Dr. Theresa Hawley, First Assistant
Deputy Governor, Education, Office of Illinois Governor JB
Pritzker; Dr. Katharine Stevens, visiting scholar, American
Enterprise Institute.
We will provide more fulsome introductions before their
testimony, but we are so glad that you all could join us this
morning, and thank you, thank you for the work that you do
every day.
The fight for childcare is such an important one, but it
breaks my heart that it has to be a fight at all. I have said
time and time given that the United States has been teetering
on the brink of a childcare crisis, but now this COVID-19
pandemic has pushed us over the edge. Even before the pandemic
began, affordable childcare was already a significant and a
severe issue. Now this pandemic has further exacerbated and
exposed existing disparities.
Women, particularly women of color, have been
disproportionately impacted by this crisis. The National
Women's Law Center reports that since February of last year
women have lost over 5.3 million net jobs and account for 53.8
percent of overall job loss since the beginning of this
pandemic. Recent data on job losses also reveal that employers
cut 140,000 jobs in December. Every single job, every single
job cut belonged to a woman. And mothers with young children
were hit particularly hard.
While this was an issue, as I said, before the pandemic,
COVID-19 has intensified these problems, again, especially for
women of color. Part of this has to do with childcare. Lack of
childcare has been cited as a reason why women are still highly
reflected in the unemployment numbers. And according to Ms.
Boteach's testimony, and I quote, ``Approximately 32 percent of
employers said that they had already seen employees leave since
the pandemic, and half of those cited childcare as the
reason.''
To be clear, women are not opting out of the workforce,
but, rather, they are being pushed out by inadequate policies.
We have a real opportunity, not just to throw money at the
problems but to build the architecture for the future and use
this as a moment to address these serious inequities that have
been further exposed by the coronavirus pandemic.
Because it is unconscionable that each day hardworking
women, mothers, and families have to make a choice between
going to work and ensuring that their kids are properly cared
for, for those parents who are essential workers or who need to
work in order to pay for childcare, this is an all-but-
impossible choice.
Childcare providers, the overwhelming majority, over 90
percent of whom are women or people of color, have been
operating on razor-thin margins. They haven't been able to stay
open at all. Their wages are minuscule. They grapple with
changing health and safety procedures. And as the bills
continue to stack up, many have had to close their facilities,
whether temporarily or indefinitely. Others that have stayed
open have fewer children either because parents are concerned
about exposing their kids to COVID-19 or because they have lost
their incomes.
These woes are further complicated by rising costs for
childcare providers as they scramble to provide PPE, to
sanitize their classrooms, to secure more space for social
distancing. As a result, many of these small businesses and
their owners are finding themselves on the verge of collapse.
We need to save the childcare industry. It is not just a matter
of economics. It is a matter of priorities. It is a matter of
right and wrong.
In my home State of Connecticut, we have more than 121,000
children, ages 5 and under, who need childcare. But without
adequate support from the Federal Government, Connecticut could
lose about 48 percent of the childcare supply, more than 46,000
licensed childcare slots. It was already the case that, for
every one childcare slot lost, there were two children in need.
Now, it is more than four. The crisis has become a catastrophe.
Thankfully our country is waking up to the reality that
childcare is essential, essential for women, for children, for
parents, for small businesses, communities of color, and for
our economy at large.
As the chair of the subcommittee, I have been working for
quite some time to draw attention to the impending childcare
crisis. It is critical for Congress to do more to ensure
programs like the childcare block development grant receive the
funding they need. As you will recall, Congress appropriated
$5,900,000,000 for childcare development block grants in 2021.
In addition, $3,500,000,000 was included for CCBDG in the CARES
Act and an additional $10,000,000,000 in December in the
supplemental.
To be frank, the funding, not nearly enough. Just as we
provided grants in the CARES Act through the Payroll Support
Program so airlines could pay their employees and keep flying
through this pandemic, we supported that effort, we must also
do what is necessary to get our economy back on providing by
rescuing the childcare industry. We provided over
$648,000,000,000 for the Paycheck Protection Program to get
small business owners back on their feet. It was a good thing
to do. We need to do what is necessary to stabilize the
childcare industry to allow parents and caregivers to get back
to work.
One of our witnesses, Melissa Boteach, will discuss a
little more in her testimony that childcare is the work that
makes work possible. So, if it is true that the childcare
industry makes all other work possible, then why have we
provided only $13,500,000,000 in supplemental funding to the
CCDBG? If childcare providers are essential workers, then why
aren't we treating childcare work as essential? $13,500,000,000
is not enough, which is why it is crucial that we act and we
act quickly. At the end of the day, if we cannot make families
feel that their kids are going to be safe, secure in their
childcare setting, then we cannot build a feasible path to a
recovery.
With that, let me turn to my friend and my colleague from
Oklahoma, the ranking member, Congressman Cole, for any opening
remarks he may have.
And I will ask those who are not speaking to please get
yourself on mute so we can move forward.
Congressman Cole.
Mr. Cole. Thank you very much, Madam Chair.
Before I begin my formal remarks, I just want to say what a
pleasure it is to have you once again as our chairman of this
subcommittee and, more importantly, as the chairman of the full
committee. I think I can speak for people on both sides of the
aisle that we think this will probably help us a lot in our
allocation requests moving forward.
And while as a Republican I certainly was not in a position
to vote for you, once it was clear we were going be in the
minority, I think it is fair to say I headed the Republicans
for DeLauro effort. So I congratulate my colleagues on the
other side of the aisle in making a very wise choice to chair
our full committee as well as obviously your decision to remain
as our subcommittee chairman here on Labor-H. I really am
grateful for both those things.
I want to begin, Madam Chair, our first hearing in the
117th Congress by reiterating my commitment to working with you
whenever we can to find common ground on what looks to be yet
another very challenging year. We will have our work cut out
for us, but our 6 years of working together has laid a good
foundation. Just last year we were able to come together and
pass not one but five coronavirus supplemental appropriations,
and from the standpoint of this committee, I think even more
importantly, a full year's appropriation for this bill. This
serves at a testament to what this institution can achieve
together, even in a divisive political climate. I certainly
hope we can continue those efforts, and I am sure you do as
well.
I also want to welcome back to our subcommittee Mr.
Fleischmann. He has been a strong member of this committee in
the past, and we are very glad to have him return. I am sure he
will make an exceptional contribution to our deliberations.
I would also like to acknowledge our newest member on our
side of the aisle, Mr. Cline from Virginia. We look forward to
working with Mr. Cline and the new perspective that he will
bring to the subcommittee. I will also just report he has been
known to smoke an occasional cigar. So he is apt to be one of
my favorite new members, Madam Chair.
And now to turn to the topic at hand today, the impact of
the pandemic on the childcare industry. The economic shock our
Nation experienced in the spring of this last year was
unprecedented. Real gross domestic product declined at an
annual rate of over 30 percent. Our lives were completely
upended. While almost no industry was spared from the economic
fallout, the childcare industry was hit especially hard. Much
of the industry had to close completely for large portions of
the year, and even those who were able to remain open sometimes
had the capacity of no more than a quarter of what it was in
the prior year.
Thankfully, in the first weeks of this year, we are
continuing to see an economic turnaround. In many respects, the
economic rebound of the last few months is unparalleled.
However, not everyone has been fortunate enough to see their
situation improve, and we continue to hear stories of too many
families struggling.
To address the pandemic's consequences, Congress provided
nearly $700,000,000,000 in supplemental appropriations,
accompanied by hundreds of billions of dollars more from other
mandatory entitlement extensions. Of the appropriated dollars,
an overwhelming 63 percent, or $434,000,000,000, was for this
subcommittee, with $13,500,000,000 exclusively to support
childcare access for low-income families. The last supplemental
passed just a few weeks ago included $10,000,000,000 to support
this critical industry to aid our continued economic recovery.
I have been proud to support all of these bills and believe
they have done much to ward off what could have been an even
more severe economic fallout.
Prioritizing funding for childcare and providing options
for parents to get back to work has been something both
Republicans and Democrats have been able to support.
I think, in addition to ensuring childcare options remain
available to parents, we also need to ensure our public schools
begin opening their doors to students. There is no substitute
for in-person learning. As we consider additional resource
needs, I hope we can also focus on reopening our public
schools. As we look towards industries still in distress, we
need to allow the resources appropriated just a few weeks ago
to make their way into our local communities. I believe we need
to see who is still being left out of recovery and tailor
future efforts for those who truly need it.
The pandemic [audio malfunction] Absent data and national
statistics in many cases, we still lack the information needed
on how to target relief to achieve maximum benefit. There is
also increasing concern that we are no longer focusing on
families in need of assistance but providing subsidies to the
well-to-do who do not need it. I hope we can address those
questions today.
I want to thank our witnesses for volunteering their time
and their expertise. I had the opportunity to read their
excellent testimony last night, and I look forward to hearing
each of your recommendations this morning.
And, with that, Madam Chair, I yield back the balance of my
time.
The Chair. I am obviously excited to chair the full
committee. But as you have noted in the past, the former chair
of the committee, Congresswoman Lowey, this subcommittee was
near and dear to her heart, as it is to mine. I am also hopeful
that our opportunities together will increase the allocations
that we get.
But I want to just say, oftentimes people will say to me:
Why can't Democrats and Republicans get along for the common
good?
And, Congressman Cole, I cite the relationship that we
have, and as you pointed out, we do have differences, and that
is to be anticipated, but it is that common ground and that
belief of knowing and understanding why we serve, as you do,
that our job here is to try to effect differences and hopes in
the lives of the people that we do represent and is that
critically important to me. And I cite our relationship as the
example of, in fact, that is what we do every day is to try to
work together in these efforts.
And I also want to welcome Congressman Fleischmann back,
and we co-chaired for a while the baby caucus, and so his
interest in children and families is well-known.
And to Congressman Cline, it is wonderful to have you.
And I was remiss in my opening remarks not to recognize our
newest member of the committee, and that is Congresswoman
Brenda Lawrence from Michigan, was on Labor-HHS, and you should
know in the organizational meeting in order to get on this
committee was really very interesting. No one knew what she was
going to do. She threw in all of her committee assignments that
she had and so that when it came around, this is what she--
Labor-H is what she selected. So that tells you about her
commitment to the issues that come before this subcommittee.
And, with that, let me again welcome and introduce our
witnesses: Melissa Boteach, vice president, income security and
childcare and early learning at the National Women's Law
Center; Georgia Goldburn, director of the Hope Child
Development Center and one of my constituents. I have been to
the Hope Development Center, and Georgia has been doing an
amazing, amazing work, and you will hear her fighting on the
front lines for childcare providers in the district. It is
really a steadfast dedication to our Nation's kids and their
families and workers. It really is beyond compare, and I know
we all have examples of the Georgias in our own communities,
but I single out my Georgia out here for efforts as well.
And I think--where is Josh? Is Josh Harder there, too?
Josh? Anyway, new to our committee, and I will talk more about
Josh in a little bit.
Dr. Katharine Stevens, a visiting scholar from the American
Enterprise Institute, and, Dr. Stevens, I don't know. It said
you taught in the schools in New Haven. So I would love to know
what schools you taught at. I am a towny. Born and raised in
the city of New Haven. So I am anxious to find out where you
taught in New Haven.
And now I would really like to yield to Congresswoman
Bustos of Illinois, who will introduce Dr. Hawley.
Mrs. Bustos. All right. Thank you so much, Chairwoman
DeLauro.
Am I audible to everybody? All right. Thank you.
And let me just start out by saying how much that I
appreciate you, Chairwoman, your leadership on this issue, and
for inviting Dr. Hawley from the State of Illinois, my home
State, who I very much am proud to introduce.
Dr. Theresa Hawley serves as the First Assistant Deputy
Governor for Education in the office of Illinois Governor JB
Pritzker. She supports State education agencies and
initiatives, birth through college, so a wide range of
responsibilities. Dr. Hawley has nearly three decades of
experience in developing programs and systems that support the
school readiness and healthy development of young children in
poverty.
Most importantly, for the sake of this hearing today, Dr.
Hawley leads the State's early childhood response to the COVID-
19 pandemic. She has been at the forefront of Governor
Pritzker's great work that I am so proud of where they are
supporting families and childcare providers during this very,
very difficult time for families all over.
With the help of the CARES dollars, Illinois was able to
provide grants to nearly 5,000 childcare providers across 95 of
our State's 102 counties. This helped--get this--three-fourths
of these grantees cover as much as half of their expenses.
These grants also helped the childcare providers retain more
than 8 out of every 10 of their employees that they had before
the pandemic. So this funding and other great work really kept
the childcare operations in our State open, kept staff
employed, and gave families options during these very difficult
times.
So I want to just say thank you to Dr. Hawley for being
here today, welcome to her, and I very much look forward to
your testimony, as I know the rest of our committee does as
well. Thank you so much for your great work.
Thank you, Madam Chair. I yield back.
The Chair. Your full written testimony will be included in
the record, and you are now recognized for 5 minutes for your
opening statement.
Ms. Boteach.
Ms. Boteach. Good morning, Chair DeLauro, Ranking Member
Cole, and other distinguished members of the subcommittee. My
name is Melissa Boteach, and I am the vice president of income
security and childcare/early learning at the National Women's
Law Center.
We are here today because American faces a childcare
crisis, one with far-reaching and devastating effects for
children, for families, and for the economy overall. As of
January 2021, half of the 350,000 childcare jobs that were lost
at the onslaught of the pandemic had not yet returned. The
National Association for the Education of Young Children
surveyed over 6,000 providers in December of 2020. Nearly half
reported that they knew of multiple centers or homes in their
community that had closed permanently. Forty-four percent
reported confronting so much uncertainty that they are unable
to say how much longer they can stay open. These numbers are a
call to action.
In addition to being crucial to children's development and
a vital support for parents, childcare is infrastructure. It
holds up our economy. It bridges workers and jobs. And like
physical infrastructure, care infrastructure makes all other
jobs possible. My testimony today will address how we got here,
the effects of this crisis, and solutions to build a stronger
childcare system.
Even before COVID-19, America faced a quiet childcare
crisis. Families were struggling to find and afford childcare
with fewer than one in seven eligible children served by
Federal childcare programs. Nearly half of Americans lived in a
childcare desert without sufficient supplies. Early educators
who are virtually all women and disproportionately women of
color and immigrant women were paid poverty wages with over
half relying on public assistance. These trends are no accident
but rather rooted in a racist and sexist history of
undervaluing the care work done by women, especially by Black
women, indigenous women, and other women of color.
Into this fragile system COVID-19 was the perfect storm.
Today, childcare providers that are open are going into debt to
operate safely, pay more for staff, cleaning supplies, and PPE,
even as their revenues are down. Thousands have shuttered, many
permanently, due to the increased cost of operating in a
pandemic paired with the reduced revenues from under-
enrollment. The sector's collapse has had far-reaching
consequences for families and the economy.
First, women's employment gains are being set back a
generation. Just prior to the pandemic, we celebrated women
comprising half the workforce. Fast-forward and last month
alone, 275,000 women left the labor force, bringing the total
numbers since the start of the pandemic to over 2.3 million
women compared to 1.8 million men. These women are not dropping
out of the labor force. They are being pushed by our lack of
care infrastructure with long-term consequences for their
family's income and retirement security.
Second, when our care infrastructure collapses, children
pay a price. Children of all ages feel the strain of parental
stress and lose out on the educational opportunities that high-
quality childcare can provide.
Finally, our lack of care infrastructure undermines our
economic foundation. The Century Foundation and Center for
American Progress estimate that the risk of mothers leaving the
labor force or reducing work hours to assume caretaking
responsibilities could amount to more than $64,500,000,000 per
year in lost wages and economic activity. For context, that is
more than the cost of legislation to provide high-quality,
affordable childcare for all.
So where do we go from here? First, we must swiftly pass
the American Rescue Plan, the minimum required to provide
settings that are open with the resources to operate safely,
ensure fair wages and protections for childcare workers,
stabilize childcare businesses to ensure that they can still be
there when the economy reopens, and support families with lower
copayments and expanded eligibility.
Second, increased and robust funding for childcare and
early learning programs in the fiscal year 2022 appropriations
would provide States with greater certainty, allowing them to
more strategically spend relief dollars without fear of facing
steep budget cliffs.
Finally, while stabilization is urgent, the goal is not to
return to an inequitable pre-pandemic status quo. Instead, we
need to build toward quality, affordable, accessible care for
all families that meets their diverse needs, along with those
of a well-supported workforce. Inclusion in future jobs and
recovery packages will be crucial for this goal.
The COVID-19 pandemic has laid bare and exacerbated
longstanding inequities in our Nation's childcare system and
presents us with a stark choice. Do we watch a childcare crisis
unfold that has set women in the workforce back a generation,
compromise children's development, and harmed businesses? Or do
we invest in childcare as a public good, laying the foundation
for stronger families and a stronger economy? As Congress
considers funding for relief, appropriations, and recovery, I
urge you to choose investment in childcare.
[The information follows:]
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The Chair. There we go.
I said thank you for keeping it under 5 minutes. I have got
to get myself together here.
I would like to now introduce our next witness, Ms.
Goldburn. You full written testimony will be included in the
record. You are now recognized for 5 minutes for your opening
statement. Thank you.
Ms. Goldburn. Good morning, all, and if you would just
indulge me for a quick second to say--and this is simply fact;
it is not an opinion--that I have the best Representative in
the entire world, and I just want to say that, not to diminish
anybody else, just facts.
Chairman DeLauro, Ranking Member Cole, and distinguished
members, thank you for the opportunities to provide testimony
on the challenges confronting the childcare industry because of
COVID-19. My name is Georgia Goldburn, and I have been a
director of Hope for New Haven for 15 years. Hope for New Haven
is a faith-based nonprofit located in New Haven, Connecticut,
and manages the Hope Child Development Center, a licensed 77-
capacity facility serving children 6 weeks to age 13. I am also
the cofounder of CERCLE, a network of 80 childcare providers in
the greater New Haven and Bridgeport area serving children and
families of color.
Early in the pandemic, our organization assessed our
options with our staff after the abrupt closure of the Paycheck
Protection Program. Hope went from serving 75 children to 25 in
a matter of days when the city and the State went into
lockdown. After laying out several possible options to our
staff, they unanimously agreed to work on a part-time basis to
ensure that the center remained open for families. This proved
to be a critical lifeline to families like little Jeeves (ph)
whose mom had been out of work for 5 months, searching for a
program that was not only open but also equipped to deal with
his complex medical needs, not limited to a cerebral shunt and
a feeding tube.
``Our parents, our families, our children need us'' became
the industry's organizing principle because we deeply
understood not only how critical our role played in
undergirding the economy but also how shortsighted policies and
structural inequities due to chronic underfunding and benign
neglect left the industry particularly vulnerable to this
pandemic and threatened our very capacity to respond to the
COVID crisis.
And as I watched our industry step up to support our Nation
from our long beleaguered economic perch, my lament was not how
broken the system was but rather how efficiently and
consistently this broken system continues to undermine women,
the poor, and most especially people of color. This was most
pronounced in the SBA's EIDL and Paycheck Protection Program,
which, because of the financial nature of the childcare
industry, effectively sidelined many providers from
consideration in these programs.
According to a survey conducted by the National Association
for the Education of Young Children, 75 percent of family
childcare businesses did not secure any funding through these
programs in the first round, a fact that is borne out by our
experience and reporting from our State's staff and the
childcare networks. In fact, this year CERCLE recently helped a
family childcare provider apply for over $10,000 in PPP
funding, an amount she did not know she was eligible for last
year.
Furthermore, the industry's effort to reopen and to remain
open continue to be stymied by critical staff shortage due to
low salary potential, voluminous expenses, and low enrollment.
All these act to form a perfect storm around the industry that
will result in catastrophic loss of programs like Hope. In
Connecticut, 15 to 20 percent of centers and family group homes
and a staggering 80 percent of license-exempt programs remain
closed as of today. The fear is that these closures will be
permanent, and the numbers will mount.
Former Treasury Secretary Timothy Geithner, in reflecting
on the U.S. response to the 2008 financial crisis, said the
failure was not acting early enough to reduce the risk of the
existentially damaging event that seems remote and implausible.
Sadly, we are at another such crossroad.
The childcare industry, like the banks in 2008, is on the
verge of collapse. It is not hyperbole or a partisan talking
point. It is a fact. And if we fail to act once more to an
event that for some may seem remote and implausible, unlike the
2008 crisis, the cost will not be measured in dollars and
cents.
Thank you so very much for your time.
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The Chair. Again, what is happening here? Hold on. Okay.
All right.
I would like now to introduce Katharine Stevens.
Katharine, where did you teach?
Ms. Stevens. Leila Day Nursery.
The Chair. Oh, for gosh sakes. Know it well. Been there
many, many times. It is great. It really is a great place,
great reputation. And they have been there for years and years
and years.
Thank you. Please go ahead. You are recognized for 5
minutes. Thank you.
Ms. Stevens. Chairwoman DeLauro, Ranking Member Cole, and
distinguished members of the subcommittee, thank you for the
opportunity to testify today on the crucial issue of high-
quality care for young children. My name is Katharine Stevens,
and I am a scholar at the American Enterprise Institute, a
nonpartisan think tank where I focus on the science of early
development and its implications for how policy can advance the
well-being of all our Nation's young children. The views I
offer today are mine alone.
It is a huge step forward that it is now so widely
recognized that children's earliest years are critical to their
long-term health and well-being. Yet as the other witnesses
have emphasized, a large number of the most vulnerable children
still lack access to high-quality childcare, even as research
is crystal clear that the quality of care matters for exactly
those children the most.
As a result, healthy development of lower income children
in poor quality childcare is compromised. At the same time,
workforce participation among parents who are unwilling to put
their children in substandard care is greatly constrained. This
is an emergency, affecting millions of disadvantaged children
and their families.
CCDBG targets lower income working families earning under
85 percent of their State's median income, currently averaging
$77,000 a year for a family of four. But many families who need
subsidies do not get them. And for those who do, subsidy
amounts in almost all States fall far short of what is needed
to access the high-quality care that wealthier families are
already using for their children. The bottom line is that too
many low-income working families greatly need help they aren't
receiving, but the childcare plan that has been laid out is not
targeted to either the providers or the families who are truly
struggling, while it disproportionately benefits much more
affluent families.
Even more worrisome to me, it is based on a deeply flawed
assumption that it is developmentally optimal for all young
children to spend a large proportion of their earliest years in
out-of-home care. As I explain at greater length in my written
testimony, I have three additional concerns about this plan.
First, as I have said, lower income working families'
access to high-quality care has long been inadequate, which has
been hurting many families and their young children for years.
But according to the most recent reliable evidence, no extreme
pandemic-caused crisis in childcare for young children really
exists. Studies show that, in fact, the primary crisis working
women are now facing is due to school closures, not a lack of
childcare for children under 5.
Second, establishing special childcare stabilization
funding separate from CCDBG accomplishes no unique ends with
respect to stabilizing childcare. What it will do, though, is
diminish State leadership in early childhood, while creating
whole new State-level administrative entities directed by the
Federal Government and focused on building the childcare
industry rather than meeting the critical needs of families and
their young children.
Finally, this plan is presented as an emergency response to
fallout from the pandemic. That is a misrepresentation though
because its primary aims are to advance a longstanding advocacy
agenda. The plan aims to leverage pandemic relief funds to
carry out a kind of trial run of universal childcare while
laying substantial groundwork for a major permanent expansion
of government-funded nonparental care.
In closing, I would like to make one final point. A large
number of adults have become increasingly enthusiastic about
expanding childcare to all young children for reasons you
already know. Of course, the economy matters. Of course,
women's careers matter. But what matters most of all is the
well-being of young children. Our growing assumption that long
hours in childcare has no negative impact on them is incorrect.
We need to think much more carefully before taking the enormous
step towards promoting institutional care for all young
children that this legislation is proposing.
I know that some object to the plan because of its cost.
That is not my primary concern, though. My primary concern is
the well-being of our Nation's young children, and I urge you
to reconsider this plan for their sake.
Thank you again for allowing me to provide testimony before
this committee on such an important topic, and I look forward
to your questions.
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The Chair. I thank you very, very much.
Our next witness is Dr. Hawley.
And, Dr. Hawley, your full witness testimony will be
included in the record. You are now recognized for 5 minutes
for your opening statement.
Ms. Hawley. Good morning, Chair DeLauro, Ranking Member
Cole, and other distinguished members of the committee. Thank
you for inviting me to speak today.
My name is Theresa Hawley, and I serve as First Assistant
Deputy Governor for Education for the State of Illinois. I work
with an incredible team in our Governor's office and State
agencies to support education, birth to college and, as such,
have a unique perspective on how the pandemic has impacted
early childhood education and care compared to K-12 and higher
ed. I want to share with you some of our experiences over the
past year.
In March 2020, we required childcare centers and homes to
be closed except to serve children of essential workers. This
posed a significant financial burden on providers whose
business model relies on per-child tuition revenue. We moved
quickly to use our CARES Act child care and development block
grant funding to minimize revenue losses for centers and homes
in our subsidy system and to offset some of the increased costs
of providing care for our emergency childcare providers.
Because only about 40 percent of care in Illinois is
subsidized, we knew that many providers wouldn't benefit from
our subsidy-focused policy changes. So we partnered with
philanthropy to help providers access other Federal relief
funding like the Paycheck Protection Program and the Economic
Injury Disaster Loans. In April, the Governor's economic team
was working with leaders across industries to develop health
and safety guidelines for their reopening. They heard from
employers over and over: What is going to happen with
childcare? Our employees won't come back unless childcare is
available. With an estimated 15 percent of the workforce
needing childcare to work, we needed our childcare programs to
reopen.
We worked with public health experts and childcare
providers across the State to develop our reopening health and
safety guidance, which included having fewer children in each
classroom and avoiding the combining of classes at the
beginning or end of the day. This meant providers would
continue to experience reduced revenues and increased costs.
According to our cost models, we estimated the overall loss
for childcare providers in Illinois to exceed $50,000,000 per
month. Meanwhile, Federal relief from PPP had run its course.
And providers were reaching out, telling us they were afraid
they were going to have to close their doors permanently. The
financial impact on childcare providers and the potential
impact of childcare shortages was part of every discussion our
team had on reopening the economy.
In our State budget passed in May 2020, Governor Pritzker
and our Generally Assembly stepped up and devoted $290,000,000
from the coronavirus relief funding to support childcare. We
quickly designed the Child Care Restoration Grants program to
stabilize and reopen childcare programs and had applications
available by mid-July. We collected extensive input from
providers and used cost modeling to develop a funding formula
for the grant to replace the substantial proportion of
providers' lost income. Our formula was designed with equity in
mind, giving an extra 10 percent to programs in
disproportionately impacted areas with COVID-19.
These grants were well received. Nearly 5,000 grants were
distributed all across our State to over 2,000 centers and
nearly 3,000 family childcare homes. Grantees overwhelmingly
reported that the grant met their needs and kept them afloat
July through December.
Unfortunately, our Child Care Restoration Grants funding
was exhausted by December. Providers have told us they still
need this funding for their business to survive. Their
enrollment is still about 30 to 40 percent lower than before
the pandemic, and they continue to suffer significant revenue
shortfalls. We plan to use most of the recent CCDBG relief
funding to extend our grant programs, but the funding will not
extend as long as we know it will be needed. Without additional
funding, we will have to give providers so much less than we
can see they need.
We support the childcare funding in the American Rescue
Plan, and we know we will be able to put it to good use. The
pandemic has shown how fragile our childcare system is because
of how it is funded. As I mentioned, I also work K-12. There
have been huge financial implications of the pandemic there,
too, but at least we were not worried that a large percentage
of our public schools might permanently close their doors
because of the financial shock.
Childcare is critical infrastructure for our economy and a
crucial component of our education system. We need to fund it
as such. We need a substantially larger, long-term, stable
commitment to funding high-quality, early childhood education
and care to ensure affordable access for every family that
needs and wants it. I urge the subcommittee to support this
critical investment in America's future.
Thank you.
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The Chair. I thank you very, very much.
And to all our witnesses, I think for both sides of the
aisle, this has been a stellar group of witnesses who have kept
their remarks under 5 minutes. So thank you all very, very
much.
And we will move to questions. I have three questions that
I would like to get in to this first round. So I will be brief,
but I want to just--I want to start with you, Ms. Goldburn. How
has low enrollment in childcare centers impacted day-to-day
operations and childcare survivor--survival as a small
business? You need to unmute.
Can someone unmute?
Ms. Goldburn. I have got it.
At Hope Child Development Center, we need at least 70
children just to break even. We have been languishing at around
45 to 50 children each month, and so we are seeing about a
$20,000 loss each month in our budget, and I cannot tell you
what that will mean for our program. We are pretty close to
exhausting all of our resources. And so for us it has just
created a situation where it is day-to-day wondering which day
is it going to be when we have to close our doors permanently.
The Chair. Dr. Hawley, how do you see efforts to stabilize
and invest in childcare as investments in the broader labor
workforce? Why does Congress need to step up and invest big so
that we can do more in Illinois and we can do--so that other
States can follow suit with the kind of program you put
together in Illinois?
Ms. Hawley. So, as the other witnesses have attested to, if
parents don't have a safe place for their child to be during
the day, they are not able to go back to work. So we heard, as
I said, over and over again from all the industries in the
State. They saw the importance of childcare as undergirding the
economy and undergirding the employment of their--the ability
of their employees to come to work. So we know that investing
in childcare with a stable funding stream that keeps it open
and keeps it available and high quality for families is
absolutely critical.
The Chair. Let me also now ask Ms. Boteach. The law center
has published a report on the different ways States are trying
to reach childcare providers, help them through the crisis
through supplemental funding, but it is not enough. Can you
explain some of the things that States are doing that have been
particularly effective, and then how vital is that it Congress
pass the $40,000,000,000 in funding that is part of President
Biden's American Rescue Plan?
Ms. Boteach. Absolutely. So, as evidenced by Dr. Hawley's
presentation, Illinois is one of the States that is really
taking the lead in terms of thinking about how we use the CARES
money and other money, but other States as well have thought
about how they give grants to childcare providers so that they
can deal with the increased costs, such as PPE, sanitation
equipment, and also the cost of substitute pools and things
like that for when providers get sick.
Others have talked about how they make sure that there is
premium pay because, you know, childcare providers are
frontline workers. They are risking their health and, in some
cases, their life in order to serve frontline workers. So being
able to provide premium pay and other things like that is
something that is important in order to retain the workforce.
And then, finally, some States have also been able to use the
funding to help parents afford care by either expanding
eligibility or lower income payments.
The Chair. Let me just, when it comes to which workers
decide to return to work, how heavily is that decision based on
their childcare needs? Do you have information about that?
Ms. Boteach. Yes. So there is not a survey that says, ``I
left work because of the childcare need,'' but you can look at
the data, and you can figure out that. For example, in
September when there was a return to distance learning, four
times as many women as men dropped out of the labor force. At
the Center for American Progress' analysis of the most recent
BLS, Bureau of Labor Statistics, data found there were 700,000
fewer parents with a child under 5 in the labor force than
there were one year ago.
And so these interruptions are not hitting mothers and
fathers equally. And Dr. Hawley testified, hundreds of
thousands of working parents will need affordable, high-quality
childcare before they can begin to look for a job, coming back
as the economy reopens, and we know that once a parent exits
the labor force, it is much harder to renter it, which has
long-term consequences for women's financial security all the
way up until retirement.
The Chair. Thank you.
My time is expired. Let me recognize Mr. Cole.
Mr. Cole. Thank you very much, Madam Chair. If I can, I am
going to go to Dr. Stevens.
And, you know, there is no question I think that this
committee wants to provide additional support for the childcare
industry. We have done that in the coronavirus bills in the
past, and we recognize that is important. But part of the
problem is figuring out exactly why somebody left the
workforce. We have a group of people that left honestly not
because of childcare needs but because their jobs disappeared.
That is particularly true in the hospitality industry, the
leisure industry, the travel industry, disproportionately
probably lower income, disproportionately people of color. That
is one group.
Then we have a group that clearly left because they did not
have childcare options, either because the centers they sent
their children to no longer had sufficient space to handle them
or were going under financially. So that is a second group.
And then there is a third group that left because of child
needs but were related mostly to public school closures. And I
suspect, as you mentioned in your remarks and your written
testimony, that is a very large group.
Do we have any data that suggests what the proportions are?
Because one of our big problems in the subcommittee will be:
Where do you target available funds? I mean, how much should go
to which groups in order to help people return to the workplace
while making sure that their children have adequate care?
Ms. Stevens. Thank you for that question.
Yeah, I think there is just no doubt that the current
childcare crisis is caused by school closures. There was a
University of Chicago economist that did a study last spring,
using Census data, to analyze how many workers needed childcare
to go to work, meaning children under age 14. That was their
assumption. What they found is that 24,000,000 workers, 15
percent of the workforce, have school-aged children, meaning
they are not going to--they need to do something with their
kids if the schools are closed. 17,500,000 workers had children
under age 6. However, about 20 percent or 15 percent of those
children are 5-year-olds. They were economists. They weren't
thinking about the school system. So those kids are actually
school-aged kids. So they are affected by school closures. And
under half of children under age 5 are in childcare in the
first place. And childcare has reopened, as nearly as we know--
no one seems to have good data on this--but it is reopened at a
much faster rate than schools have.
So, at the time they did this study, less than 5 percent of
the workforce requires childcare to go to work--childcare for
young children--while 15 percent of the workforce requires
schools, school care, if you want to put it that way, to go to
work.
So, you know, I want to emphasize that I think the question
that I and the other witnesses have emphasized in terms of the
access to high-quality care of low-income children, that is
something that I know you are concerned about. I know the
committee has addressed. But if we are talking about the
childcare crisis caused by the pandemic, the driver, the
primary driver of that is the school closures.
I think you are on mute.
Mr. Cole. Thank you very much.
I want to stress again our aim here isn't to create an
either/or situation, but just what is the appropriate targeting
of the resources that we have?
Let me ask you a second question which you touched on and
certainly talked about in your testimony, in your written
testimony, and that is this idea of really targeting resources
to families that need them, to literally lower income families
that need additional help.
In my own case, my wife took a one-year maternity leave
that lasted 12 years because we made the choice, and she made a
great sacrifice professionally. We made a sacrifice financially
that that was what was best for our kids, but we had the
ability to do that. A lot of families don't, clearly. So we are
most concerned about people that literally don't have the
resources to get the childcare they need.
Could you tell us what kinds of options we should be
considering to make sure we direct the dollars we have where
they are most needed? And that tends to be, I would think,
lower income families, particularly single moms, situations
like that. What are the kinds of programs we either have that
we should be beefing up or maybe even additional programs that
we should be considering?
Ms. Stevens. There is only one second left. Should I answer
or----
Mr. Cole. Yeah, go ahead and answer the question. And then
that will be my last one.
Ms. Stevens. Yeah, so I think that all of the witnesses
have are experts on this. There are many children who--I think
what needs to be done is there needs to be careful analysis of
the data around CCDBG vouchers, TANF subsidies to identify the
children who are in this low-income, often single parents. It
is in our interests to have their subsidies high enough that
they can afford the kind of childcare, those families afford
the kind of childcare that wealthy families pay for for their
children. That to me is something that is worth focusing on,
but that is a whole different topic, and we need to be--we need
to look at the data that exists very carefully to figure out
who those children are.
But I would say starting with the families on TANF, if we
were simply to get those families into high-quality childcare,
that would be a game changer, I think, for those families.
The Chair. Thank you.
Congresswoman Roybal-Allard? I just saw you. No, that is
Katharine. Congresswoman Roybal-Allard. No?
Then let me----
Staff. Chair, she has been having some technical
difficulties.
The Chair. Let me go next to Congresswoman Lee.
Ms. Lee. Thank you, Madam Chair. This is such an important
hearing. I want to thank you and our ranking member for putting
it together.
Let me just ask our witnesses--and thank you all so much
for being here, but I want to find out: What are the long-term
structural issues that bring us to this point once again? I
share my personal story in the seventies. I needed childcare,
raising two small children as a single mom. I started college
as a freshman, of course, and the line was so long, the waiting
list, I didn't get them in childcare for 2 years until I was a
junior, and the cost of childcare then was so expensive. I
barely could afford it. My children went to school with me.
They know statistics better than I do because I had to sit them
in the class with me. So I am trying to understand the big
picture in terms of why we are here still when for I know for a
fact I was going through the same, same issues that women are
going through now, especially women of color and low-income
women.
And then, secondly, just let me hear what the legacy of
undervaluing childcare work done by our women of color, what
that means long term, in terms to maybe Social Security, in
terms of stability of their families and just what does this
mean in terms of their life as they, as we do not value their
work by paying them what a decent living wage should be. Anyone
who can answer? Melissa.
Ms. Boteach. Sure. I can go ahead and take a stab. I think
that the big structural argument we are talking about here--and
Dr. Hawley touched on it as well--is that we treat childcare as
a private responsibility for every family to struggle with on
their own, and long-term structural racism and sexism means
that it is women of color both as providers and as parents that
are struggling the most.
In reality, childcare is a public good. It is critical
infrastructure to hold up our economy because right now parents
are paying unaffordable sums. Providers are earning poverty-
level wages, and that is the business model that we are
operating on in childcare because we have historically
undervalued care work, precisely because of who does it, women
and disproportionately Black, indigenous women, and women of
color.
And so I think that there is a long history all the way
back to enslaved women, Black women caring for the children of
White landholders, all the way up to intentionally excluding
domestic care workers in the Social Security--in the New Deal
programs, all the way up to TANF and talking about the ways in
which we are not adequately supporting low-income single moms.
So this is a long arc. It is a long history. When we come
to this day and this sort of inflection point in the pandemic,
we were finally seeing care and the work of the women who are
doing this--doing the caregiving and undergirding our entire
economy I hope to make a different choice.
Ms. Lee. So shouldn't--anyone else could respond to that,
because it seems like we should also at the same time be
looking at these structural issues, because otherwise it is
going to be another 30 years and we are still going to be in
the same place where we are now, where I was in the day.
Ms. Goldburn. And if you don't mind, I would just like to
add to what Melissa said. All of that stuff is true, and I
think if we continue to situate the child care industry
rightfully in the history of child care then we will start to
understand some of these issues.
But I also want to reference what Katharine said as well,
because one of her concerns that she cited was that we are
going to be institutionalizing child care. And the problem for
this country historically has been that we are very comfortable
institutionalizing Black and Brown people in the prison system
but not in the systems that actually will transform their lives
for the better.
Ms. Lee. Well, thank you very much, Madam Chair. Anyone
else? I have 50 minutes--50 seconds left.
Ms. Hawley. Sure. Yes, so I think an interesting analogy
here is thinking about public transportation. Like people pay
their fee for the--to get on the subway, and we might give some
subsidy to them to get a reduced fare card or something like
that, but what we are not looking at is like that whole
transportation system is undergirded by a public investment so
it is there in the first place.
And we don't--we recognize that the cost of that system is
more than anybody is actually able to pay on their own. With
child care we don't do that. We base how much child care costs
on how much people are able to pay, and it doesn't match up to
their cost of providing really good high-quality care. We need
an investment that undergirds the entire industry so that it is
there for all families and is able to provide the quality that
children deserve.
The Chair. With the one second, Barbara, with the one
second I would just say, in the same way that we are dealing
with the airline industry. We deal that, we undergird it, we do
that, we understand the problems, and we respond and we act,
and we do that both for the industry and we do it for the
workers. That is not the case with child care, so great
question, Barbara.
Ms. Lee. And we never have. But we never have.
The Chair. Well, it is true.
Ms. Lee. It is not our choice, but we never have.
The Chair. Well--Congresswoman--I am sorry, Congressman
Harris, I am sorry to take your time. You have got plenty of
time. So they will unmute you, I think. There you go. Okay.
Mr. Harris. Thank you very much. And, you know, thanks for
the timely topics, discussing a timely topic.
I have a question for Ms. Stevens. A lot of the issues,
some of the issues revolve around children having to be home
from school, so having virtual education from home. We now know
that it is safe to be back in school. We have always known it
was safe for the children to be back in school. That was even
known last spring, early last summer. But now we have data. We
have data for months and months of school systems that have
remained open.
So my first request question is, wouldn't getting us back
into school mean--these children back into school also relieve
some of the burden on the child care system?
And the second one is, if schools are not going to reopen,
couldn't we alternately take, in order to get--again, to free
up the ability of some of those parents to go to work, couldn't
we also offer school choice more broadly so that you have a
choice to actually send your child to a school that does remain
open during the pandemic?
So those are my two questions for you.
Ms. Stevens. Thank you for those questions. I think there
is quite a lot of evidence that parents' enthusiasm for school
choice has been growing a lot during the pandemic because there
is--what you have just said is occurring to them. And, yes, if
we were to open schools, that--if we were to be--if more
schools were open, that would make an enormous difference for
parents going back to work. And, obviously, if parents could
send their children to a school that was open if they wanted
to, that would also help.
I worked for 10 years in the New York City--I ran a not-
for-profit that worked with the New York City Public Schools.
Those two things are going to--those are going to be hard to
pull off in the timeframe we are talking about. That is just
the reality of it.
I mean, certainly the school choice issue is, I think the
pandemic has given a lot of momentum to that, but it is not
something that can be done as a solution to the pandemic, I
don't think. And knowing the New York City school system the
way I do, I am not sure--I think this problem is going to be
going on for quite a long time.
There are wonderful organizations--I wrote a piece on this
recently--that do after-school programs. And if we were to give
them funding to expand to school day programs, that might be a
solution for especially large urban areas, that I think it may
be--we--it may be a while before we see the schools open.
Mr. Harris. And let me just follow up with that. So in
those urban areas, these after-school programs, some of which
could be educational in nature, actually, I would say, would be
a twofer, because not only we enable parents to work outside
the home but we also enhance the education of the children who
are left furthest behind.
Ms. Stevens. Yes.
Mr. Harris. And, honestly, I think what the COVID pandemic
is going to show us is that the children who were furthest
behind at the beginning----
Ms. Stevens. Yes.
Mr. Harris [continuing]. Are going to be much further
behind at the end. So going forward as a policy issue, wouldn't
this make sense as a way to kind of make up for the time lost
during COVID?
Ms. Stevens. Yes. I mean, I know in New York City some of
these not-for-profits ran summer schools where children gained
more learning over--in going to these summer schools that
weren't regular schools than they did the whole year. I would
be happy to send you the information that I have on that, but I
think that would be a win-win for the kids and obviously for
parents who need to go back to work.
Mr. Harris. Sure. No, and thank you for your testimony.
And, Madam Chair, I will yield back the balance of my time.
The Chair. Thank you. And let me recognize--Ms. Roybal-
Allard is not back yet, so let me next recognize Congressman
Pocan.
Mr. Pocan. Great. Thank you very much for that. And, yeah,
I just--this hearing has been very helpful. You have brought a
lot of really strong points together in one spot.
I want to thank both our chairperson and Katherine Clark
and others who have been such strong advocates for child care
for years while I have been on this committee, and I love the
``work that makes work possible'' line. I am definitely going
to remember that because that is very helpful. And care
infrastructure also, you know, this is really important as we
are talking about infrastructure and what this means.
I think one of the things that was most surprising was, Ms.
Goldburn, when you talked about 80 percent of the businesses
remain closed right now, and as someone who has been a small
business person for over 30 years, you know, it is hard to try
to start that back up from nowhere.
Do you have any recommendations how Congress could perhaps
be helping in that way too? Because I am afraid--you know,
restaurants have kind of gone to takeout. You can't do that
with child care.
When you look at some of the industries that have found
ways to partially make up for it, you don't have that here, and
to reboot could be more difficult without some additional
assistance.
Do you have any thoughts on that at all?
Ms. Goldburn. Nothing cures poverty like money. We are
poor. The industry is poor. We have been languishing in poverty
for a very long time. And I just want to clarify that 80
percent of the license-exempt program that serves primarily
school-age children are the ones that are closed.
Mr. Pocan. Ah, okay.
Ms. Goldburn. And so, I mean, the argument for me is a
really very basic and simple one. As a business person you know
that you are not going to stay open and operating if the
margins are not correct. And if you are not going to make a
profit in your role to endure a loss every year, then there is
no point in being in this business.
For many years child care providers have been making that
personal sacrifice, and COVID has basically just pushed them
beyond the brink where there is no more money in the kitty to
keep this thing going. And so what we need is an immediate
infusion of cash. We cannot continue to charge parents to use a
service that we do not--that they are not using. We don't have
it in our personal account to do it.
And so the only place that can step in to fill the gap
right now is the Federal Government. And without sustained
efforts to ensure that this remain a critical part of our
infrastructure, we are going to be back in this place again.
As a business person, we are all business people here, we
do love children, we are educators, but at the end of the day,
it is still a business and you need money to continue to
operate a business.
Mr. Pocan. Yeah. We have a friend who currently isn't doing
her home-based business for younger children just because of
the current situation and, you know, having a big impact. I
will never forget when I got stopped at a grocery store when we
did the Affordable Care Act, when it finally got implemented, I
had a provider who did--who takes care of children in her home
crying, saying, ``Thank you. I can finally have health
insurance for the first time.'' So here she is running the
business and never even had healthcare for herself until we had
that in place.
You know, the other--the thing is that we often hear about
too is just we are caught in between this extremely low-wage
difficult business, and then the cost of child care for some
makes it impossible for people to be able to take advantage of
that in some ways.
That is another part of what, I guess, I am curious on how
you can recommend moving forward what we have learned through
this pandemic, like we have learned the importance of things
like broadband.
What have we learned about helping so that anyone who needs
to be able to go to work has the ability to have their child in
a child care environment? Is there anything that we can take
forward from here?
Ms. Goldburn. I think what was wonderful about the crisis
is that it stripped away all of these barriers and regulations
that allowed State--I have an amazing Commissioner Beth Bye,
who used the opportunity to just basically, with the resources
that were finally coming in to the industry, to put in place
those systems and those innovations that we needed.
And one of the things that in our network meeting, our
circle network we were in, which is one of the twelve staff
family child care network, that the State was quickly able to
ramp up to support, those very vulnerable family child care
business, was that they made--they ensured that every single
provider became a vendor of the State and then they just made--
cut checks directly to the program.
Every single one of our providers reported that across the
board, and we serve family child care providers, group homes
and centers, and so every single provider heralded that as the
biggest success of the pandemic. And when I--when we sat
enviously looking at Illinois, they paid their providers
$25,000 a month. If we had $25,000 a month, we could--we would
be able to remain open, keep all of our staff and be there and
available for parents. The Federal Government is the only
entity that can step in to do that.
Mr. Pocan. Great. Thank you. I yield back.
The Chair. I would just say that Commissioner Bye is
extraordinary, as Dr. Hawley is extraordinary in the States in
which they have really tried to address this system.
And with that, please let me recognize Congresswoman Jaime
Herrera Beutler.
Ms. Herrera Beutler. Thank you, Madam Chair, and thank you,
all. You know, this is an issue I have been working on since
before the pandemic. You know, this is a--I have three little
boys outside right now on the trampoline. My husband is
shoveling snow off. In order--like they are our co-op. Like we
are sending them around to each other because there was no
preschool this year. And then my 7-year-old is on her e-
learning thing, and I don't know where the baby is. I am just
hoping she is cool.
Before this, I introduced bipartisan, bicameral legislation
called the Child Workforce and Facilities Act, and it would
authorize $100 million in grants to States where there are
child care deserts. In my district and my State, we are a child
care desert. I think we are the sixth most lacking in
facilities and in providers. So there is a pipeline issue.
There is physical space, then there is the provider space, but
then there is also like you know what Ms. Goldburn has been
speaking to, how do you stay afloat, the ones we have, how do
we keep them afloat.
And I think that Ms. Stevens' comments are just really--are
really interesting as well. I look at--you know, as I have
done, you know, roundtables and worked with our State chamber
affiliation, because obviously this has such an impact on
business and the economy at large, like how do we--so pre-
pandemic it was, how do we fix this? And, you know, we talked
about training and getting--and then, you know, what it takes
to maintain those employees. And a lot of those providers were
really honest with me with some of the challenges, whether it
was the hike in minimum wage and their ability to stay open.
You know, this is not an easy problem to fix here, which is
why I think some advocate for a federally run system that is
federally funded that federally institutionalizes, and I--man,
the one thing I really love are options as a parent. And I like
the idea that we need to make sure that those who can't afford
options, like in home or a higher quality center or, you know,
one that is more geared towards--some kids, you know, with
special needs, right, more wealthy families can do that.
I would really be interested in seeing how we can bring the
CCDBG more in line--that and the TANF in line with making sure
that it allows an equalization among working-class kids to
their peers whose parents make more money. Like I would like
them to have the choice, because I also wrestle with and agree
that my kids are only young for a certain period of time.
I have not--you know, my husband has stayed out of work. We
talk about all the women who are dropping out to support the
family. My husband has stayed out of work for me to do this job
and to be home, and not going to pretend like it--like, I am a
Member of Congress and we are on this thin line. I can't
imagine--you know, I talk to working families in my districts
where they are in the same spot and they have three and four
kids and they are just trying to piece it all together.
So obviously we have to do something, I really feel, like
that targets the middle-income families who don't have the
money to make it work and don't qualify for subsidies, and that
is really for me the sweet spot. But I think we need to
recognize--and I have some real misgivings about a giant
federally institutionalized program, because the best years of
your kids' lives--I mean, you only get them for what, maybe
they pay attention to you until they are twelve maybe, but
these are those really, really special years where I want help
and I need help and we do everything we can to piece it
together.
But I also, I want to be their main source of learning and
I want to help speak to who they are and pull out their
strengths and giftings. And so I want to be careful that we
maintain choice in this, we maintain choice for families. And
if it means getting more money to families who don't have
choice because they don't--right, they don't have access, then
we need to look at ways we can do that.
But I am very concerned with the idea that the Federal
Government and a big Federal program is going to do it best.
The one thing I have noticed with the airlines and with the
prisons and with the roads is we have kind of screwed all that
up, I mean, big time. I don't know that I want to do that with
our kids.
And maybe, Ms. Stevens, if you could speak to that and if
there is time left, Ms. Goldburn, I would also like to hear
from you.
Ms. Stevens. Yeah. I mean, I agree with your
characterization of this. It is not clear to me--I feel as
though the definition of what problems we are trying to solve
here is we are kind of all over the map with what problem we
are trying to solve, so that is--there is two different--there
is two questions. Question one is, what problem you are trying
to solve; the next question is, what exactly is the nature of
that problem and how to solve it. And to some extent, we are
talking about different problems and different solutions to
different problems, so obviously that is what you guys have to
figure out.
When you--what Georgia was describing makes, I--perfect
sense to me. I think what she is describing is an important
thing to be addressing. I have read this legislation carefully.
That is not what this legislation is aiming to do, in my read
of it. Just, for example, the increases in the child and
dependent care tax credit are a through-the-roof tax break for
wealthy people, and I don't understand that. Once all low-
income kids are in very high-quality child care, okay, that is
a separate question, but until that has happened, I just don't
understand why we would make that choice.
The Chair. What I am going to do is since, Congresswoman,
that you said if there was any time, I would just like to get
Ms. Goldburn to very briefly comment----
Ms. Herrera Beutler. Thank you.
The Chair [continuing]. To the same piece.
Ms. Herrera Beutler. Thank you.
The Chair. So let's do that. Thank you.
Ms. Goldburn. I appreciate that. I think we are trying to
actually solve one problem, and that problem is high-quality
access to early learning experience for every single child
regardless of the setting that a parent chooses. I am Jamaican.
We are culturally averse to child care centers. We have family
members that take care of our children.
My sister made that choice to keep her child at home for 3
years, even though I have a child care center and my mother
works in a child care center. I am a Christian, and we have a
Christian program. And so we do not have like equal access to
Federal dollars to continue to offer the choices that families
want.
We are not asking to create an institutionalized system. We
are asking for money to fund an early care and educational
system that can be responsive to every single parent regardless
of the child care option that they choose. That is what we are
asking for.
I do not want Black and Brown children to be in a school
system or the prison system that is going to produce really
terrible outcomes for them, especially at the most critical
time of their development. But if you starve the industry of
money, programs like Hope will disappear, family child care
providers will disappear, and what will be left are those
institutions.
So we are having these disjointed conversations because you
have backed many advocates into a corner where we have to
advocate for the things that we know that we are going to get
hoping that we can live to survive another day to advocate for
the things that is needed for children and families.
And so if we finally start to invest in the early care and
educational system, where as a former teacher who basically
came out of the educational system, because I saw how
difficult--how it was harming Black and Brown children and
enter into the early care system and saw the benefit that those
Black and Brown children were getting from the program, if I
had the money to do more, we could radically transform the
lives of Black and Brown children and poor children and women
and families. So that would be my response.
The Chair. Thank you. And [inaudible]--I apologize to him
because in the order I didn't get to him next, but you are on
top, Congressman Fleischmann.
But let me now recognize Congresswoman Katherine Clark, and
as Congressman Pocan pointed out, as someone who has been
deeply, deeply involved in the entire child care debate in how
we can address it.
Congresswoman Clark.
Ms. Clark. Oh, thank you so much, Madam Chairwoman, and
thank you for being such a champion. And this has been a
fantastic panel, which is really getting to the core of how we
are going to rebuild a more inclusive economy after this
pandemic. And thank you for the recognition that child care is
infrastructure and really is the--it is the underpinning for
our economy.
And I wanted to continue the conversation about choice and
how we meet the needs of different families, in different
settings, in different parts of the country and make sure that
everybody has access to affordable, quality child care. And I
don't think we can really have that conversation without
talking about who makes up the provider workforce, that this is
also predominantly women.
Here in Massachusetts, child care providers are--over 96
percent of them are women, and nationally about 40 percent of
child care providers are women of color. And I think it has a
large part--it is a large part of the explanation of why we see
such low wages and benefits.
And so I wanted to ask you, Ms. Goldburn, what have you
seen in your experience as a woman of color? How have you seen
racial injustice permeate the child care industry, and what
steps do you think we need to do to address it so that we
maintain this choice and diversity?
Ms. Goldburn. We could be here for 10 hours talking about
that.
Ms. Clark. Yes. We have 3 minutes to answer these next
questions.
Ms. Goldburn. And I am just going to paint this picture.
The public schools, which are made up in Connecticut of 90
percent women who are White, maintain their salary, maintain
their benefits, got to remain at home, and had no fear about
whether or not they were going to be ill or they were going to
lose their income and their homes during this pandemic.
The child care industry, on the other hand, which are made
up of about almost 50 percent of women--it is the only
educational institution that is that diverse--we are here
begging for scraps. That is the difference of institutionalized
racism.
When you are White, your issues are heard, it is
understood, it is responded to immediately; when you are Black,
you are here begging for scrap, for people to recognize your
humanity. And that is what has been going on for years in the
early childhood education system.
The difference now is that we have understood with the
pandemic how we cannot continue to ignore the cries of the
child care advocates anymore because child care is so
interwoven into so many parts of our system. We were not going
to be able to respond to this pandemic without a child care
industry.
As a matter of fact, the reason why many parents were still
able to keep their employment when the schools shut down was
because all of those children shifted in large part into the
child care industry. And so we have been there to respond, but
even after we are here basically saying we need help, we need
help, our issues and our cries are unheard because of the color
of the workforce, and this would not happen anywhere else.
The United States spends less than .05 percent of its GDP
on child care. It is the only developing country, first-world
country that does that. We are cohorted with countries like the
Czech Republic and Turkey. When has that ever been a good
thing? No offense to Turkey and the Czech Republic. When has
that ever been a good thing? And that only happens in
industries that are predominated by poor, by women, and by
women who are poor and are women of color.
Ms. Clark. Thank you so much for that answer.
And, you know, to Ms. Boteach, I would like you to, in the
brief time I have left, try and answer this too, and really
address how this is so tied to how much of our economy is based
on the unpaid or low-paid work of women and in particular women
of color.
Ms. Boteach. Thank you for that question. I think it is
crucially important. I mean, as noted earlier, the airlines are
looking at losses of $90,000, which is nearly half of what
child care has experienced, and no one is making the argument
that the airlines are doing just fine. This problem is sort of
uniquely--the lack of relief has uniquely targeted an industry
where women are not--over 90 percent of the workforce and women
of color are so disproportionately affected.
And I would say that this predated the COVID-19 crisis.
Inequities in the Federal child care system go back, again, all
the way to slavery in America. And I think that when we look
even today at the legacy of that, it is African-American
parents, Latino parents, Native-American parents who face the
most barriers to affordable, high-quality child care. It is
African-American, Hispanic workers who are more likely to be
relegated to lower-level positions even within child care
programs even when you account for educational levels.
So, for example, African-American early educators are
typically paid 78 cents less per hour than their White peers.
And so it is cruciately important that as we rebuild and that
as we move forward that racial and gender equity is at the
center of the system, not as sort of a sideshow but something
that is intentionally baked into every policy decision that we
make.
Ms. Clark. Thank you. Thank you, Madam Chair.
The Chair. Thank you. And I see Congressman Fleischmann.
Let me recognize you. My apologies for not strictly going in
seniority a few minutes ago. Congressman Fleischmann.
Mr. Fleischmann. Well, thank you, Madam Chair and Ranking
Member Cole. It is great to be back on this wonderful
subcommittee. This was one of the first subcommittees when I
became an appropriator I was privileged to serve on, and look
forward to working with my friends and colleagues on both sides
of the aisle, so I thank you.
Dr. Stevens, some of my constituents have come to me and
said that remote learning is negatively impacting the emotional
and mental well-being of our students. They also claim that it
has the potential to stunt their academic growth.
In my previous efforts on a this subcommittee, I have
worked in conjunction with colleagues across the aisle and with
outside stakeholders to provide STEM education. Opportunities
to rural and low-income communities have clearly been affected
by this. Many of these STEM programs require an in-person lab
class. While teachers are doing their best to adapt during
these difficult times there are some learning experiences that
cannot be replicated virtually.
Moreover, a recent study shows that 30 percent of all K
through 12 public school students live in homes without proper
internet connections and without suitable devices for at-home
learning, making the attempt to stimulate the hands-on STEM
experience even more difficult.
My question is, can you speak to some of the financial
challenges disproportionately facing low-income and rural
families and how outdated, anecdotal evidence, as mentioned in
your testimony, impact the policy seen before us today?
Ms. Stevens. Yeah. Thank you for that question. I actually
did a webinar a couple of weeks ago on--with four--with two
teachers and two administrators on teaching in the pandemic.
They talked about what it was like to teach on video all day
every day. It is very difficult for the teachers.
What you are describing in terms of the students that they
are serving are--fall into the category of students you are
describing, who many children do not have the support and the
technological resources at home to enable their effective
participation in remote learning. Also, as you mentioned, the
impact on children's social, emotional well-being, it seems
pretty clear that it is having a negative impact.
Because the schools are controlled at the State and local
level, I really don't know how quickly we will be able to
address this problem nationally. If we are thinking about what
we could do in the meantime, I mean, we can continue to support
States and localities in opening their schools.
There are a couple--England has just launched a really
wonderful national tutoring program. There are a couple of
States in the U.S. that have launched tutoring programs for
kids. I think that is worth looking at. I think that, as I
mentioned before, looking at partner--figuring out how to bring
after-school--high-quality after-school organizations on board,
I think that makes sense to look at while at the same time
continuing to work with States and localities to figure out
what they need to open. As you know, the Federal Government
just doesn't have very much control over schools, so I think
that that is what you--that looking at supporting other kinds
of solutions may be also worthwhile.
Mr. Fleischmann. Thank you, Doctor.
And, Madam Chair, I see I have got under 40 seconds left,
and I know there is a lot of folks asking--wanting to ask
questions, so I will yield back the balance of my time and I
thank you.
The Chair. Thank you, Congressman Fleischmann.
And with that, let me recognize Congresswoman Frankel.
Ms. Frankel. Thank you. Thank you, Madam Chair. Thank you,
everybody, for a great discussion, to the panel.
So I tried to--I think I bring some commonsense to this
because I was a working mother and now I am a working
grandmother. And I will say that both as a working mother and a
working grandmother, I do always look forward to the nap time.
I say that because, listen, taking care of children is a 24-
hour job. It is not--not just 9:00 to 5:00.
And so, you know, just with all due respect to some of--to
one of the panelist's comments, I think that it is happy,
fulfilled parents that are best for children, and hopefully we
are not at the point where the government decides what will
make a parent happy and fulfilled.
So I really think for this discussion, you know, the first
question is, what is the public interest in having a good child
care system that is equitable, and that is, I think, well, I
have heard a lot of reasons today, including the well-being of
children and the need for our economy for parents to be able to
get to work.
And I don't even think the issue is why we are having what
we call a ``shecession.'' I mean, the fact of the matter is,
whether somebody is out of work because they don't have daycare
or whether they are out of work because they don't have a job,
we are going to get to a point where hopefully people will have
jobs. And if the child care industry is decimated, they are not
going to have child care.
And so I think this is a very, very important issue, and
just to say--and I know Brenda Lawrence can confirm this--the
Democratic Women's Caucus will make child care a top of our
priority to make sure that this industry is stable and fair.
I also want to say this, child care workers should not have
to be on food stamps. And I do want to ask--I am going to ask
this question in terms of the pay for child care workers, and
that is, how does the low pay impact the turnover, for example?
And what are your specific suggestions on how we up the pay for
our child care workers?
And then, finally, before you answer the question, I wanted
to say this, again, commonsense approach, for parents to go to
work you need a job, right, and what is the second thing you
think of? What am I going to do with my children? And you
actually think about that before you say what is the road like,
what is the bridge that I am going to have to go to get to
work? And so child care has to be part of our infrastructure.
With that, I yield to--if someone will answer my question about
the low pay and the turnover.
Ms. Boteach, I think you are shaking your head. Go ahead.
Ms. Boteach. I was going to say, I mean, I am sure Georgia
can also speak to that, but, I mean, right now child care
workers on average make less than $12 an hour, and as I noted
in my testimony, over half need to turn to some form of public
assistance or support in order to make ends meet.
And so if providers are having trouble making ends meet in
a job, not only are they more stressed, not only are their
families more stressed, but there is more turnover in the
industry because people don't see a stable job that has long-
term growth for them.
Child care providers are exhausted. They have been the
heroes on the front lines sacrificing so much not only during
the pandemic, during which, I mean, they have been on the front
lines, but before that they have been holding up our economy on
their shoulders for poverty wages. And I think this pandemic
has laid bare those inequities, and it has exacerbated them.
And we have a choice going forward. We can't do this on the
cheap. We can't do this without big Federal public investment
for the very reasons that you said, child care is
infrastructure. Child care is education. Children's brains
develop most quickly between the ages of zero to five. It is in
our interest to make sure that they are in loving and high-
quality settings, whether that is at home or whether that is in
a center. And so this is public good, like K through 12
education, like roads and bridges. And we have been investing
in it or disinvesting in it as though it is not for a long
time, and yeah.
Ms. Frankel. Yeah, quick question. COVID and child care,
what is--can someone comment on that?
Ms. Hawley. Sure. We have found that child care providers
are really great at infection control. It is part of the
everyday work that a child care provider does with young babies
and young children. We found that children really are safe in a
well-run child care center that is using all the safe--health
and safety guidelines and are able to operate safely and even
in the pandemic. So we have been incredibly proud of the way
that our providers have stepped up, implemented these new
health and safety guidelines, and kept the children in their
care safe.
Ms. Frankel. Thank you. Yield back, Madam Chair.
The Chair. Mr. Moolenaar? I think he may have had to leave.
And it is my understanding that Congresswoman Roybal-Allard has
lost the internet connection, you know, and she is struggling
at her end with that. If that can be done, we will get the
Congresswoman in the mix.
And I have just been told that Congressman Moolenaar is--
had to leave, as well as Congressman Harder, and my fault in
not introducing Congressman Harder at the outset. I will call
and apologize to him for that.
With that, Congressman Cline, you are recognized.
Mr. Cline. All right. Thank you, Madam Chair. Am I coming
through all right?
The Chair. You are, indeed.
Mr. Cline. All right. Thank you.
Chairman DeLauro, Ranking Member Cole, thank you for
holding this timely hearing. I am honored to be joining the
Appropriations Committee to ensure that taxpayer dollars that
are allocated by Congress have proper oversight and
accountability. And coming over from the House Educational and
Labor Committee during the last Congress, I am proud to be able
to continue to work on these important policy areas in the
Labor, HHS Subcommittee.
As we all know, COVID-19 has significantly altered the
daily lives of millions of Americans. This is clear most
notably when it comes to child care. We need to, as we get the
vaccine rolled out, we need to open up our economy, get folks
back to work, get kids back to school.
But that, as evidenced by the conversation that has been
happening over the course of this hearing, has to happen in a
specific order. It can't--you can't just send--open up an
economy and have folks go back to work if there is not
availability for the kids to either go to school or have child
care available.
Different States have different economic challenges facing
it when it comes to child care, when it comes to schools
reopening. What is going on in Virginia right now is very
different than what is going on in New York or Connecticut or
out in Seattle, Washington.
My colleague, Congresswoman Herrera Beutler, was talking
about child care deserts. We have challenges in Virginia, but
because we have maintained a lower level of regulation on the
child care industry, it is not as challenging to start up a
child care business. It is not as challenging to operate a
child care business.
Now, in COVID it definitely is, but State to State you are
going to have different levels of regulation and those are
going to create different challenges for the industry and for
parents, for pricing, for options, for choices for those
parents.
So, as Dr. Stevens has mentioned, the solution to child
care may be more aligned with school openings than with
drastically increasing Federal funding or a Federal role for
child care. And while relief aid is important as appropriators,
we must ensure that funding is going to where it truly is
effective, and we shouldn't head down a path that allocates
taxpayers' hard-earned money to programs that won't effectively
relieve the most pressing and devastating impacts of COVID-19
on our communities right now.
So, Dr. Stevens, as you mentioned in your statement, the
child care provisions and the rescue plan appear less as a
response to effects of the COVID-19 pandemic but rather a
massive scaleup of government spending on nonparental out-of-
home care for young children. And as you stated, proposed new
spending would bring the total spending to address this to
almost $59 billion, which is 1.7 times total public spending on
early child, early care and education.
Can you expand upon how this funding level might have been
determined, what factors may have led to any inaccuracies,
quite frankly, and analyzing the need for it?
Ms. Stevens. Yeah. Thank you for that question. I think
that the problems that the other witnesses have been bringing
up, Georgia has been describing these problems, those are real
problems. There is some different problems squished together in
there. So you are talking about very low-income, Black and
Brown people who have inadequate access to child care say, then
you have much wealthier people who can pay they just would
rather not because it is too much money. So there is a whole
bunch of issues being squished together in this, not to say
that they are not important; however, if--they are big picture
issues that are not directly related to the pandemic.
I also just want to make one point, the Bipartisan Policy
Center did a fascinating survey of parents in December. One-
third of the women respondents said that their ideal child care
arrangement was to stay at home and raise their own child, one-
third. On the other hand, there is a big division in this by
education and income.
So among parents, men and women, earning over $75,000 a
year, 59 percent describe out-of-home, nonparental child care
at their ideal arrangement; among families who earn under
$50,000, only a quarter say that. So this assumption that
everyone's ideal is out-of-home child care is just not true.
And I think that that is something that needs--we need to take
a step back and decide on what the goals are, which--or we are
not going to know what problem we are trying to solve.
Mr. Cline. Thank you for that question. I am also glad to
see that my colleague found the baby. I yield back.
Ms. Herrera Beutler. She was totally safe.
The Chairwoman. That is very good, Jamie. She is back. And
speaking of being back, Congresswoman Lucille Roybal-Allard.
Yes for technology. Go for it.
Ms. Roybal-Allard. Thank you. Let's see how long I can stay
on.
Ms. Boteach, I represent the 40th Congressional District of
California, and it is a district that is distinct for its
having the highest percentage of Hispanic residents in the
country and one of the highest number of immigrants. In 2019
Class published a report about inequitable access to child care
subsidies. In that report it stated that access to child care
development block grant funding varied considerably by race and
ethnicity, with Latino and Asian children having the lowest
rates of access nationally, further exacerbating child care
subsidy access.
Given the demographics of my congressional district and the
fact that approximately half of all Latino children under age
13 are members of immigrant families, it is no surprise that
access to affordable child care is a particular problem for my
constituents and other Latino and Asian families.
How do you propose that CCDBG dollars be allocated
equitably to reach the most vulnerable providers and families
particularly in communities of color where there has been
historic underinvestment?
Ms. Boteach. Thank you for that question. First to note,
before getting to the CCDBG answer, I want to note that one in
five child care providers is an immigrant. And so from the
provider perspective as well, you know, recent attacks on
immigrants in the past administration or, you know, fear in
communities has caused great stress among those--that workforce
understandably. And so I really appreciate you drawing the
connection between child care policy and immigration policy
more broadly.
On the CCDBG question, I think that there is a need to do
greater outreach by language for children with disabilities,
for underserved populations to make sure that home-based child
care providers, friend, family, and neighbor care providers,
and other kinds of providers that tend to be in areas or tend
to be the preference of lower-income Black and Brown families
are getting access to the subsidies and also getting access to
the services that CCDBG provides.
One challenge here is that CCDBG has been and continues to
be so chronically underfunded that only one in seven eligible
children at all are getting access to a subsidy. And so I think
that it is really important when we think about rebuilding the
system to have a growth and approach.
The first thing we need to do is to make sure that there is
adequate funding, and that is one of the reasons why we are
encouraging not just the relief and stabilization but also in
considering fiscal year 2022 appropriations to really increase
and robust investments in the child care and development block
grant.
Then once we have money and resources it is also critical
to think about how you intentionally do outreach, how you
intentionally engage home-based providers that maybe don't have
the same level of information as center-based providers to make
sure that those dollars are actually reaching them, and so I
think it is a both/and.
I don't want a world in which child care providers are
scrambling over the crumbs of a system that has been broken for
so long. I want a world where we see that we have the resources
to invest in the kids and that the policies then within those
resources can make sure that they are appropriately targeted
and putting racial and gender equity at the center.
Ms. Roybal-Allard. Thank you. So I think you covered some
of it, but are there any specific programmatic or structural
changes that we need to address in order to increase the number
of eligible Latino children who receive the CCDBG subsidies for
child care?
Ms. Boteach. I think the main issue is that the program has
been so drastically underfunded that there is very small
percentages of children across the board that are getting child
care subsidies, and Latino children are, again, amongst the
worst of the percentages getting the subsidy.
And so the main thing we need to do is to dramatically
expand investment in CCDBG and our public--and our child care
system more broadly, and then within that to really think about
how are we reaching out, how are we making sure they are
linguistically appropriate services, culturally appropriate
services, that we are making sure that immigrant providers have
access into the same systems that everyone else does. And those
are all steps that we can take in the design of programs but
that they will continue to be constrained until there is
actually funding to do all those things.
The Chair. Congresswoman Bustos.
Mrs. Bustos. All right. Thank you, Madam Chair.
I am going to direct my question at my fellow Illinoisian,
Dr. Hawley. As you know, it is not just Illinois but, you know,
all States throughout the country are facing this terrible
problem with child care providers because of COVID-19.
Governor Pritzker was kind enough to come to my
congressional district last year and stop at a place called
Skip-a-Long. You are probably familiar with it. I am a big fan
of Skip-a-Long and all they do to help our community. So it is
one of the larger child care providers in the Quad Cities,
which is where I live.
And I know you are familiar with it, but just to share a
couple staff, they went from serving 1,000 children prior to
COVID-19 to 50 back in March. Now, obviously and thankfully
they have moved closer to full capacity, but providers like
Skip-a-Long won't be able to be fully back to normal really
until the vaccines are widely administered.
So, you know, this impact has just been so tough for child
care providers wondering if they are going to be able to keep
their doors open, for parents wondering how they juggle their
careers and their families and just all of the challenges with
that.
So let me go on record saying, I am proud of the Pritzker
administration. I am proud of you and how you have been able to
use State and Federal dollars to take this issue on directly,
and that is why you were invited here today to share your
successes.
I want to ask you specifically how the Illinois child care
restoration grant is helping providers and families in
Illinois, and just to drill down a little bit deeper on that,
what do you see coming up next for the Child Care Restoration
Grants in order to meet the needs of the providers and our
families, and how are you looking to improve that program?
Let's start with that, if we could, please.
Ms. Hawley. Well, thanks so much. I want to say that in all
the conversation here today our challenge with the child care
industry right now is probably less one of--that there isn't
enough child care out there right now for families who are
going back to work; the challenge is the child care providers
that are out there right now are not getting enough revenue.
They are under enrolled. They are dramatically under enrolled.
And that has to do with families who are working at home in
this sort of unnatural, like we all are right now, and maybe
are having their kids home with them. Lots of families are not
choosing to put their kids in child care right now.
But when we are able to open up our society and go back--
everyone go back to work in their sort of more normal settings,
people are going to need to have somewhere to go. And if their
child care centers have been financially ravaged by a lack of
revenue for a period of a year or more, they are not going to
be there for families to be able to use.
So you ask what is sort of next with the Child Care
Restoration Grants. We need to keep it going. We used all the
resources we could and it really helped support providers, but
they still need that help. And we have kind of calculated out
that the money that we received in the last relief package
won't even get us to the end of 6 months in terms of providing
the relief that providers need in order to be able to keep
their staff on board, the staff that they have worked so long
to build.
Yeah, Skip-a-Long is a great example of a place that invest
in their staff, helps them complete college degrees, helps them
get the qualifications they need. We can't afford to have them
leave our child care workforce. We need to keep them engaged in
there. And so we are planning to continue to invest in the
restoration grant model, providing direct relief to providers.
Something we haven't been able to do as much is investing
in the child care workforce more, and we want to be able to do
that with the funding, as well as some of our license-exempt
providers that we haven't been able to provide the necessary
relief to, and we are looking at that, how we can support them.
So that is--if you send the States the money, we will find ways
to use it well to support this industry that so critically
needs it.
Mrs. Bustos. I would just say to my colleagues on this
hearing today that what Dr. Hawley is doing and what the
Pritzker administration are doing really can be a model. And,
again, Chairwoman DeLauro, I know that is why you invited Dr.
Hawley to be with us today, but I do want to point that out if
you are looking for a good model.
Since I have got 40 seconds, I am going to follow up with
one other question, Dr. Hawley. So an interesting data point
that we have seen coming out of Illinois is that parents with
the youngest children, so the children under age one, aren't
returning to child care, and wondering what you think is going
on with that and what we can do to address it?
Ms. Hawley. So I think the operative word there is
``returning'' to child care. I think the older children, they
were in child care and the families were comfortable with it,
and when you think about going back, that is to a familiar
place and they are able to--even if there is a little
nervousness about COVID and all of that, it is a familiar place
and they have that trust.
If you just had a baby and in this sort of strange time
that we are living in, it is a little more nerve wracking to
bring your child into care right now. We know that we are going
to have to invest in outreach to parents to help them
understand that it is safe for them to use these services, use
our preschool services. Even early education is way down, so we
need to be able to invest in reaching out to families and doing
that kind of parent engagement.
Mrs. Bustos. Very good. Thank you, Dr. Hawley.
Chairwoman DeLauro, I yield back.
The Chair. Thank you very much. Congresswoman Watson
Coleman.
Mrs. Watson Coleman. Thank you very much, Chairwoman. Let
me thank my colleague Katherine Clark for revealing or having
discussion about something that I find very important. This
pandemic has revealed institutional racism in just about every
aspect of our living in this country, and so we are very
concerned about this particular industry, how it impacts our
future and how it impacts our families right now.
And I agree that we are in a crisis situation, and we need
to lift up and gird up and protect this industry so we can get
through this pandemic. I also am concerned about how do we
repopulate the industry, to what extent are we giving direct
subsidies to families to be able to afford to send their
children back into early childhood education, because I also
know that there are families who are totally unemployed but
need to look for jobs and they need access to high-quality,
early child care, education and child care.
I know that the evidence suggests that early education is
vitally important to both our economy and to the future as it
relates to our children. So I am very interested in the
discussions that we might have regarding the kinds of things
that the Federal Government ought to think about moving forward
beyond this pandemic, as to what is it that we need to sort of
ensure that the public good of early childhood education is
supported, that those who are working in that industry are paid
a fair wage and have access to Social Security and other
pension benefits, and that those families who are financially
challenged have access to the same high-quality early childhood
education?
And with that, I would yield to--I would like to ask Ms.
Boteach first and then anyone else who would like to respond to
that issue. And, Madam Chair, that is my only question.
Ms. Boteach. Thank you so much. It is a terrific question.
And the way I have been thinking about the various
opportunities to respond to this crisis during this year is of
thinking of the child care system or sector as a patient right
now that is in crisis. And the first thing we need to do is to
stabilize the patient, and so that is the American rescue plan.
That is making sure that we are getting money in to make sure
there is a child care sector to come back to.
But then we have an opportunity--immediately this committee
has an opportunity through the fiscal year 2022 appropriations
process to really start with the rehabilitation, and so that
means a dramatic increase in the child care development block
grant. I would also add in other early education programs like
Head Start and early Head Start and all those other programs
that this committee oversees as well, but focusing on child
care for right now.
A robust increase there is, number one, going to allow
providers to be able to spend down the relief money as
strategically as possible knowing there is not going to be a
dramatic cliff if they are trying to bring workers back in or
they are trying to make investments about how they are going to
be there when the economy reopens.
So that is really important, both to make sure the relief
money is spent as well as possible but also to begin thinking
about, okay, what have we learned during this crisis? We have
learned--and I--like I keep saying it because it keeps--bears
repeating, if we take one thing away from this hearing, care is
infrastructure, care is a public good. And so if we are going
to build that infrastructure, let's start with what this
committee has jurisdiction over and make robust increases in
the child and development block grant.
And then, finally, I think that we need to really think
about what does the long-term system look like. There is--you
can't really separate access, quality, accessibility. All of
these things interact with each other. All of them are an
investment in children. When you invest in the child care
workforce you are investing in children.
And so I think it is really important to think about long
term as you are building a system where parents have choice of
different kinds of settings that are culturally appropriate and
high quality, where providers are being paid a fair wage with
benefits and career ladders, where you have building supply,
particularly in child care deserts where the populations that
are most underserved tend to be rural areas as well as
communities of color, when you put all of those things together
you are asking for a robust investment over many, many years.
And the cost of that are nothing compared to the cost of
inaction, because when we don't act we are costing our economy
$57 billion a year according to ReadyNation. That was pre-
pandemic. That number has grown. And so when we think about--we
can pay for this one of two ways: We can pay for this through
lost wages, family suffering, businesses having retention
issues, and just a lot of stress and economic pain, or we can
invest and have a pathway where we actually have affordable
high-quality child care that is accessible for all.
Mrs. Watson Coleman. Thank you. I yield back. Your answer
was very comprehensive so I didn't get a chance to hear from
others, but thank you very much.
And thank you, Madam Chair.
The Chair. Thank you very much.
And Congresswoman Brenda Lawrence.
Mrs. Lawrence. Thank you so much, Madam Chair.
I represent the city of Detroit. And according to a recent
report by the National Women's Law Center, it concluded that 6
in 10 women of color are experiencing difficulty home
schooling, including a portion of the respondent describing
insufficient childcare coverage. While predominantly Black
neighborhoods tend to have more childcare providers, my
hometown of Detroit is an outlier. It has a vast childcare
desert. As our economy continues to recover, this could pose a
major issue for many of my constituents.
So my question is, Dr. Hawley: Can you speak to how
Illinois has addressed childcare deserts, especially in
communities of color? And what advice would you give to other
States?
And I just want to say in conjunction with my co-chairs--
and Lois Frankel is here--we must invest in an infrastructure,
a social infrastructure, to improve the quality of life and
equality for women in America, and I feel strongly that this is
one of them. And when I speak passionately about the community
of Black women, we have so much to do. So what can you
recommend for those communities that, you know, I would put my
child in childcare if I could afford it, but I also would put
one if it was one available in my community?
Ms. Hawley. Yes, thank you for the question. This issue of
childcare simply not being available in so many communities is
so important for us to be looking at. In Illinois, we have
included early childhood education and care facilities in our
State infrastructure plans. When we do a capital bill, we
include in this last capital bill a record $100,000,000
dedicated to facilities for early childhood, and we have done
that because we know that there are so many communities around
our State that simply do not have the facilities they need in
order to be able to care for young children.
It is not facilities alone, though. It is the program and
the programmatic money. We are going to be investing with our
GEER funding, with our CCDBG funding, investing in communities,
and helping communities do the planning that they need to do to
be able to open new settings and new programs for young
children and families in their community.
We have to invest in the data systems that help the State
identify where the needs are. We have to invest in the
communities to do the planning that it takes to be able to open
this. We have to invest in the bricks and mortar to open a
childcare center. It is not an easy thing to do.
Mrs. Lawrence. You are driving home a point that I and the
Women's Caucus are going to be really pushing. The fact that
Illinois is investing in the infrastructure of childcare--we
must improve the workforce. We must compensate them. But if we
don't invest in the infrastructure of childcare, we won't
achieve our goal for so many communities.
And, lastly, I just want to ask Dr. Boteach: Do you have
any recommendations on how we can increase the labor workforce
for childcare? I had a wonderful opportunity to travel to
Japan, and they have elevated childcare where you see young men
choosing that as a career. First of all, they are compensated.
Second of all, it is a respected profession. Can you speak to
that?
Ms. Boteach. Absolutely. I think you hit the nail on the
head. When you respect something, you don't expect that they
are going to hold up the entire economy on their shoulders
without fair pay.
So I think crucial to this conversation about attracting
but also retaining a workforce in childcare and early education
is treating them like the educators that they are, and
children's brains are developing at their fastest rate between
zero and 5. Childcare is education. And so when we treat
childcare providers as the heroes that they are but pay them
like the heroes that they are with fair wages, benefits, taking
serious their safety--in some States, they haven't even been
given the vaccine at the same rate as public school teachers.
So, again, what does that say? They are open. They are
operating now, putting their lives and health on the line. In
some States, they were not even in the top of the pack to get a
vaccine.
So, when we start respecting this profession, when we start
paying fair wages, benefits, and having career pathways, you
are going to see a lot more people coming in to the profession
and staying there because every childcare provider I know loves
kids. They love that job, but they are also deeply exhausted.
So I think that we need to acknowledge that.
Mrs. Lawrence. Thank you.
And I yield back.
The Chair. I thank you very much.
And it is after 12, but we are not going to be able to get
to a second round, but this has been an enormously, really
very, very productive, the content, the richness of the content
and the contribution by all of our panelists today and the very
substantive questions and concerns demonstrated by members.
So, to you, Dr. Stevens, to Dr. Hawley, to Georgia and
Melissa, thank you so, so much for what you bring to the
debate. And even if there are, you know, differences, the
ability for us to examine this issue in all of its pieces I
think is critical for all of us.
I am going to ask Congressman Cole to make some closing
remarks, and then I will, and then we will bring the hearing to
a close.
Congressman Cole.
Mr. Cole. Thank you, Madam Chair.
I want to associate myself with your remarks. I thought
this was an excellent hearing. Very appreciative of all our
witnesses and their perspectives, very informative testimony.
It seems to me that the challenge we will have is simply
targeting this. I don't think there is a big debate we need
additional assistance in this area for the childcare industry.
There is obviously, what is the right mix for getting our
schools reopened? What is the right mix for making sure that
people that want to send their kids to supervised daycare and
with quality so that they know their children are not only
being looked after but are having the opportunity to grow?
And, finally, and we didn't talk about this, but, you know,
a piece of this to me is home schooling or making, you know,
parents that want to be able to stay at home, something that
Ms. Stevens talked about, and there is evidently a difference
with socioeconomic groups as to how they view that. We didn't
really get into that, but that is an important thing for us to
consider as well.
I thought my friend and our colleague Ms. Herrera Beutler
made a really good point, talking about options. How do we
create options so that parents can actually do what they think
is best for their children and not be limited by circumstances?
So I know we will be wrestling with all these questions in
the weeks and months ahead. There is never enough resources.
And that makes targeting, I think, that much more important. I
just want to thank you for the hearing. I think it is a really
important topic, and I want to thank all of our witnesses, and
I certainly want to thank our members. I think you could tell
by how engaged everybody was. This is a real live issue for all
of us because we hear about it at the grocery store or at
church or at the civic club. This is very much on the minds of
the people that we are privileged to represent.
So, again, thanks to you and thanks to our witnesses for
giving us a really spirited discussion and I think a good look
at a really important problem.
I yield back.
The Chair. I want to thank the ranking member for his
comments.
And if I might, please, I just want to what I view as, you
know, what we lift out of this very, very rich discussion.
COVID-19 did not create the childcare crisis. It exacerbated
it, and it exposed the racial disparities with regard to
providers, with workers, and to families. Childcare providers
were already operating on razor-thin margins. Early childhood
educators themselves were making so little that nearly half
accept public benefits, and the families living in low-income
circumstances struggled--struggled--and are still struggling to
gain access to affordable high-quality care. I think the
framework of childcare infrastructure or the industry is
infrastructure is a critical message that comes out of this.
And I just want to make a point here that $60,000,000,000
for the airline industry, we believed it was necessary. We
voted for it for our economy to survive. Corporations have
received $522,000,000,000 for PPP loans. That was critically
important. We provide infrastructure, especially in these
crises, for agriculture, for the auto industry, for Wall Street
and the banking industry, for housing and mortgages, for
families. When these industries are in trouble, we act. The
Congress moves and in a very big way in real time. And yet we,
because of what has been said about undervaluing childcare and
undervaluing the women who provide it or the workers who
provide it, so that that is where we need to move, to take this
undervalued and under-respected industry and place it where it
needs to be, at the center of the economy.
Childcare--this is what Melissa told us--is the work that
makes all other work possible. It, therefore, needs to be at
the center of what we are trying to do. The economy is not
going to recover until childcare is back, and that it is
better, whatever form it manifests itself, providing families,
yes, with the choice that they need. And as lawmakers, we need
to recognize that childcare is essential, and it needs to be
funded in that way.
So it is just you have demonstrated really across the board
of, you know, we looked at--and I will just say this--not that
long ago on the fringes we talked about paid family and medical
leave, that it was too far a stretch. Today it is at the center
of public discourse. We talked about equal pay for equal work
for women, on the fringes not that long ago; now central to how
we move forward. And right now the revenue and the resources
for the childcare industry needs to have that central place in
our discussion as we move forward.
And, again, just thank you all very, very much for your
being here today, for shining the light on this, and you can
tell--and I say this to you know, Georgia, Dr. Stevens, Dr.
Hawley, Melissa--the women and the men who are on this call
today understand that nature of what we need to do. You have
heard from them, and you know that you have allies within the
Congress to allow us to move forward.
So I thank you very, very much. I also am going to beg your
indulgence for one more moment. A final note, I want to do
this. It is fitting that the hearing is on childcare. But it is
the last hearing for a woman who has been devoted to this
issue, my chief of staff, Letty Mederos. She leaves today to
embark on a well-earned retirement, though I cannot imagine
Letty Mederos retiring. She has been a confidant, a friend, a
leader of the team for 12 years, real results not only for
Connecticut but for the country and for families. And early
childhood and labor policy has been at the center of her work.
She started on Capitol Hill in 1998, a leading labor policy
expert, raising the minimum wage, equal pay, paid sick days.
These are the areas that she has been a champion of. Labor
director for the House Education and Workforce Committee under
George Miller, Labor Director Senate Health Committee under
Patty Murray, before coming back as chief of staff.
Letty grew up in Cuba. She came to the United States in the
Mariel boatlift. She has fallen in love with the American West.
We will miss her. We thank her for her dedication to public
service. We wish her well. As I say, though, I can't imagine
her retiring. Personally, I will deeply, deeply miss her, just
her ability, not her just her ability but her friendship and
the closeness of our relationship. So I wanted to give her so
much credit as we leave, and this is her last hearing.
Thank you all again very much.
And I will bang on the table, you know. This hearing is
concluded. Thank you. Take care.
Wednesday, February 24, 2021.
READY OR NOT: U.S. PUBLIC HEALTH INFRASTRUCTURE
WITNESSES
MARILYN BIBBS FREEMAN, DEPUTY DIRECTOR, DIVISION OF CONSOLIDATED
LABORATORY SERVICES, OFFICE OF THE SECRETARY OF ADMINISTRATION,
COMMONWEALTH OF VIRGINIA
JENNIFER KERTANIS, DIRECTOR OF HEALTH, FARMINGTON VALLEY HEALTH
DISTRICT, CONNECTICUT
UMAIR SHAH, SECRETARY OF HEALTH, STATE OF WASHINGTON
KATHRYN TURNER, DEPUTY STATE EPIDEMIOLOGIST AND CHIEF, BUREAU OF
COMMUNICABLE DISEASE PREVENTION, IDAHO DIVISION OF PUBLIC HEALTH
The Chair. This hearing will come to order. As this hearing
is fully virtual, we must address a few of the housekeeping
matters. For today's meeting, the chair or staff designated by
the chair may mute participants' microphones when they are not
under recognition for the purposes of eliminating inadvertent
background noise. Members are responsible for muting and
unmuting themselves. If I notice that you have not unmuted
yourself, I will ask you if you would like the staff to unmute
you. If you indicate approval by nodding, staff will unmute
your microphone. I remind all members and witnesses that the 5-
minute clock still applies.
If there is a technology issue, we will move to the next
member until the issue is resolved, and you will retain the
balance of your time. You will notice a clock on your screen
that will show you how much time is remaining. At 1 minute
remaining, the clock will turn to yellow. At 30 seconds
remaining, I will gently tap the gavel to remind members that
their time is almost expired. When your time has expired, the
clock will turn red, and I will begin to recognize the next
member.
In terms of the speaking order, we will begin with the
chair and ranking member, then members present at the time the
hearing is called to order will be recognized in order of
seniority. And, finally, members not present at the time the
hearing is called to order.
Finally, House rules require me to remind you that we have
set up an email address to which members can send anything they
wish to submit in writing at any of our hearings or markups.
That email address has been provided in advance to your staff.
With that, let me begin. I want to acknowledge Ranking
Member Congressman Cole and all of our colleagues for joining
us today. If there is one thing we have learned from the COVID-
19 pandemic that has raged across our Nation over the past
year, it is that our Nation's public health infrastructure is
extremely fragile. Simply put, we are not adequately prepared
to respond to public health emergencies of this scale.
Dr. Schuchat from the CDC observed in our COVID-19 member
roundtable yesterday, and I quote, ``Emergency resources are
very different than sustainable, longitudinal capacity. And
what health departments really need is help,'' end quote,
improving the data, improving the workforce, skill sets, and
improving the lab capacity.
Even now, a full year into this pandemic, the virus
continues to move faster than our ability to collect, share,
and analyze the data. Decisions are being made based on stale
information.
During our Public Witness Day in 2019, this subcommittee
heard about health departments and labs that still use fax
machines to communicate. In many cases, data has to be
reentered by hand. Health agencies analyze data retrospectively
rather than with an eye to the future. Effectively, that means
even data as basic as a patient's demographic information,
race, ethnicity, or pregnancy status, is not being
electronically transmitted across health providers and
agencies, and that lack of communication can have serious
consequences.
For example, to answer the question of how COVID-19 affects
pregnant women, researchers must first figure out who is
pregnant as there is not sufficient data on who is pregnant. In
response to this health data transmission problem, we
championed the Public Health Data Modernization Initiative at
the Centers for Disease Control and Prevention. This committee,
this subcommittee, has provided a total of $100,000,000 for the
CDC to start the data modernization initiative in fiscal year
2020 and 2021.
The labor appropriations bills, on a bipartisan basis, as
well in 2020, included an additional $500,000,000 to be
directed to data modernization in the CARES Act. Unfortunately,
when the coronavirus hit, this multi-year data modernization
initiative was barely getting off the ground.
Turning more broadly to health departments across America.
Let me just make this point, which is made by one of our
witnesses this morning: State and local public health officials
are the foundation of every public health response. A year into
the pandemic, they are still understaffed. Our health
departments are still understaffed. Following the Great
Recession, local and State health departments have lost more
than 20 percent of their workforce since 2008, shedding over
50,000 jobs across the country.
This staff shortage has worsened because as much as one
quarter of our health workforce is eligible to retire. In fact,
22 percent of the workforce plans to retire in the next 5
years. Many more are moving to the private sector. Twenty-five
percent plan to leave public health for reasons other than
retirement. And, overall, this means nearly half of the health
department workforce is leaving their organization in the next
5 years, and the COVID-19 pandemic certainly hasn't improved
matters.
We need to look at our workforce, we need to make sure that
there is diversity and equity, we need to incentivize and hire
a whole new generation of public health staff, and we need to
do it now. Our public health departments and laboratories must
be equipped with a capacity, the equipment, and, again, a
diverse and trained workforce that they so desperately need.
I think this is a very, very interesting statistic which
was brought out in Dr. Bibbs Freeman's testimony. Public health
laboratories are central for the public health practice. COVID-
19 has shined a light on the capabilities, the workforce, and
data modernization needs in our Nation's 110 public health
laboratories. Dr. Freeman's testimony states, and I quote: In
March 2020, 3 percent of all public health laboratories, and
only 3 percent in the country, were capable of performing the
advanced molecular detection tests needed to combat COVID-19.
Just 3 percent.
This is an example of the virus being able to move faster
than our public health capabilities. Dr. Freeman's testimony
highlights the challenges of recruitment and retaining a
diverse, qualified laboratory workforce. We need to invest in
not only the equipment that public health laboratories need,
but the people. These are not one-time budget requests.
Though Congress has provided more funding to local Tribal
and territorial public health organizations to respond to the
pandemic over the past year, we have much to do in order to
make this a lasting difference. We are here today to learn more
about how these supplemental funds have been used, how much
more we must provide to adequately meet the challenges of the
ongoing COVID-19 response, which is why we will need our
witnesses and others in the public health arena to tell us what
you need, especially in terms of the long-term challenges of
the public health workforce, and what we need to do to build
that architecture for the future.
But while the national attention has been laser-focused on
the impacts and challenges of the COVID-19 pandemic, it is
important for us to keep in mind that this is just one of the
many battles our health system is facing. I want to mention one
or two other pieces here, if I can. This pandemic is only
compounded by the already existing public health crisis of
youth vaping, the anti-vaxer movement, the rise in food safety
challenges following the past administration's deregulation of
the food industry.
These are challenges, and they are reasons for us to invest
in our public health agencies, which, in turn, keep our
communities healthy and functioning. Historically as a Nation,
we appreciate the need for a strong public health system when
we are in the middle of a public health crisis, but never
before. We think about it in the midst of, but never before.
If we want to have a public health system that is prepared,
we need to invest now in personnel, in labs, equipment, and
data systems not just this year, but every year, and not forget
about this when the pandemic subsides. I will reintroduce the
public health emergency fund which would provide $5,000,000,000
to the existing public health emergency fund which was created
in 1983, but is currently empty. By dedicating funding ahead of
time, this bill would enable our public health agencies to
respond quickly to these emergencies.
We have provided billions for an airline industry. Billions
more for small business through the Paycheck Protection
Program. We needed to do that. It is only logical that we would
need to invest as much, if not more, in the very system
designed to keep us healthy and safe from this disease.
We save the airlines. We have saved small businesses. We
now need to be in the business of saving lives. This is not
about throwing money at a problem; this is about creating a
stable, solid, sustainable, public health infrastructure system
for the future. The witnesses we have joining us today
represent key partners in public health. We will gain
perspectives from the State health department, a local health
department, and a public health laboratory system. We will
learn about these institutions and their roles in COVID-19
pandemic response, what the needs are in the field and the
recommendations for strengthening our public health
infrastructure.
To meet the moment, we need to transform our public health
infrastructure. The health of our families and our communities
depend on it.
And with that, I would like to yield to the ranking member
of the subcommittee, Congressman Cole, for opening remarks.
Mr. Cole. Thank you very much, Madam Chair.
Before I begin my formal remarks, I want to tell you how
impressed I am with your background. I have an old saying that
if I know what you read, I know who you are. So I have been
straining looking at the titles, and I am pretty impressed with
our chairman. And I am also dazzled by this collection of
athletic memorabilia of baseball and football that you have
behind you. Pretty impressive. It speaks of a very well-rounded
person.
The Chair. Go Yankees.
Mr. Cole. And I very much want to associate myself with
some of the points you made about the importance of the topic
we are talking about. I want to thank you for this hearing. I
think it is a really important hearing, and I think these
investments are important. As I have told our own side, and, I
think, the last year has illustrated to all of us, sometimes
you need to spend billions to save trillions. And just look at
the cost of what this pandemic has been, and think of the
difference some of the very investments you talked about and
laid out in your opening remarks might have made had they been
available earlier.
And I know you have been a constant champion of this
throughout your career. So I am, again, very pleased to have
your leadership at this critical point for our subcommittee. I
know that COVID response continues to be at the forefront of
everyone's mind, and the public health experts are front and
center in defending our people.
In addition to hearing about COVID this morning, I am
hoping that we can also discuss other priorities I know we all
share, such as reducing opioid abuse, overdose deaths,
addressing the threat of antibiotic resistance, and preventing
the growing problems associated with chronic diseases. All
critical public health issues for our country, but all issues
that require a robust public health infrastructure to deal with
over time.
Six years ago, Congress began shaping policies and
prioritizing investments in our readiness, including boosting
funding year after year for the National Institutes of Health,
Centers for Disease Control and Prevention, and the strategic
national stockpile, all in an effort to prepare our country to
be able to quickly respond to a pandemic, such as COVID-19. And
we created new tools, like the Infectious Disease Rapid
Response Fund.
These accomplishments were done on a bipartisan basis and
driven not by any administration, but by Congress itself. It is
my hope that this year Congress will, once again, assume a
leadership role in the areas of biomedical research and public
health preparedness. Unfortunately, our experience over the
past year has shown, while we have done much, we still have
much to do in the area of preparedness and modernizing the
public health infrastructure.
Despite many heroes working tirelessly on the front lines,
we have encountered many challenges with technology,
infrastructure, and basic access to supplies and other
resources that added frustration to an already difficult
situation. I am grateful to our healthcare workers and public
health professionals for continuing to press ahead and save
lives over the past years in the face of enormous difficulties.
One of the programs I am most proud of during my tenure as
chairman of the subcommittee was the establishment and
investment in the infectious disease rapid reserve fund, which
was immediately available to the public healthcare system to
respond to COVID. And I want to thank our chairman for not only
continuing that program, but, frankly, investing even more
robustly in that program.
Again, this was a bipartisan accomplishment. Indeed,
because Congress had the tools in place ready to deploy at a
moment's notice, we were able to respond quickly before an
initial funding supplemental was passed. This outcome was the
aim in our creation of the reserve fund, and while it was
unfortunate we had to use the fund, I am glad those resources
were available.
And, again, I associate myself with my friend, the
chairman's remarks, about the need to continue to do that and
build upon that going forward. While there is a long road ahead
with many unknowns, I am encouraged that one of those unknowns
is not whether the funding will be there for public health
defenders to continue in their response.
Congress has provided unprecedented funding for these
unprecedented times. I am hoping that at this hearing today we
can talk about what has worked, what went right, what these
resources are doing to build up our infrastructure, and where
gaps remain, and what we should be doing going forward to
fulfill those gaps and, again, make sure that we have a system
that is robust enough to defend us from the challenges that the
biosphere would surely present us with, again, in the future.
As we discuss this today, I am hoping we can also move
beyond the specifics of COVID and have a broader conversation
about the areas of public health that need to be further
modernized to respond to other threats as well. As we have
unfortunately seen and are continuing to witness, a deadly new
disease is literally just a plane ride away. We need to be
ready for the next threat, and not just prepared to fight the
last war. Moving rapidly to contain other communicable
diseases, such as influenza, combating the opioid epidemic,
making progress toward treating chronic diseases that threaten
our most vulnerable population, and reducing antibiotic
resistance are all key challenges in our public health mission.
We need to be sure we are ready to tackle them. Each may
require a different approach, and all will almost certainly
require additional investments and resources. Thank you for
your work to our witnesses on the front line to protect all our
people from this pandemic and from other threats in the public
health. We are grateful for your service. We look forward to
your insights.
And, again, Madam Chair, I want to really thank you for
holding this hearing. I think it is an extraordinarily
important hearing, because I don't think of anything more
important we do than the work in these particular areas for all
the American people.
So thank you for your many years of leadership, and I look
forward to working with you on this as we go forward together.
The Chair. I thank you very, very much. And I think it is
so clear that we are really joined in this effort. We
understand what has happened, what hasn't happened, and what we
need to do. And it is now time, while we have shown a light on
some of these other areas of our economy that have cratered,
that is now time to talk about what has happened to our public
health infrastructure and shine that light here, because, as
you pointed out, this is about saving peoples' lives and there
isn't anything more important than that. So I want to thank
you, Congressman Cole.
With that, let me introduce our witnesses. I am delighted
to welcome Dr. Kathryn Turner, who is Deputy State
epidemiologist and Chief, Bureau of Communicable Disease
Prevention at the Idaho Division of Public Health.
Dr. Marilyn Bibbs Freeman, Deputy Director, Division of
Consolidated Laboratory Services in the Commonwealth of
Virginia.
Ms. Jennifer Kertanis, the Director of Health for the
Farmington Valley Health District in Connecticut. Farmington
Valley neighbors my district, and we know well now that the
viruses do not stop at any borders, so I want to just say thank
you to Ms. Kertanis for your work, and it impacts my
constituents, and for that, we are grateful. A graduate of
Southern Connecticut State University, is currently an adjunct
professor there as well, which is located in my district. And I
would just say, go Owls.
So, and Dr. Umair Shah, who is Secretary of Health for the
State of Washington.
With that, Dr. Turner, you are now recognized for 5
minutes, and your full testimony will be entered into the
record.
Dr. Turner. Thank you. Chair DeLauro, Ranking Member Cole,
and members of the subcommittee, thank you for the opportunity
to appear before you today. I am Kathy Turner, a public health
epidemiologist or disease detective, and I currently serve as
Idaho's Deputy State epidemiologist. I am also a board member
of the Council of State and Territorial Epidemiologists, and I
am here today representing CSTE.
Our job is to investigate outbreaks, no matter how large or
small and identify the cause of the disease, the people at
risk, and how to control the spread. We are now in the second
year of a great public health crisis that has exposed deadly
gaps in our public health data infrastructure. And while COVID-
19 is just the latest threat demonstrating that our public
health data systems are outdated, it is not the last public
health threat that we will face.
Led by CDC, State and local health departments across the
country need a nationwide public health surveillance system to
detect emerging health threats and facilitate immediate
response for their individual populations.
What does a strong, nationwide public health surveillance
system really look like? Well, the reality is we have many of
the pieces in place, but we need to make larger regular
investments to modernize our systems, connect them using
current technology, and ensure they have the resources they
need to stay up to date when technology advances.
Using COVID-19 as an example, let's examine a small piece
of the data pipeline to better understand how data flows from
providers to State and local public health. When you visit your
doctor with a suspected COVID-19 infection, the doctor will
order a laboratory test. Remember, your doctor has a lot of
important information about you--your race, ethnicity, sex,
pregnancy status, and vaccination status, and demographic data,
including your address and phone number.
When the test is complete, your results are sent to your
doctor. And, because COVID-19 is a reportable condition, the
lab must also report the results to the health department. And
while lab results are typically returned to the provider
electronically, they are often reported to the health
department by fax or by phone, and the results are almost never
accompanied by the critical demographic, racial, and ethnicity
data.
A full case report that would include more robust
information is often never received by public health, despite
the data collected in the patient's electronic health record.
Every day, my team spends valuable resources tracking down
addresses and phone numbers for positive cases and without data
on race, ethnicity, and pregnancy status, public health cannot
use the data to protect those communities most at risk.
In today's digital world, we have to make our provider
systems interoperable; in other words, let them talk to our
public health systems and pass on the required data. State and
local health departments must also share essential deidentified
data with the Federal Government where it is used to develop
national policies to reduce morbidity and mortality and protect
those most vulnerable.
Data help to identify hot spots, new strains, and emerging
threats. We cannot, and should not, make essential policy
decisions without timely and accurate data. But if we don't
have those data, we cannot share them.
It is that simple. CSTE initiated the call for improved
public health data systems before COVID-19, and it is now
critical that we transform our existing public health data
system to live beyond this pandemic. There are five pillars
that must be included in public health data modernization that
I outline in detail in my written testimony.
Those five pillars are electronic case reporting, also
called eCR; syndromic surveillance; the electronic vital record
system; laboratory information systems, including electronic
laboratory reporting; and the national notifiable diseases
surveillance system.
Without a modern public health data infrastructure in
place, we will continue to face obstacles in responding to
public health threats. For instance, multi-system inflammatory
syndrome in children is a complication of COVID-19, and not
identified in a laboratory. It is reported by providers who
diagnose the symptoms. Without electronic case reporting and
syndromic surveillance, discovery of this dangerous
complication is delayed while public health fields phone calls
and reviews faxed medical records.
Another essential component of public health data
modernization is a skilled workforce that includes
epidemiologists, public health informaticians, data scientists,
and other experts, all of whom work together so that the public
health surveillance system is ready for the next pandemic.
We do not have a science problem; we have a resource
problem. The core data systems for national infrastructure
already exist to make it work now, and in the future, we need
regular, sustained annual funding, and we have to start
somewhere. We respectfully request the subcommittee provide
annual funding of at least $100,000,000 for the Public Health
Data Modernization Initiative at CDC.
Thank you. I look forward to your questions.
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The Chair. Thank you very much.
Dr. Bibbs Freeman.
Dr. Freeman. Good morning, Chairwoman DeLauro, Ranking
Member Cole, and all assembled representatives. My name is Dr.
Marilyn Bibbs Freeman, and I work with the Department of
General Services, Division of Consolidated Laboratory Services
in Virginia. I am also a member of the Association of Public
Health Laboratories where I also serve as the chair of the
diversity, equity, and inclusion task force. I would like to
thank you initially for the funding that is already available
through a variety of packages dedicated to COVID-19 relief, as
well as data modernization.
Today, I hope to list some challenges as I see them,
describe their impact, and propose solutions, where applicable,
to address the challenges. I would like to just start by saying
that while the COVID-19 pandemic did not elucidate any unknown
weaknesses in our current system, it did exacerbate those that
we already knew.
Personnel are our most valuable, as well as our most costly
asset in the public health industry. For reasons related to
salary compression and otherwise noncompetitive compensation,
these items have resulted in minimal, or no salary increases
over time. The impact is significant impacts to morale,
employees who have vastly different skills and knowledge sets
are paid the same amount of money for extended periods of time.
Additionally, it becomes very easy to find employment in
private industry where compensation is higher oftentimes for
the exact same job or similar job. We are unable in public
health to compete with that. Ongoing and dedicated financial
support to ensure that employees are paid commensurately with
their skill set, but also competitively with the current job
market is essential to meeting the needs of the current
workforce.
In coming years, as Chairwoman DeLauro indicated, we are
facing crippling attrition in up to 41 percent of our workforce
in some public health laboratories are within retirement age,
and then we have another 31 percent that are considered
millennials and planning to leave within the next 5 years. Not
only does significant attrition affect our ability to deal with
basic public health laboratory testing needs, it also threatens
to make impossible our ability to respond to urgent public
health threats such as COVID-19.
Feedback from our employees indicate that salary and job
satisfaction in the form of skill development, as well as
knowledge investment, will assist with retaining them here in
the industry. But I think we also need to take the time to look
at creating a pipeline for public health laboratory science.
There are actually no public health laboratory science
undergraduate programs currently in the country, and of the
three graduate programs specifically designed for public health
laboratories, one of them is currently not accepting
applications.
Funding educational facilities to create and expand
programming for public health laboratory sciences is an
innovative approach to ensuring personnel are available to
address future public health vacancies. The majority of public
health employees are Caucasian women who are paid
disproportionately less than men in our setting. A lack of
diversity within our current workplace threatens to increase
turnover due to feelings of not being included. Additionally,
research demonstrates that we are able to maximize our talents
by simply improving the diversity of the business.
One solution can be found in grant application requirement.
Having laboratories design their diverse recruitment strategies
or other DEI activity within a grant submission is an active
and intentional approach to fostering a diverse work culture
from the top down.
A second option is to require each governmental public
health entity to have an assigned diversity equity and
inclusion professional on site, or otherwise easily accessible.
I would like to kind of move on to our data management,
which has been discussed at depth by Dr. Turner, but it is a
fact that our current data management strategy is no longer
address the expanding needs of public health. The issues are
varied and expansive, but include outdated software and legacy
hardware, where upgrades are difficult because versions are no
longer compatible or supported by the vendors where we have
purchased them.
This makes it difficult to utilize applications, such as
cloud-based computing, mobile computing options, and storage
for the management and analysis of large data sets. It further
limits the laboratory testing equipment that can be purchased
for the use of public health advancement. Data modernization is
truly a situation where we have placed a bandage over the
problem. But COVID-19 has pulled it off. We have been unable to
quickly or easily implement system modifications that will
support things like patient registration portals, COVID-19
variant analysis, or information management system upgrades.
Dr. Turner also alluded to health information exchange
between one agency to another. We need to be able to seamlessly
transfer information between agencies in a secure manner to
mutually benefit both parties. Our inability to officially
exchange health information impedes the prompt allocation of
services to the communities that we have been dedicated to
serve and support.
A continued, ongoing funding strategy that takes into
account yearly inflation for supplies, market comparisons, and
other direct and indirect cost increases of doing business is
needed to maintain all elements of data modernization
incrementally over time instead of more costly, less efficient,
instantaneous overhauls as we are doing now.
Thank you for your time.
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The Chair. Thank you very, very much, Dr. Freeman. Ms.
Kertanis.
Ms. Kertanis. Hello, everyone. Good morning, Chair DeLauro.
It is great to see you. I wish we were in person, Congressman
Cole and members of the subcommittee. My name is Jennifer
Kertanis. I am the director of health for the Farmington Valley
Health District. We serve a population of 110,000 in 10 towns
just north and west of the Hartford, Connecticut area.
I also serve as the current president of the National
Association of County and City Health Officials, the
association that represents our Nation's nearly 3,000 local
health departments. I want to thank you for the opportunity to
speak to you today about the critical importance of our
Nation's local public health system, the vital work that we do,
and the importance of investing in a robust and well-funded
public health system.
While many of my public health colleagues at the Federal,
State, and local levels have long advocated for a robust and
well-funded and well-supported public health system, there is
nothing like a pandemic to illuminate the real impacts of years
of disinvestment on our response efforts and the health of our
communities in general.
I would like to speak to the following: First, while it is
easy to make the case for investment in public health during a
crisis, it is the well-funded and supported capacities and
functions of a local health department and State and Federal
health departments before an emergency that best position us to
respond to emergencies be that a pandemic, other disease
outbreaks, or natural disasters.
Second, the investment in a public health system must be a
national priority. For the past year, I have witnessed the
incredible efforts of my department and local health
departments across the country in responding to this pandemic
and supporting the communities we serve. We are the boots on
the ground, but the response we have had to mount has been
limited by lack of resources and years of disinvestment,
including outdated data systems and technology and lack of
human resources.
The Great Recession of 2008 hit all sectors of local
government; however, whereas many of these sectors were able to
bounce back, funding for local public health did not recover.
Between 2008 and 2019, the average local health department
expenditure per capita decreased by 30 percent. This led to
severe workforce reductions and local health began this
response with a 20 percent reduction in workforce capacity. And
one can argue that even at our 2008 capacity, we were still not
investing in a robust, well-funded public health
infrastructure.
The work of local public health, as you have heard,
requires the investment of a diverse workforce and skill set,
including epidemiology, health educators, environmental health
professionals, public health nursing, community health workers,
public health information officers, and administrators, to name
a few.
Since 2008, local health departments report a one-third
reduction in public health nursing. Pretty staggering,
considering the work we are currently engaged in to vaccinate
our population not once, but twice.
This is but one example many local health departments, mine
included, did not have an epidemiologist, a public health
information specialist, a community outreach worker, or other
key public health professionals critical to this pandemic
response.
Our current workforce is overworked and stressed as they
are working tirelessly in an attempt to fill gaps and best
serve our communities. With limited staff and a need to focus
on our pandemic response at the local level, we have had to
reassign staff, other public health work has diminished
considerably or stopped altogether.
Even before the pandemic, the United States did not enjoy
the highest life expectancy of developed nations, and, in fact,
we are seeing reductions in life expectancy prior to the
pandemic due to diseases associated with overweight and
obesity, particularly among our youth. One illustration of this
is CDC study which revealed that nearly three quarters, three
quarters of young people were not eligible to join the military
if they so chose because of overweight or obesity.
Preventable or delayable chronic diseases are taxing our
healthcare system. Our medical expenses in this country are
astronomical, and, unfortunately, we are seeing how health
inequities among certain populations are resulting in higher
rates of illness and death among certain segments of our
population due to the pandemic. Public health is about
prevention. Some of the greatest gains in life expectancy and
quality of life are associated with historic public health
initiatives.
Moving forward, strong Federal appropriations that fully
fund the needs at all levels of our governmental public health
and equitably reaching the local level are key to building back
our public health workforce, our most critical public health
asset. There are workforce initiatives and bills. We urge
support for data modernization that includes local public
health. We need data at the local level to ensure that
investments are placed on initiatives that address health
conditions and risk factors resulting in the greatest risk of
premature disease and illness.
I will just finish by saying that the benefits of a strong
local, State, Federal Government public health system has wide-
ranging impacts for our Nation, including national security, a
healthier workforce, better educational achievement, improved
quality of life, and more resilient communities during
emergencies such as the one we are currently living.
Let's learn from this pandemic and make the necessary
investments to ensure that all Americans can be confident in
the public health system, no matter where they live.
Thank you, again, for this opportunity.
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The Chair. Thank you very, very much.
And now Dr. Shah, I think you are back on with us in a
video. Is that right?
Dr. Shah. I am. I apologize. I have been on three different
technologies.
The Chair. But we are glad to see you. We are glad to see
you.
Dr. Shah. Thank you. Good morning, Chairwoman DeLauro, and
Ranking Member Cole and members of the subcommittee, thank you
for your leadership and for inviting me to testify today. Let
me start by saying, I can tell you, firsthand, exactly why
investment in public health infrastructure is necessary. I am
not only a responder, but a survivor of numerous emergencies:
natural disasters, hurricanes, chemical incidents, infectious
disease outbreaks, and now COVID-19. Each time, my own
community was impacted. This past week, my family and I
survived yet another emergency with the massive winter storm in
Texas. While the focus rightfully has been on the immediate
aftermath of loss of powers, people have struggled to stay
warm, we cannot forget the big picture of climate change in
leading to extreme weather events. This is a conversation I
would love to have, Madam Chair, at a later date.
My name is Dr. Umair Shah. In late December, I was honored
to be appointed by Governor Jay Inslee as the Secretary of
Health for the great State of Washington, honored because
Washington has been a leader in responding to this horrific
pandemic. This is a testament to Governor Inslee's leadership,
as well as the work of our State health agency, our teams, and
countless partners on the ground.
Previously, I was the executive director and local health
authority for Harris County Public Health and a past president
of NACCHO, and so I am glad to join with Jennifer here. She is
fantastic and I really appreciate the work that NACCHO has been
doing.
I am now a proud member of the Association of State and
Territorial Health officials as their representing State and
territorial public health agencies and the District of
Columbia. And as an emergency department physician for over 20
years, I have had the distinct honor of taking care of our
Nation's veterans through the Houston VA Medical Center.
Over this past year, we have all witnessed the loss of
life, impact on countless patients and families, and
communities devastated by COVID-19. It is shocking that we
passed another grim milestone this week with 500,000 American
lives lost.
As a leader in health, I have been frustrated by seeing the
strain on our public health system to ramp up epidemiology,
laboratory testing, communications, contact tracing, and now,
getting vaccines into arms. I am here today, though, not to
just express frustration, but to work towards solutions. You
have my full testimony today. I will touch on three main
points:
One, public health truly matters and there is a cost to
chronic under funding; number two, we must commit to investing
in a strong and capable public health workforce; and number
three, public health data systems must be modernized so data
move faster than disease. So, first, public health is vital to
all of us. This is truly boots on the ground performing all
sorts of key activities behind the scenes in assuring our
communities are healthy, protected, and safe. Yet, over the
last 40 years, we have spent ever increasing amounts on
personal healthcare and largely neglected public health.
During this time, life expectancy, relatively speaking,
compared to similar countries has decreased and this has only
gotten worse during COVID-19. The public's health is headed in
the wrong direction. Decrease investment in public health
doesn't make us stronger; it leaves us more vulnerable.
Constantly scrambling to address the next crisis upon us and
forces us to rob Peter to pay Paul by taking from elsewhere.
The pandemic has been horrific in so many ways, yet it is a
transformational moment to build back better. Now is a time to
make smart, strategic, and sustained funding in public health
infrastructure.
In making these investments, we must also address long-
standing health inequities. COVID-19 did not start these
inequities, but it has made them markedly worse. Inequitable
distribution of death and disease means we have seen
communities with disproportionate impacts from this pandemic.
This is simply unacceptable. To reset, reform, and rebuild
Federal investments must prioritize and resource equity.
Thank you to this subcommittee for your approval in
multiple emergency supplemental bills, which provided funding
necessary for the ongoing COVID-19 response, and now it is time
for Congress to provide an additional annual appropriation of
at least $4,500,000,000 for public health infrastructure. We
must commit to investing in our workforce as well.
The Washington Department of Health had to bring on nearly
1,000 more people, and more than 1,000 staff were redeployed to
respond to the pandemic. Many other essential public health
programs had to put their work on hold as staff were shifted to
the pandemic response. Similar actions occurred in Harris
County across the country as well. This is not sustainable.
Public health staff have been working around the clock for more
than a year in COVID-19 response are generally, mentally, and
physically exhausted and are leaving the field.
We must support these public health heroes, and we need
more of them. This is why we need a national effort to hire a
100,000 new public health personnel to ensure we can build back
a better public health system. Data systems, the lack of
investment in at all levels of government, has strained our
ability to respond to the everyday, and to emergencies.
Given advances in technology, there is no excuse not to
invest in the tools necessary to help our teams do their jobs
efficiently, effectively, and equitably.
Annual funding of at least $1,000,000,000 for a CDC's Data
Modernization Initiative and across all levels of public health
is a necessary step to modernize data systems.
Let me close by saying public health infrastructure funding
should be seen as an investment and not a line item in a
budget. Public health is the invisible offensive line of a
football team, and we are not doing enough to support and
invest in that offensive line.
We keep focusing on the quarterback. We have had an
invisibility crisis in public health for far too long. If
nothing changes, we will get more of the same--systems without
the robust capacity capabilities to respond to the next
emergency. We are at a crossroads. Either we can act now and
invest in public health, or we act later and overspend dearly
to undo that which should and could have been prevented.
On behalf of the State of Washington, ASTHO, and my
colleagues across the Nation at all levels of government, I
appreciate the opportunity to testify today. We look forward to
working with you in building safe, healthy, and protected
communities across this great Nation of ours.
Thank you.
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The Chair. Thank you. I just would just make comment and I
am going to now move to my question. And I am--I have two
questions, so I want to do that quickly, but we have listened
to a lot of testimony in this subcommittee over the years, and
a lot of powerful testimony. There has been such a sense, and I
think that ranking member would agree, such a sense of
consistency. It was almost--you know, you are all talking about
the same thing. There is no different approaches. It is the
singular effort that if we don't make it, we rue the day. So it
was just very, very powerful testimony.
And with that, let me just try to get my two questions in.
Dr. Turner, the CDC's Data Modernization Initiative that we
have begun to reduce the amount of effort that is spent chasing
the data, whether it is address, gender, et cetera, how will
this modernization initiative that we have begun move beyond
reporting information about past events, and do you know of any
agencies using a modernized system?
Dr. Turner. Thank you, Chair DeLauro. So the first
$50,000,000, the first ever allocation that occurred during
late last fiscal year, CDC immediately made steps to ensure
that the money could go out the door to States, the States
received the funds through their epidemiology and laboratory
capacity grants, and States immediately began using the funds.
And CDC has been working actively on planning efforts to ensure
that all of those right pieces are in place for data
modernization, and the States have been using that money to
improve their information systems.
Unfortunately, with the pandemic, we were building the
plane while we were flying it essentially. And so getting past
the pandemic will allow us to more focus on investing in our
current systems. While work has been done, it has been delayed
because of the pandemic, and so, we really need to move this
forward. I think the pandemic has put on the spotlight some of
the challenges and that is being put into those plans now.
The Chair. Thank you.
And Ms. Kertanis, let me just--you talked about long-term
challenges in the public health workforce. Can you just tick
off some of the things that you think we ought to be trying to
do with regard to the workforce and its sustainability and its
recruiting?
Ms. Kertanis. Yeah. There is any number of aspects of this.
One I am very concerned about what this workforce is going to
look like after the pandemic. You spoke to the aging of our
public health workforce. So, one, we need to incentivize young
individuals going into the public health arena in all different
disciplines and areas of expertise--epidemiology, laboratory,
and et cetera, as you heard about.
Two, we need to invest in competitive salaries. I have a
colleague in one of our large metro areas that has lost public
health nurses to this pandemic to a for-profit, temporary
agency, because they could pay more doing the exact same work
of contact tracing. So we need to make sure that we are
investing in good salaries and benefits.
The third thing is, that we need to remember that
oftentimes, the Federal funding comes in buckets or a siloed
approach dedicated to specific diseases of the day. We need to
get past that and make sure that we are investing in a
workforce that supports the functions and the capabilities of a
local health department, regardless of what health outcome we
are dealing with.
Because it is the work of epidemiologists, community health
workers, health educators, public information officers. That
work and expertise is needed, regardless of whether you are
focusing on chronic disease like heart disease, stroke, mental
health, the opioid issues, et cetera. So we have to invest in
that type of a workforce, and not just a siloed approach that
is not sustainable and doesn't build our capacity long-term.
The Chair. The use of a Federal loan repayment program,
does that exist now in your area?
Ms. Kertanis. It does not, and that is one thing that I
think there are over 100 public health organizations and
agencies, including NACCHO that have signed on to workforce
development bill that would include a loan repayment program
for graduates that commit to serving 3 years at either a local,
State, or Federal health agency, kind of like the health
services--I am going to forget the name, but I got it here
modeled after the National Health Service Corps. So that could
definitely be something that brings a workforce into the local
government or public health sector and State and Federal as
well.
The Chair. Let me go back to Dr. Turner for one second. No,
I can't. I have 6 seconds, so I am going to yield my time to
Congressman Cole.
Mr. Cole. Madam Chair, you are the chair. You can do
whatever you want to do. If you got another question to ask,
please do it.
The Chair. No. You go ahead. We may not--if I can. So Dr.
Turner, we are talking now about COVID, but just give me a
sense of the data modernization as it has to do with food borne
illness and other areas? Congressman Cole mentioned the opioid
crisis. There are other areas of chronic diseases. Just talk
about the mechanics of this system and how it really is spread
over the entire public health area.
Dr. Turner. Yeah. Thank you.
The COVID-19 pandemic has highlighted how far behind we
are, but, frankly, the data modernization initiative is disease
agnostic. The infrastructure once in place, it wouldn't matter
if it was Salmonella or influenza or E. Coli or a coronavirus.
The systems would work for any infectious disease, and for
chronic diseases as well. You know, the data could be--the
systems could be leveraged for data to go into a diabetes
registry, for instance, or information about opioid use.
There is--if the system is not disease-specific, and that
is really the key point, is that we need it to be a system in
place that is flexible and modular so that we can respond to
any public health threat or any event that comes up.
The Chair. Okay. Thank you. And thank you so much,
Congressman Cole. So I love disease agnostic. I think that is
what we are looking for.
Congressman Cole.
Mr. Cole. Thank you very much, Madam Chair.
Like you, I am struck honestly by the uniformity of the
testimony that we have heard, that I read last night, which
actually makes the work of the committee a lot easier. I mean,
you all talk about the need for data modernization and exchange
in lab modernization. You all talk about the need for workforce
development. You all talk about the need for better
compensation and better training for that workforce as it comes
in.
So you have actually made, I think, in some ways, our job a
lot easier than it normally is, because we normally have a
little bit more diversity of opinion, and it is interesting to
me you come at this from so many different perspectives, and
yet, you arrive at the same points.
And I was particularly struck, Dr. Shah, by your
observation that we may overinvest in personal health and
underinvest in public health. That was a nice way to actually
frame the challenge that we have in front of us. I have got a
question, and I am going to start with Dr. Turner and just
going to ask all of you the same thing so you can just move
right down. I am curious as to your observation having--we are
still in the midst of coronavirus, what has worked best in the
public healthcare system in dealing with this, where have the
biggest shortcomings been in your professional opinions in
dealing with the current pandemic?
So Dr. Turner, let me just start with you. Tell us what we
have done right, tell us where we need to really improve?
Dr. Turner. Thank you. So one of the things--one of the
areas we have had great success in over the course of the last
year is with electronic case reporting. We have used some of
those investments to build that infrastructure, and we have
seen 6,800 more facilities come online who were able to send
electronic case reports from the electronic health record
systems to public health. It has made a lot of difference in
getting the demographic information and clinical information
that is contained in those electronic records, and it really
merges well with our electronic laboratory reporting, but we
still have a long way to go. You know, it is sort of sporadic,
and sort of the bigger clinics have kind of come on board, but,
as you know, we have a lot of areas across the United States
where we don't have these big health systems.
I would say that what we have noticed during the pandemic
itself is that the data needed to identify vulnerable
populations and to really target interventions and target
communication and target prevention efforts has not been as
robust as it needs to be, because we are just not getting a lot
of the information from the clinical visit.
And so, that is where we need a lot of work, and that is
why it is so critical for this data modernization initiative is
so that data is flowing seamlessly between, you know, clinical
healthcare and public health, so that we have that data really
quickly and we cannot only communicate to the public, we can
also implement policy changes, we can pivot more easily, and we
can target our interventions a lot more efficiently.
Mr. Cole. If we could go to our next witness, please. I
think that was Dr. Freeman, or I am not sure.
Dr. Freeman. Yes. So I think that what has worked best for
us, I would say over the last year, is our ability to have a
wealth of training accessible in a very flexible format. It has
been great with communicating new concepts, new principles to
our work staff, and being able to offer it to more of a work
staff has been instrumental in being able to have us respond to
various threats in parts of this pandemic, but I see that
moving forward, since we have gotten use to a world in a
virtual land, we can apply this moving forward to increase the
amount of training that is available to our work staff in a
very cost-efficient manner.
I would say that what would be our biggest shortcoming, I
have to wrap back around to data modernization. A lot of the
tools that we want to use to advance public health are really
built around the systems that we have to do it. Some of the
systems need upgrading and before we can upgrade, we have to do
something else first. And before we can do that, we have to do
something else first. And it becomes a burgeoning issue and
unable to keep up with it.
So you go into a modernization task thinking you are going
to update one thing, but then you find out you have to update
and address five. And so you are already behind before you can
move forward.
Mr. Cole. Thank you. Madam Chair, for whatever reason I am
not seeing my time, so I may be running out of time and I don't
want to overuse it. I know we have got a lot of questions.
The Chair. Why don't we just try to get the other two
witnesses in and then we will move on.
Go ahead.
Mr. Cole. Okay. Thank you. Very kind to do that. I
appreciate it.
Dr. Shah, I think you are next.
Dr. Shah. Thank you, Congressman Cole, for that question.
There are a lot of things that, obviously, my colleagues have
already mentioned. I would just say that the fact that our
strategy nationally has meant that States and localities have
had to work things on their own has been a challenge
throughout, but the fantastic thing has been just the bringing
together of public health healthcare and incredible number of
partners.
And I will say that another thing that we have to recognize
is that the miracle of a vaccine, even we are a year in and we
have got vaccines that are actually protecting human beings
today is incredible. And now, our job is going to be to get as
many people vaccinated as quickly and equitably as possible.
Mr. Cole. I am very struck by the same fact. I actually
thought that is what we have done the best. Maybe if we had a
more robust system, we could have slowed it and done a lot
better initially, saved a lot more lives just by the speed of
the vaccine. And, actually, I think Ms. Kertanis, you were next
and I am sorry, I sort of jumped the line there. I apologize,
but very much interested in your thoughts as well.
Ms. Kertanis. No problem. I never mind yielding to Umair.
So I think we really appreciated that Congress acted early
and quickly last March in issuing some emergency appropriations
and allocation. I think one of the things that hasn't worked so
well, and I think there is work that can be done at the Federal
level is ensuring that this money flows equitably right down to
the local level.
In Connecticut, I can tell you, I have received $176,000 in
Federal pass-through dollars from my State. $176,000. So that
is not the case across the board. Some States are doing this
very well. I think the other thing is we have suffered at least
a little bit early on from kind of the lack of a national plan
that is really been informed by local and State perspectives
and expertise.
We know our communities best. We know our partners best. We
have been practicing for this, and I think this has included
vaccine administration. I mean, we are doing a yeoman's job
with little or no resources, but we should have been investing
as much in the vaccine administration capability as we were in
the development of the vaccine itself.
Mr. Cole. Thank you very much.
And Madam Chair, thank you for the extra time. I appreciate
it. I yield back.
The Chair. Thank you. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Dr. Kertanis, I would like to go back to
the issue of the public health workforce. As much as we would
love to provide all the resources that you need, the fact is
that there is always limits to our funding. So how would you
prioritize the public health programs? And at what level of
investment do you think is needed to train and to sustain a
public health workforce that will be adequate to meet the needs
of the next 20 to 30 years?
Ms. Kertanis. Sure. So, you know, as has been commented,
State, Federal, and local partners in public health have been
working on what it would take to modernize our public health
system, and what that looks like for a long time. There has
been a proposal of $4,500,000,000 annually to build and support
a robust public health system at all levels. I don't know if
that is the perfect number, but that is one that had been
grounded in. Evaluation of what does it take at the local,
State, and Federal level to respond appropriately and to
protect our communities. So I think that is a good start.
It is grounded in public health science and information
about what we know it takes to protect our communities. The
fact that we need data systems and modernization, the fact that
we need epidemiologists and all of these other disciplines. As
I said, whether we are talking about dealing with chronic
illnesses or a public health emergency.
So, I think that, you know, I would also like to flip it
around and think about what is the cost, the ongoing cost, of
not investing in these things? We are about prevention. I think
you could probably not identify a discipline where the return
on investment could be greater. We are talking about extending
lives, improving quality of life, improving the resilience and
the health of our communities. So those are some comments and
thoughts there.
Ms. Roybal-Allard. Dr. Bibbs Freeman, as has been
mentioned, one of the critical components of public health
infrastructure is laboratory capacity. And one of my
legislative priorities has been newborn screening. And we are
currently working to reauthorize the law that provides Federal
support through the CDC and HRSA for State newborn screening
programs which can save babies' lives and prevent them from
suffering from disability genetic diseases.
It has been brought to my attention that the COVID pandemic
response has created shortages in the availability of the
plastic material that is necessary for carrying out the newborn
screening test. Can you tell us how the Virginia Newborn
Screening Program is being affected by the pandemic response?
And is there a long-term solution to prevent shortages, such as
impacting other critical laboratory tests?
Dr. Freeman. Yes. Thank you for your question. And so, I
would definitely say that the availability for supplies,
materials, and plastics, as you have indicated, have not only
been an issue for newborn screening, but it has become an issue
ubiquitous within our laboratory. All of the vendor systems and
manufacturing systems have been reprioritized to sell to COVID-
related functions only. Because of this, we have had delayed
deliveries. We have been unable, in some cases, to perform
testing at the time we expect to do testing, and have had to
delay it. Thankfully, we are able to prioritize some critical
functions for the purposes of newborn screening, and, so, we
were able to minimize the impact of those delays.
Another thing that we have had to do are build contingency
plans and continuity plans in real time. The plans that we
built previously were definitely sustainable for short periods
of time, but COVID-19 is now well past a year. And, so, we have
had to build continuity plans in real time in order to address
our newborn screening needs.
I will also say we need to look very closely at our mail
system, and our private and commercial carrier systems as well.
We here in Virginia have the access to a courier that we have
purchased that services all of our customers, and very few of
our newborn screening samples come via mail or through a
commercial carrier. However, my counterparts in other States
are using the mail system and commercial carriers in order to
have their samples delivered to the laboratories for testing.
With the delays that we saw in the mail system related to
COVID-19 pandemic, it became increasingly difficult to give
timely result reporting to hospitals, where they need it most,
for lifesaving measures for babies.
Ms. Roybal-Allard. I think we lost her.
The Chair. Just right at the end.
Ms. Roybal-Allard. Right. We can get the rest of the
testimony.
The Chair. Okay. Thank you very much.
Congressman Harris.
Mr. Harris. Yes. Thank you very much, and thank you all.
You know, just this week, I was speaking with one of the health
officers in one of my counties, one of the largest counties in
the district. And he was talking about the difficulty in fully
staffing the department. So, he had brought up, again, what
last Congress, H.R. 6578, the Workforce Loan Repayment Act, but
I have some questions, and I am sure many of the panelists have
thought about this act.
So, at many different levels, we have a workforce
requirement, going from the very top level, which, you know,
frequently might be a physician who is also trained in public
health who graduates with literally hundreds of thousands of
dollars of loans. But there are other workers who don't have
that much loan, but it seems this bill was kind of one-size-
fits-all.
So first of all, let me know is that true? Was the bill
last year written as a kind of one-size-fits-all up to $35,000,
not depending on how many loans you have? And second of all,
where is the distribution of need within the professional
levels of the public health services and the public health
departments throughout the country? So, if we can start there,
that would be great. Anyone?
Dr. Shah. This is Umair Shah. I will start. And I don't
have enough on that specific bill, but let me just answer your
second question, which I think is a critical one. I do think it
is in all levels of the workforce within the public health
workforce. And as you know, that with physicians, sometimes it
is the incentivization of physicians so that they are not going
into the specialties and going into primary care. But then
another sub primary care, or another specialty, is public
health and prevention. It is a very different field, and being
a primary care doc, which I have been before, it is actually
being in public health departments. And as you know, that is a
different area that not a lot of physicians have been exposed
to. But then you can go down the list of nurses, you can go
down the list of those with other kinds of loans for a masters
in public health, or other kinds of even now bachelorette
programs in public health where everywhere the workforce needs
support. So even though a physician, or one of the higher
paying fields, may get more of those dollars, and then we have
to try to figure out how to incentivize them to look at the
field.
We also have another issue, the conundrum of other
professionals who are going into the field who still, for their
income level and for those dollars, especially for people who
are coming from disproportionately impacted communities when we
say we want our workforce to be diverse, we want to make sure
we are doing everything we can to give them the opportunity to
be able to not just pay back their loans, but to support them
as they are doing good public health work, public sector work.
Mr. Harris. Let me follow up on that. But if you look at
the workforce, I mean, is there an absolute need for--because
this loan repayment program is structured after the public
health service loan repayment, which is specifically targeted
to, as you suggest, primary care providers, people who go into
rural communities, places where you can't--this is a little bit
different, because a lot of these public health departments,
for instance, are not in rural communities. I represent a rural
district. I imagine my rural district is much more difficult to
recruit someone into than in the Baltimore-Washington parts of
my State. So how difficult is it to recruit physicians into the
public health field?
Dr. Shah. It is very difficult. I will tell you, I have
spent a whole career trying to get physicians into public
health. It is extremely difficult. I mean, the fact that, first
of all, there is not a recognition of the value proposition of
what public health brings. Why should I be looking at this
field? There is not exposure in medical education and residency
programs. You always know, you know, when you are a resident,
you know, even a student, you see an intern, a resident, a
fellow, an attending, you know exactly a pathway. In public
health it is a completely nebulous pathway.
And so, many people get there in different ways. And, so, I
do think it is very difficult to get physicians into public
health. It is not impossible, though, because there are many
mission-minded and service-minded individuals, but we need to
get them exposed. And then we also have to do what we can to
support them as they are making career choices, and that is the
incentivization, whether it is an urban area, a rural area. We
know we have to do a lot more so that they are exposed, and
that we can get them to retain their activities within those
areas and those departments.
Mr. Harris. Thank you very, very much.
I yield back.
The Chair. Thank you. Congresswoman Lee.
Ms. Lee. Thank you very much, Madam Chair. And thank all of
our witnesses for being here.
Let me just preface my question by this: Public health
infrastructure and increasing support is something that I
always believe we must do. But we cannot increase support in
the public health infrastructure as it is, because for the
majority of people of color, systemic racism is part of that
infrastructure. So, I hope we are seeing building this support
for public health infrastructure as a way to dismantle those
policies that have created such disproportionate impacts of
diseases on people of color.
And so, of course, I am working on my antiracism and public
health bill, but I wanted to make sure that we understand a
couple of things about the public health infrastructure as it
is.
First of all, just in terms of the data, 78 percent of
Americans over 65 are White. The life expectancy of African-
American men is 68, that was last year, it is down now again.
Okay? When we look at the Asian American, Native Hawaiians,
Pacific Islanders, they are often labeled as ``other.'' And so,
we don't even acknowledge race and ethnicity among and AAPI
groups.
And, so, there is so much in our public health
infrastructure that just needs to be totally dismantled. And
so, I am wondering how you all address systemic racism and
structural racism, which we know have negative outcomes for
people of color?
Dr. Shah, would you like to first respond?
Dr. Shah. Yes. Congresswoman Lee, thank you, first of all,
for your leadership on this issue. I have watched it over the
years. I will say a few things. In Harris County, my previous
position, we actually are elected officials, called out racism
as a public health issue. And Governor Inslee, at the State of
Washington, is also very much of that same mind set. And this
is a really important issue, because it is one thing to talk
about diversity and equity and inclusiveness; it is another
thing to enact it. And it is really not about theory, it is
about practice. And when we are looking at our own workforce,
we have got to be intentional on who comes in and how we
represent the entirety of that community.
As you say, I am a proud Asian American. I will tell you
that this is an incredibly difficult area in public health. But
at the same time, we also have to recognize the very champions
and those messengers for the messages that we are trying to
enact in many, many, many, many communities who mistrust,
distrust, and do not even believe that many of the things that
we are doing, or don't have the information, is the right thing
to do. So Broma Torres (ph) and people who are of that
community are the best ways to be able to promote that
diversity. But if you don't have a diverse workforce, then you
are starting all over, and then that mistrust, distrust rears
its ugly head.
Ms. Lee. Anyone else? Dr. Freeman, would you respond?
Because I know that in California, for example, less than 14
percent of practicing physicians in our State, California, are
people of color, physicians of color. But, again, there is some
systemic issues, some structural issues in our public health
system that need to be unraveled first before we can just,
quote, ``build it back, move it forward.''
Dr. Freeman. Yes, ma'am. So, I think a few things, and I
think I will try to reserve my comments to the public health
laboratory space, where I work in primarily. So through my
partnership with the Association of Public Health Laboratories,
I am the chairman of the Diversity Equity and Inclusion Task
Force. And I feel very strongly that in order to move to a
situation where we are as diverse as we possibly could be, we
would have to first understand where we are. I am not sure that
the attention that it deserves has been given to assessing, at
a baseline level, the diversity within an organization, within
a laboratory space. And so, our task force is working very hard
to identify how we want to operate, kind of clarify what
diversity and define what diversity means to us. But in doing
that in our member laboratories, we are hoping to do diversity
surveys so that we know where we are starting with and where we
have to go to. And then we look to build tool kits that are
associated with training laboratories, training professionals,
and training leaders on how to increase the diversity within
their own laboratories.
In addition to that, the diversity isn't really enough. We
also still have to really be sure that people feel included in
the space that they are in, and that they have the tools
necessary to be successful. I really think that it all goes
down to being where we actually are.
And I think I would like to just end with in building trust
in communities, as Dr. Shah mentioned, people want to see
employees that are working for them that look like them, that
represent what their communities look like. And that is our
first step into building trust in public health.
Ms. Lee. Thank you very much, Madam Chair. And Madam Chair,
may I just say, I hope we have a hearing, or can do something
as it relates to the structural issues that have really
prevented the whole effort toward making sure that health
outcomes for people of color----
The Chair. Sure.
Ms. Lee [continuing]. Are what they should be within our
public health system, because structurally we can't move
forward until we dismantle those old policies.
The Chair. Okay. Thank you.
Congressman Fleischmann.
Mr. Fleischmann. Thank you, Madam Chair and Ranking Member
Cole. I really appreciate the bipartisan tenor of this entire
hearing. Thank you so much on this very important issue. And
for all the witnesses, all of your testimonies have been so
helpful and insightful. So I want to address my questions to
all of you all. And please, just take them in order, and we
will just do that until we run out of time.
Effective vaccine distribution plays a vital role in
eventually getting back to some sense of normalcy.
Unfortunately, the digital infrastructure used to schedule
vaccine appointments has created significant obstacles for
those without certain technical resources.
First, and I have three questions, what offline avenues can
we take to ensure vulnerable populations have equal access to
the vaccine? Second, essential workers often have schedules
that extend outside the regular 9-to-5 working hours. How can
we provide viable opportunities for those individuals to
receive the vaccine? And thirdly, we are seeing, in some cases,
where individuals in rural areas are being forced to travel
long distances in order to reach a vaccine site. Although large
scale vaccine sites work well in urban areas, how can we better
balance distribution to our rural communities? And I will rest
and then let all four witnesses respond, please, Madam Chair.
Dr. Turner. Thank you. This is Dr. Turner. I think that--
first of all, we cannot do outreach, and we cannot target
interventions, and we cannot target efforts unless we have data
with which to do that. And so, building the public health data
infrastructure gets us the data we need to target those
interventions, including vaccination clinics. If it is not a
disease-specific system, then we can use the data that we are
getting on all diseases and identify those vulnerable
populations. We might have data on lead, or hepatitis, or the
opioid crisis, regardless of what types of--the reason for
looking at the data as long as we have the systems that have
those data in them, public health is in a better position to be
able target intervention, such as vaccination clinics.
There is no doubt that our immunization systems need to be
interoperable with healthcare and public health. I think that
effort will require its own dedicated resources outside the
Data Modernization Initiative, which has the five pillars. But
the Data Modernization Initiative can be leveraged to assist in
those efforts.
Mr. Fleischmann. Thank you.
Dr. Freeman. To address your first question in regards to
offline avenues for equal access, I think one of the things
that we skip in the vaccine distribution scheme was that we
usually market that this is coming, and we work very hard over
time to build trust. But the truth of the matter with COVID-19
was we didn't have that time. And so, a lot of times in
building trust, you have to go and be ready to partner and
speak with local communities.
Because we skipped over the marketing to the local
communities and engaging community leaders, we are at a
disadvantage to getting vaccine to the areas that are being
more affected. And so, I think it is time for us to possibly
relook at those partnerships that we had before with community
leaders to be sure that we are making sure that avenues are
available for equal access to the vaccine.
In addition to long distances to reach vaccine sites, I
would propose that we look at more mobile vaccine clinic
strategies. We have been able to mobilize testing in a number
of ways. It has been highly effective in reaching the areas
that do not have as much access as other more urban areas. And
so, I do think that that is something we could definitely look
at. It will require that we have appropriate storage and
refrigeration and handling, but I think that is something that
we can figure out fairly easily.
Mr. Fleischmann. Thank you so much. And would either Ms.
Kertanis or Dr. Shah like to respond in the remaining time we
have got?
Ms. Kertanis. Yeah, I would love to, because I think that
you have asked questions that really highlight the strength and
the value of local governmental public health. We know our
communities best. We have had to develop significant
workarounds for populations that couldn't access the VAMS
system or figure out how to register. We know our partners
locally. We have engaged senior centers, and social service
departments, and our town municipal officials to support us in
that effort to make sure that it was accessible.
With respect to essential workers, you are absolutely
right. But at the local level, we have a good sense of when and
how those clinics need to be operated, what resources we can
bring to bear. Rural areas are particularly challenging, and we
are hearing about that from my NACCHO colleagues that are
struggling with this right now.
Mr. Fleischmann. Thank you.
Dr. Shah. From the State of Washington's standpoint, I am
really excited about two initiatives that is in my testimony.
One is called the VACCS, the other is called the VICs. The
Vaccine Action Command and Coordination System, which is
bringing public private partnerships that we have, Microsoft,
and Starbucks, and Costco, and others that are at the table
that are helping us really harness the power of the public
private partnership, so we can improve the experience of end
user, the individual, the Washingtonian.
We also have the VICs, which is the Vaccine Implementation
Collaborative. It is really designed for equity feedback
dialogue. And so, the VACCS on the one hand is about throughput
and numbers, and the VICs is about equity and making sure we
are doing things equitably. I think a lot of people in the
vaccine world think that it is a false dichotomy that, for some
reason, you can't do both. You can't vaccinate quickly, and you
can't vaccinate equitably. I believe you can do both. It is
just that we have to make sure that we are complementary and
intentional in how we go about doing that vaccine effort.
So Congressman, those are two efforts that are very much
about what we really need to be doing is, at the end of day,
prioritizing public health and prioritizing working with our
partners, such as what Jennifer just mentioned with her local
partners; and, frankly, all sorts of other partners across the
table that can help us, because they have a lot of incredible
know-how. But we in public sector, oftentimes, are not able,
willing, or develop the systems so that they can actually be a
part of the solution. And so, I just wanted to point that out
as well.
Thank you.
Mr. Fleischmann. Thank you.
The Chair. Congressman Pocan.
Mr. Pocan. Thank you, Madam Chair. And thanks to all of the
witnesses for being here today.
There are two different areas I would like to try to get
questions in on contact tracing and on vaccine hurdles. Let me
start with contact tracing. Dr. Turner, you might be the most
appropriate person, or if anyone else is, please feel free to
answer. We have been told the mantra was testing, tracing,
isolation for a very long time.
In my State of Wisconsin, we have largely had local units
of government doing the contact tracing as opposed to the
State. There are only a few hundred contact tracers at the
entire State level. And when we hit our peaks, we probably were
only tracing one out of five people, maybe last fall, with some
really tough numbers. Have there been any policy
recommendations or personnel changes in contact tracing? And
would any different increased or sustained funding in this area
be helpful?
Our problem really has been retention, also. It has been a
little bit difficult to attract, extremely difficult to retain
contact tracers. I am wondering your experiences?
Dr. Turner. Thank you. You probably already know this, but
we have been doing contact tracing in public health for 100
years. So, it wasn't anything new. We already know how to do
it. But one of the key elements with the COVID-19 outbreak has
been robust contact tracing. What we have found is that phone
numbers and contact information is missing in over half of the
lab reports that are sent to public health authorities across
the Nation.
So, the contact tracers have to figure out even to get
ahold of people who have a positive result first. It makes the
job incredibly difficult. And when they are doing the contact
tracing, you are absolutely right, they are running into
roadblocks. People don't want to talk to them. And that has do
with trust and what is happening with their data, who is
getting access to my information, who are you sharing it with
and that sort of thing.
So, that is all kind of part of the whole topic of making
sure that we have data systems that will talk to each other,
and making sure that we have data systems that are secure, and
that the public has trust in public health keeping their data
private and confidential. And so, it is all part of, sort of,
that data focus. You can't contact people if you don't have
contact information. So that is the importance to being able to
have our systems interoperable.
Did I answer your question?
Mr. Pocan. Yes, you did. I think it really does come a lot
to the data collection side of things that we have been
lacking, so.
The second question is on vaccine hurdles. So, one of my
concerns is that, just personal opinion, that we are going to
get to 50 to 60 percent of people relatively easy. I think we
are going to have struggle to get to 70 to 75 percent of
people. I actually think we should be doing advertising and
things right now, even though there is not the supply issue
yet. I think you need to build the demand question. But one of
the concerns I had is one of the largest vaccination sites in
the country in Los Angeles recently was closed down by antivax
protesters, because of what, you know, Facebook, as a platform,
did. We have written to them. They have not replied back.
Although I saw recently Facebook's ad policies are going to
block messages from cities, healthcare providers, and community
and faith-based organizations promoting COVID vaccines, which
that gives me great concern.
Are you seeing disinformation becoming a problem yet on
vaccinations? Because, again, my real concern is that gap we
are going to get to between 50 and 60 percent, and then the 70
to 80 percent.
Dr. Shah. Yes. Congressman, this is Umair Shah. I will take
that on very quickly. I say, yes, we are. And I think you are
absolutely right that right now, for every vaccine you have,
you have 10 people ready to get in the chair to get it. So it
is a supply/demand issue right now that has flipped in a way
that supply constraints are really masking this issue that is
going to be coming.
You are right, in my opinion as well, that later on--not
that much later on, by the way, sooner than later, we are going
to have this real issue around people hesitating because the
misinformation, disinformation, mistrust, distrust, or,
frankly, wrong information that is going to be driving
decisions.
And unfortunately, it is happening even in the healthcare
system where we are having healthcare workers who, honestly, we
would hope would not hesitate, because they have seen up close
what is happening with COVID-19, how devastating it can be, and
they are also having questions.
I have gotten the vaccine. I have gotten two doses. My 83-
year-old mother has gotten her two doses. I will tell you that
we have to do everything we can to not just be about the
science, which is where it starts, but we have got to be
markedly better about the engagement, and, so, that we
communicate to our communities so they trust us and they trust
the science.
Mr. Pocan. Thank you. I yield back, Madam Chair.
The Chair. Thank you.
Congressman Cline.
Mr. Cline. Thank you, Madam Chair, for holding this
important hearing. Ranking Member Cole, members of the
subcommittee, and witnesses, thank you for being here.
As we have seen, States within the U.S. have been impacted
differently by this virus, and also responded differently to
it. Further, States' ability to curb the spread has also
varied. The responses to this pandemic were first made
noticeable by the availability and the access to timely
testing. Now, response is also being measured due to the
efficiency of the vaccine distribution. Both the national and
State public health infrastructure is being put to the test as
they have scaled up to mitigate the effects of the COVID-19
pandemic.
Unfortunately, in late January, my State of Virginia was
ranked 41st out of States for vaccine distribution by State
population. Thankfully, in the last few weeks, much progress
has been made, bringing Virginia are up to 22nd percent of the
population that has received the first dose of the vaccine,
with it, totaling 14 percent of its population. Virginia is
currently 2 percent away from vaccinating the maximum percent
of the population for which we have vaccines allocated.
And it is vital for Virginia to keep on the trajectory it
currently is with regard to vaccination and testing. But,
unfortunately, the slow start definitely hurt us when we were
ranked last, at one point not only in testing, but at one point
we were ranked last in vaccine distribution. That is cause for
concern.
So let me ask Dr. Bibbs Freeman, in a tele townhall I held
last night, I heard from many constituents who were frustrated
with Virginia having one of the slowest rollouts for the
vaccine. Many Virginians were frustrated not only with the lack
of access initially, but also lacked information available.
Thankfully, Virginia's has made substantial progress. And while
I understand you are in the Department of General Services
Division of Consolidated Lab Services may not have been
directly working on this, you spoke to it.
Since you are still with Governor Northam, can you please
speak to some of the reasons for the delays that Virginia had
with getting the initial groups the vaccine?
Dr. Freeman. As you indicated, my knowledge of the vaccine
program in Virginia is very minimal. But I can say that I would
like to kind of wrap back around to data modernization. I
understand that there were a number of issues related to
registration and preregistration of citizens into the systems
that were available. Because there were multiple systems that
were available to the public at different times, there was
confusion created in the population. As you well know, when
things don't operate seamlessly, you begin to lose citizens who
are willing to be vaccinated, and that is a concern.
Based on the information I know, things are being handled
way more efficiently. The current system registers citizens
more seamlessly. I think the thing that is most concerning,
based on the feedback that I have heard from the citizens
around me, and not necessarily the Department of Health is the
slowness with which they are being contacted to be scheduled
for their vaccine.
So while they are preregistered now, there is a slowness
associated with callbacks to go and actually receive the
vaccine.
I do think that it would be worthwhile to let the citizens
know that we are vaccinating at the levels that we have
available. What we have here is a supply issue. There is not
enough supply to vaccinate all of the people that we would like
to. And until that supply becomes available, we will be unable
to do so. But I think that the system now we have available can
register the citizens, we also have a system to vaccinate the
citizens, but what we need is the actual vaccine.
Mr. Cline. And you mentioned this in response to another
answer to a question. As you know, we are blessed with many
rural communities in the State, but many in the communities,
many of which are in my district, have issues with access to
healthcare in general, but, specifically, to the vaccine.
You mentioned the idea of mobile vaccination, and I think
that is an excellent suggestion. I would hope that we could
pursue that further, and strengthening infrastructure in these
areas, both through retention of medical personnel and through
avenues for care.
Can you expand further on what might be necessary to make
these mobile vaccination opportunities a reality?
Dr. Freeman. Absolutely. So, I think the first thing we
actually need is actually a mobile device of some sort, a van,
a truck where we can actually mobilize.
So one of the things that some of partners, and I will
reference the Fairfax County Public Health Laboratory; they had
a mobile system, but it was not enough had to cover all of the
areas that they would like to use it in within Fairfax. And I
think the same exists. We need to possibly look at creating a
fleet that could be easily mobilized for these purposes, for
not only this event, but for future events as well.
In addition to that, we will need storage. A lot of the
vaccine that we have had available has some very stringent
storage requirements. And, so, we will have to work out exactly
how that occurs. But to kind of push back the workforce a
little bit, you will need people to coordinate the mobilization
clinics. You will need people to register as well. One person
on a mobile van can't handle all of those pieces and parts.
And, so, we are going to have to look at creating systems that
will only support not only the registration and the
distribution, but we also need to look at systems that will
handle the coordination and the actual vaccination process in a
safe manner.
Mr. Cline. Thank you very much.
I just want to also add you have got a beautiful building
on that poster behind you. Is that a new building in Richmond?
Dr. Freeman. That is our building that we built in the
early 2000s that we are currently housed in now.
Mr. Cline. Where is that?
Dr. Freeman. It is in Jackson Ward in Richmond, Virginia.
Mr. Cline. Awesome.
Thank you, Madam Chair, for humoring me for a couple of
seconds. And thank you for those answers. I yield back.
The Chair. Thank you. Congresswoman Frankel.
Ms. Frankel. Hello, everybody. Thank you to the panel.
I have a couple of questions. Just to follow up, in terms
of registration, I would say probably one of the most
frustrating, confusing parts of trying to get a vaccine, at
least where I am, is for people to sign up for the vaccine.
There has been a lot of different systems. In the early days, a
lot of the systems crashed. The people who don't have computers
were not able to even sign up. If you could just comment on
that. Is that part of your responsibility to try to get these
registration systems up and running well?
Ms. Kertanis. This is Jennifer. I would be happy to share
what is happening in Connecticut. So there are a lot of moving
parts. And we do need a Federal mechanism to monitor and track
vaccine and first dose, and second dose, and allocations and
that sort of thing.
So, I appreciate all of that. But for the recipient, the
end user, we have not taken them into account when we develop
this vaccine administration management system and the need to
register through it. It has been very cumbersome.
In my jurisdiction, in particular, as the rollout started
for beyond first responders to population 75 and older, we had
to abandon that system for them. We still use it, but we had to
engage the people that they are used to working with, their
senior centers, their municipal partners, so they could simply
pick up the phone and make an appointment. And then, we worked
with those agencies to capture the data we needed. But then,
this required a lot of back-end data entry on our part. But it
was a necessity if we were really going to reach those
vulnerable populations.
Many of my colleagues across the country are working on
similar workarounds. Health systems that have electronic
medical records, I think, have an easier way of doing this, but
the majority of local health departments, one, don't have a
mechanism to build for administration of this vaccine and/or to
use those electronic medical records. So it has taken
additional resources, but that is the work that is our
responsibility as we work to get vaccine into peoples' arms.
Ms. Frankel. Thank you for that.
Madam Chair, we don't have anybody I think from the Federal
agency today, but I do think that the situation which I
describe or present to describe is very common, probably across
the country. And I think there needs to be some Federal
response to this.
The Chair. Well, just for one second. Yesterday, we did
with the roundtable, did with Dr. Walensky, Dr. Schuchat, and
Dr. Messonnier in terms of the Federal piece, but you are
right, in terms of pursuing where that needs to go with that.
Ms. Frankel. Yes. But I think just in terms of people
registering for the vaccine [inaudible].
Can I get another? Do I have----
The Chair. Go ahead.
Ms. Frankel. Okay.
On the issue of the disparity in the salaries, could
somebody give me an example of what the public health nurse is
earning versus someone in the private sector, and also, in
terms of benefits?
Ms. Kertanis. Umair can probably speak to this as well,
but, of course, as you well know, it depends on where you live
in this country. In Connecticut, a public health nurse working
in a local health department might make $65,000, $70,000 a
year. It used to be when you worked in the governmental sector,
because I worked at the State governmental level as well, that
we offset those lower salaries by richer benefits. But that has
diminished over time. So, you know, the benefits are not as
rich anymore in the public sector.
A private nurse, you know, working in a hospital or doing
comparable work for a temp agency, probably can make $10,000,
$20,000 a year or more. And I would look to NACCHO, we may have
additional data on this, as many of our members, as I spoke to
earlier, have struggled with this, actually losing their public
health nurses into other agencies.
Ms. Frankel. Thank you.
Dr. Shah. What I have also seen, Congresswoman, is that
epidemiologists, for example, will get recruited by hospitals
to be infection control practitioners, because they see them as
being good as disease control, better sometimes than nurses.
And so, you now have--it is not just nurse going to nurse, it
is an epidemiologist going to a completely different position
that pays higher in that private sector model. So, I think that
is another piece that needs to be looked at.
Ms. Frankel. Thank you. Thank you, Madam Chair.
The Chair. Congresswoman Herrera Beutler.
Ms. Herrera Beutler. Thank you, Madam Chair. And I am going
to ask a similarly more State-specific question of Dr. Shah, as
Mr. Cline kind of did. I recently saw a report in a Columbian
newspaper, which is our biggest paper of record, that showed
that Clark County, the fifth largest county in Washington
State, is being shorted vaccines by the State, which explains a
baffling low vaccine administration rate in Clark. More
specifically, Clark County received 94 doses per 1,000 people;
whereas Spokane County has received 145 doses per 1,000;
Snohomish has received 121 per 1,000; Pierce has received 111
doses per 1,000; and King has received 132 doses per 1,000.
According to public health data analysis of the five
counties with the highest, lowest, and medium population sizes,
Clark ranks 14th out of 15 counties for first-dose allocations.
Honestly, this is just unacceptable. It is absolutely
unacceptable. It clearly shows that the current allocation
metrics that public health is using are not creating equity,
but instead, causing Clark County to have weird lottery-like
system for people who are eligible.
I hear all these people talking about what we are going to
do to convince people to take vaccines. I am, like, wait, wait,
wait, I have got eligible people in 1A population who cannot
get their vaccine.
We have heard repeatedly that this is a supply issue, but
given this revelation, I think it points to a systemic issue
and how the State chooses to allocate the vaccine. And I need
to know what your department is doing to rectify this error,
and why Clark is being shorted vaccines, compared to the other
four largest counties?
I similarly want to put Lewis County on your radar for the
same exact reasons. The older population is not receiving an
adequate amount of vaccine. Lewis, in the last place for
vaccine distribution, but has the highest population of elderly
residents at 21 percent. And all my counties are on I-5, or in
distribution corridors. I just wanted to see if you could speak
to that?
Dr. Shah. Yes. Thank you, Dr. Herrera Beutler--
Congresswoman Herrera Beutler. It is great to see you by
camera. And I hope to see you in person soon. So thank you for
your leadership, and thank you for that question.
The reality is that January 3, we were at 29 percent of
every vaccine that was coming into the State that was being
administered. We are now well over 85, actually, we are at 90-
plus percent right now, although some of that is impacted by
the weather. So it is going to be dancing between that 80, 85,
90 percent for the next several days to a week.
I have seen that article, and I will say that we had
already been reaching out to the jurisdictions where we had
seen decreases, or not as much of the supply even prior to
this. This was actually over the weekend. And Lewis County was
one of those, so I just wanted to make sure you were aware of
that. What one of the real challenges has been that, you know,
as we were starting with 1A, we were going with hospitals and
healthcare systems, and then we were pivoting to those
jurisdictions. And obviously, with community providers and
pharmacies, et cetera, looking at a number of factors including
the pro rata in terms of what was going into those counties,
and data from the providers who were actually asking for the
vaccine, the populations that they were willing and able to
vaccinate, which included the equity piece that you had
referred to, and, then, information on their throughput and
their ability to vaccinate.
The reality is, that when you take all that together, it is
absolutely imperfect when it comes to jurisdictions. And so
what we are now doing is going back to the ones that have the
most--the gap, if you will, and trying to figure out what we
can do.
The other piece is that we have more Pfizer vaccine, so,
okay, let's move Pfizer vaccine there. And then some of the
providers said, we don't have the capability because of the
storage requirements with the Pfizer vaccine. So there are a
lot of these factors that are not excuses, by the way, but
explanations. But what we need to do is to continue to do a
better job of working with the local health jurisdiction,
because I have been at that local level for 17 years. I tell
you, it is something that is key for me. But right now, we have
got a lot of these moving pieces that need to be addressed as
we work with our local partners.
Ms. Herrera Beutler. I appreciate that. And I appreciate
your attention to this.
I understand, one of my challenges has been, as we set up
these mass vaccine sites, which is great--oops. Doggone it. I
just lost you all--there you are. I am trying to, like, click
to my next thing. What we saw was we had providers, we had
small pharmacies who were already set up--my office has helped
them get set up to administer vaccines. And when you set up the
mass sites, those vaccines got pulled from them. And so, yes,
the number went from 30 percent to 80 percent or higher,
because you got the shots in the arm, but in doing [audio
malfunction].
Dr. Shah. I think I lost you.
The Chair. Okay. I think we will----
Dr. Shah. Madam Chair----
The Chair. We can follow up with Congresswoman Herrera
Beutler here. Okay. I can't see her now. Okay, now I can. Let
me move to Congressman Harder. No, I am sorry, Congresswoman
Bustos. I apologize. Congresswoman Bustos.
Mrs. Bustos. Thank you, Madam Chair. I appreciate it.
The Chair. I am sorry.
Mrs. Bustos. No. That is all right. That is all right. You
got it right, and Josh is right, ready to get in there.
I want to share a story, this is just fresh off of a phone
call I had yesterday with the Henderson County Health
Department leadership. Henderson County is a county in my
congressional district in western Illinois. The smallest county
in my district by population, 6,500 people, but it is 400
square miles. And if you do that math real quickly, we are
talking about 17 people per square mile.
Let me tell you a little bit about the challenges that they
have had with the COVID vaccination. They have all of two phone
lines throughout the whole health department where they can
take appointments, that is it. There were no online options,
because it is a rural county; many, many people do not have
broadband.
So, they don't have the infrastructure even to set up an
appointment. So they got a little more money. So now they have
four phone lines, and they have got a total of, for this entire
county, 11 staff. They do have a volunteer corps, where it
seemed like the average age is somewhere around 80 years old of
the volunteer corps. They want to provide mobile vaccine
clinics in the communities, but they don't have the staff to do
it. They don't have the volunteers really who can go out and do
that. And I share that with you as just one story, but really,
something like this is all too common in rural America. And
despite all of Congress' support through COVID relief, we
clearly need to do more and find new ways to support these kind
of communities that are smaller and more rural.
So here is my question, other than mobile units, have you
seen any innovative ideas or best practices in other rural
communities that we can share and help some of the smaller
counties, not just in my congressional district, but all over
the country, where they can stand up more vaccine sites and
make vaccine appointments that are more accessible? If we can
start there, and I welcome anybody to answer that question.
Dr. Shah. Go ahead.
Ms. Kertanis. I would just comment that NACCHO is an
incredible resource for model practices of this type. And, so,
I would ask the NACCHO staff to provide you with whatever they
have learned. Because you are right, these are issues that we
are seeing across local health departments serving our rural
communities. And one of the strengths of NACCHO is really
sharing those best practices so they can be replicated. So, we
will get back to you on that.
Dr. Shah. Yes. And I would, similarly ASTHO has from across
the States, a number of different models that also would be of
use. And our staff at ASTHO can also get that information to
you. Just as an aside, you know, 2 weeks ago, I was able to go
to Spokane on the eastern side of Washington and then down to
the Tri-Cities area, which is southeast Washington, and then to
Yakima, and then coming over the Cascade Mountains back into
the Seattle Olympia area.
And I think you are absolutely right that what is happening
in rural areas and NACCHO represents the vast majority,
Jennifer will attest to, a rural frontier and smaller
jurisdictions that the themes may be similar, but the solutions
and the real how to bring people together have to be very
methodical and intentional. And one thing that I saw was very
successful was the use of the pharmacy partners. Pharmacies
within those smaller jurisdictions still are very good
partners. And they are absolutely able to do appointments and
do all sorts of things.
So, I do think that that is another practice that we should
also be thinking about is how do we look at those partners who
are already on the ground, and really help support them, which
is was obviously the role of States. But when Jennifer speaks
of what NACCHO and the local health jurisdictions do, that is
absolutely what we have to do is working Federal, State, local,
all throughout the system with our partners.
Mrs. Bustos. And are there other partner organizations that
you have seen specific to the rural areas that we might want to
explore in addition to the pharmacists and the pharmacies?
Dr. Shah. Yeah. So as Dr.--as Congresswoman Herrera Beutler
had brought up at the very end there, is that we are also, you
know, I think the States can also be and as well as locals, be
very intentional about mass vaccination sites because that, I
think, is also helpful in the rural areas.
We also have to be thinking as the news came out this
morning about the J&J vaccine, the Johnson & Johnson vaccine,
because of the one dose. That may also, and this is something
very important for our Federal partners, to give us guidance
on, the best setting and best news, best population to be able
to use that vaccine because it is a one-dose vaccine. And, so,
in rural areas it may make sense that that would be a vaccine
that would be optimized.
So anyway, there are a lot of these issues with ag workers
and those who are migrant farm workers that we have to really
be addressing, as well as the partners that are already in
those areas.
Mrs. Bustos. Very good. Madam Chair, my time is out. I
yield back. Thank you very much.
The Chair. I just want to say, if we can get those
documents from NACCHO and from ASTHO, et cetera, on work in the
rural areas, I think it would be critically important to our
entire, you know--to every member, and what we try to deal with
in terms of best practices. So if you can get that material, we
will get it out far and wide to the not only the subcommittee,
but beyond. Okay.
Mrs. Bustos. Thank you, Madam Chair.
The Chair. Thanks.
Congressman Harder.
Mr. Harder. Thank you, Madam Chair. And thank you so much
to all of our speakers and guests. And thank you for the work
you are doing on the front lines during the public health
crisis and well before.
I have seen in my district our two public health officers
in our two counties that have really gone above and beyond over
the past year. But unfortunately, they have come under a lot of
stress and attacks at the same time. I think this has happened
across the country, many of our local public health officers
have received death threats just because they are doing their
job.
And, of course, we have also spoken about vaccine hesitancy
as well. It strikes me that one of the costs of this pandemic
is a loss of faith in our public health system, at least to
some degree. And, so, I would really love to hear from folks
working on front lines. How do we restore confidence and trust
in our public health system, especially because so much of the
work that you all do at the population level really relies on
that confidence that we really seem to need to do a little bit
of work to shore up and rebuild? So I would love to hear from
anybody if they have ideas about what we could be doing there.
Thank you.
Dr. Shah. I would start by saying thank you for that
question. It really is all of us, including elected officials,
to help us. Federal, State, and local health officials across
the country have been vilified in this process. And whatever
you all can help us do because of the incredible reach you have
in, you know, across the country in your jurisdictions, your
congressional districts, to help support public health
officials in the work that they are doing, I think that is
absolutely critical. We cannot politicize public health. And
unfortunately, that is what has occurred. And that vilification
then leads to exactly what you said. So this is a real concern.
So when I talked about supporting the public health workforce,
that is what I meant. It wasn't just about putting dollars
there, but it is also really truly supporting the frontline
people. They are truly heroes as well, and, unfortunately, we
are not always addressing them in that manner.
Ms. Kertanis. This is Jennifer. I know, as a public health
professional, we watched with, you know, great dismay, the loss
of some of our public health leaders at both the State and
local level, because of the politicization. That is a tough
word.
I can tell you that the one thing that continues to fill my
bucket every day is the partnerships that we have had the
opportunity to build and strengthen through this pandemic,
despite the fact that we are underresourced, we are overworked.
And I am just hoping that through this, and when we get through
this, we will continue to be able to build those partnerships,
be that with our first responders, our emergency managers, our
town officials, our school superintendents, our business
partners. They are recognizing the value and the importance of
the work that we do. We need the support of people like you to
invest in us, to demonstrate the value that you place in public
health. And I think those things can go a long way in moving us
past the victimization of our public health leaders that has
occurred.
Mr. Harder. Thank you.
Dr. Freeman. Congressman Harder, could I also respond to
that question?
Mr. Harder. Go for it.
Dr. Freeman. I think part of restoring confidence, as well
as appropriate messaging in a culturally relevant way, being
sure that we can understand what is being given out to the
citizens, in addition to improving the access to that
messaging. But I think we need to communicate our wins just as
loudly as our failures are being communicated. I think in
public health, we just kind of push forward and we do the work,
and we worry about everything else last. But I think we have to
be dedicating to communicating our wins just as loudly as our
failures are being communicated.
Mr. Harder. Absolutely, thank you.
One other quick question. We have talked a lot about the
challenge of really getting public health workers, especially
in more rural areas like my district, I am very interested in
the role of the U.S. Public Health Service in trying to embed
folks from the CDC. I think that could be an interesting
opportunity here.
Have any of our guests had experience with the public
health service corps? And do you think there are opportunities
there to plug in some of these gaps that we have talked about
today?
Dr. Turner. Yes. Representative Harder, this is Kathy
Turner. We actually have a long, long history in Idaho of
working with the Public Health Service and having career
epidemiology field officers, as well as epidemic intelligence
service officers stationed--assigned to Idaho. It has been--
workforce development is one of my passions, and so, it starts
at the local level, support for these people, because they are
in training, a lot of them are being trained to do something
else.
I think one of the great benefits of the public health
service, and the EIS service in particular, is these folks get
to be stationed in a State or local public health agency. They
may go on to a Federal agency, but they have experience and
they know the experience of the local and State level. And they
can speak to the importance of some of the challenges that we
have been talking about today like, you know, data flow and the
importance of infrastructure.
Mr. Harder. Thank you. I yield back. Thank you, Madam
Chair.
The Chair. Yes. Congresswoman Clark.
Ms. Clark. Thank you so much, Madam Chair. And thank you to
all our panelists and witnesses today for this really important
discussion. There has been so much loss in our country and so
much frustration about the rollout of vaccinations once we have
this incredible product, lifesaving vaccination in hand, how do
we get it into arms quickly and equitably? And, so, as we look
at the role of data and the importance of that to our
infrastructure, I had a question maybe for Drs. Turner and
Bibbs Freeman: The variants that we are seeing, the one
originating from the U.K., I understand, may be the predominant
strain by the end of March.
But it was only last week when Federal officials made
investments to track down and start to identify these emerging
threats. We are months behind other countries in using tools
like sequencing to detect new strains. So, if you could speak a
bit about how does data play a role in monitoring and
controlling the spread of variants? And in the short term as we
prepare for vaccines and booster shots, how can we streamline
and increase the genomic sequencing efforts to track down
variants?
Dr. Turner. This is Dr. Turner. I will start, and let my
colleagues jump in.
So one of the key components that we have already talked
about is contact tracing. So there are sort of clues to whether
or not a variant might be detected, and we are watching for
those clues, the S gene dropouts for instance. And as soon as
we have any inclination that this might end up being a variant
infection, we do overdrive on the contact tracing. And so,
getting travel history, finding out who they were in contact
with, who they might have exposed.
But we need the data in order to get that done, and we have
already had a couple of occasions where it was sort of a
scramble to figure out how to get a hold of the person that we
suspected to have a variant.
Data modernization will assist in us seamlessly exchanging
the data with that healthcare provider who calls us on the
phone and says I think I might have a patient who might have a
variant versus, you know, trying to go to other databases to
find out what this person's phone number is, or what their
address is.
So, that is one of the things that data modernization can
do. Also, we are exchanging data with the CDC. So, you know,
building that infrastructure so that we can share data very
quickly with CDC not only from the lab's perspective, but, also
from the epi perspective, the epidemiology data, so that it can
be brought together to build that picture to help us move
policy forward and move those mitigation measures forward. That
is all about--that is how the data modernization will help. And
I will defer to my colleagues for some additional elucidations.
Ms. Clark. Thank you.
Dr. Freeman. Yes. So variant analysis really does come
back, again, to workforce, unfortunately, at least in a public
health laboratory. While the testing itself is not highly
sophisticated as compared to other things that may occur in our
laboratory currently, the analysis of that data is actually
quite a unique skill. It is a skill set that, in private
industry, commands over six figures for an average
bioinformatician. A lot of public health laboratories cannot
afford to pay that type of salary to a bioinformatician within
the site.
In addition to that, from a data modernization standpoint,
as Dr. Turner indicated, we definitely have needs for upgraded
servers and cloud storage, so that we cannot only store the
data, but we can analyze the data. This data, for lack of a
better term, is huge. It is very large, significantly larger
than what we would normally store or transmit on a daily basis.
Because of that, the servers in the cloud storage is
essential to making sure we can do it in the most efficient
manner possible. Here in Virginia, we begin to establish some
private and public partnerships, so we are trying to leverage
the power of not only the State public health system, but our
educational partners, as well as our private partners in order
to get the amount of sequencing and variant analyses done that
is necessary for good surveillance, so that teams like Dr.
Turner's team can then move forward with their case
investigation and public health measures.
Ms. Clark. Great. Thank you so much for all your work and
your testimony and answers today. Really appreciate it.
I yield back, Madam Chair.
The Chair. Thank you. Thank you very much. We,
unfortunately, don't have time for a second round of questions.
So with that, what I would like to do is just ask Ranking
Member Congressman Cole if he has any observations and closing
comments, and then I will close it out.
Mr. Cole. Thank you very much, Madam Chair.
Just quickly, I want to thank you, again, for having this
hearing. I think it is a really, really important hearing. I
want to thank all of our witnesses and congratulate them on
coordinating their testimony so well, which I know you didn't
plan to do, but you might as well have.
And I--that actually makes our jobs so much easier when we
find such unanimity amongst professionals that we all have a
great deal of respect for. So I was particularly struck by
that, Madam Chair.
And as you know, Madam Chair, we have done this, you know,
as chairman and ranking member on both sides for 6 years now,
and we have always gotten to the same place at the end of the
day, always been able to vote for the final passage of this
bill, regardless of who the chairman happened to be. And while
I know that there will be differences, it is a big bill and we
have, obviously, differences, this is not one of the areas
where we differ. This is one of the areas I think that we can
build common agreement on.
I was struck by that, listening to the questions, again,
and observations from both sides of the aisle. I don't think
there is any doubt that we all believe this is an area that we
need to make a significant and continuous investment in, and I
just pledge to work with you in the weeks and months ahead as
we address the difficult issues in the bills and build on the
areas that we agree on, because I do believe we agree here
broadly and we can find common ground and, honestly, I suspect
we will be able to do the same with our counterparts in the
United States Senate, which, again, we have been able to do six
times in a row.
It isn't just this bill that passed the House, it got
through both Chambers in one form or another, and that couldn't
have happened if we hadn't found agreement with Senator Murray
and Senator Blunt and their colleagues.
So, again, I just end with thanking our witnesses. I
thought this was a very, very productive hearing. We appreciate
you taking the time. We very much appreciate your professional
insights, and take very seriously the common ground that you
have amongst yourself as to where key investments need to be
made.
And as one of our colleagues pointed out, I think it was
Ms. Roybal-Allard, there is a limit that we get to do, but we
may be able, given what has happened, to be a little more
robust in this area than we have been able to be in the past.
And this has been an area where we have tried over several
years to make systemic and systematic investments. And you have
helped us highlight the areas that we ought to be looking at
going forward.
So I thank you all. And again, Madam Chair, I thank you for
this very important hearing, and look forward to working with
you on this very important topic.
I yield back.
The Chair. Thank you so, so much and, again, pledge to work
closely with you in this particular area because, again, I am
struck as you are where the actual--the power of the
presentations and the testimony and the consistency and the
revelations of--sometimes, you can't get witnesses to tell you,
you know, what if--they can lay out the problem, but they can't
give you any solution.
In this instance to all of you, I am so grateful you have
powerfully expressed the difficulties that you are having in
this very critical area, but as important as you provided us
with a roadmap of what we can try to do in order to deal with
this. And I have got, you know, some of the phrases, and I
underlined them in the testimony as well, you know. We don't
have a science problem; we have a resource problem. We have to
deal with, you know, of predictable and sustained funding,
diversity and equity, expanding the public workforce.
Everyone has talked about data modernization and underlying
all of that. And it was smart, strategic, and sustained, and I
will put the emphasis on ``sustained,'' because we have a
tendency, as the ranking member knows, in Washington, you know,
we do it, we do this on an emergency basis, we check the box.
Okay, yeah, we took care of public health infrastructure. That
is not the case.
So that I just wanted to say to you that we are committed,
and you have seen what we have done in the past. We are
committed as you are in your professional lives of doing the
jobs that you do that we cannot go from crisis to complacency
to crisis. That is not what we need to do here and what we have
doing as I--and this has become a favorite phrase of mine--is
the architecture for the future for our Nation's public health
system.
We look forward to talking with all of you, getting your
views, getting your ideas even more so than through your
testimony, but to help us as we try to move forward and make
the investments.
This is the investment that we ought to be making, and the
results of that investment is saving lives.
And, so, I thank you all again. I thank the ranking member.
And with that, let me adjourn the hearing.
Thank you.
Tuesday, March 2, 2021.
HEALTH AND SAFETY PROTECTIONS FOR MEATPACKING, POULTRY, AND
AGRICULTURAL WORKERS
WITNESSES
DEBORAH BERKOWITZ, WORKER SAFETY AND HEALTH PROGRAM DIRECTOR, NATIONAL
EMPLOYMENT LAW PROJECT
DULCE CASTANEDA, FOUNDING MEMBER, CHILDREN OF SMITHFIELD
IRIS FIGUEROA, DIRECTOR OF ECONOMIC AND ENVIRONMENTAL JUSTICE,
FARMWORKER JUSTICE
CARMEN ROTTENBERG, MANAGING DIRECTOR, GROUNDSWELL GROUP
The Chair. This hearing will come to order. As the hearing
is fully virtual, I must address a few housekeeping matters.
For today's meeting, the chair staff designated by the chair
may mute participants' microphones when they are not under
recognition for the purposes of eliminating inadvertent
background noise.
Members are responsible for muting and unmuting themselves.
If I notice that you have not unmuted yourself, I will ask you
if you would like the staff to unmute you. If you indicate
approval by nodding, staff will unmute your microphone.
I remind all members and witnesses that the 5 minute clock
still applies. If there is a technology issue, we will move to
the next member until the issue is resolved, and you will
retain the balance of your time.
You will notice a clock on your screen that will show how
much time is remaining. At 1 minute remaining, the clock will
turn to yellow. At 30 seconds remaining, I will gently tap the
gavel to remind members that their time is almost expired. When
your time has expired, the clock will turn red, and I will
begin to recognize the next member.
In terms of speaking order, we will begin with the chair
and ranking member, then members present at the time the
hearing is called--called to order--will be recognized in order
of seniority, and finally members not present at the time the
hearing is called to order.
Finally, House rules require me to remind you that we have
set up an email address to which members can send anything they
wish to submit in writing at any of our hearings or markups.
That email address has been provided in advance to your staff.
And with that, I want to acknowledge Ranking Member Cole
and all of our colleagues for joining us today.
It has been over a century since Upton Sinclair's novel,
The Jungle exposed the horrifying working conditions in
Chicago's meatpacking industry. And yet, 115 years later, the
conditions for workers within our Nation's meat and poultry
plants, as well as farm workers on the largest corporate farms
still bear many concerning resemblances to those depicted by
Sinclair.
Just as in 1906, workers in these industries toiled away
for hours, crammed virtually shoulder to shoulder in dangerous
processing plants, repetitively cutting and preparing at
treacherously fast speeds the food that we eat.
Federal data shows that America's meatpacking, poultry, and
agricultural industries are among our most dangerous to work
in. A Bureau of Labor Statistics analysis of 2017 data found
that agriculture has some of the highest fatal work injuries
rates of any sector. Meat and poultry workers are injured at
rates on average 50 percent higher than all other workers in
the private sector. And a 2016 Government Accountability Office
report found illness rates are four times higher in the
meatpacking and poultry industry than the other manufacturing
industries. Even more alarming, a CDC analysis of data between
1994 and 2013 found that agriculture has the highest number of
deaths of young workers in any industry.
I formerly the chaired Agriculture Appropriations
Subcommittee, and during that time, I visit many upholstery
processing plants where I witness these conditions firsthand. I
have seen how close these workers are to each other. I have
seen the slime on the floors and the horrifying conditions in
which these people work.
One of our witnesses today, Dulce Castaneda, will share the
horrible experience she and her father endured and some of the
chilling accounts she has heard from those who are forced to
work, and I quote, ``forced to work with blood-soaked masks, as
sweat pour down their faces into the meat they were
preparing.''
Companies like Tyson, Pilgrim's, Cargill, JBS, and
Smithfield are some of the worst offenders. According to a
human rights watch analysis of Federal workplace injury data,
between 2015 and 2018, Tyson Foods ranked fifth out of all
companies. While Pilgrim's Pride, Cargill, JBS, and Smithfield
all ranked within the top 30. This is despite meat and poultry
companies having significantly smaller workforces than other
companies on the list, such as UPS and Walmart.
I have also heard directly from farmworkers about the
egregious conditions they are working under, and, frankly, the
gross negligence of the employers who are forcing them to work
under these conditions. Some workers told me that their hands
bleed from tying plants. Some told them they have choose
between taking their kids to the fields where there are toxics
or pesticide or leaving them home alone. They endure all of
this while barely being able to make ends meet, working twice
as hard to feed their families.
It is unconscionable that the very people we depend on to
help deliver a safe and abundant supply of food are themselves
subject to unacceptably lax safety standards and dangerous work
environments riddled with wholly preventible safety hazards.
Workplace injuries are commonplace in these industries.
Moving machine parts and the tools of the trade such as knives,
saw, hooks, scissors can cause serious cuts, broken bones,
concussions, and amputations. Chemicals used for disinfecting
and storage, like ammonia and liquid nitrogen can lead to
chemical burns, eye and lung injury, and asphyxiation. And the
repetitive forceful motions that workers perform at breakneck
speed can over time cause traumatic and debilitating injuries.
As Upton Sinclair wrote in The Jungle and I quote, ``This
is no fairy tale and no joke.'' Unfortunately, with the advent
of COVID-19, the conditions facing workers in the meat and
poultry plants as well as farmworkers has only grown worse.
According to data from Food and Environment Reporting Network,
to date there have been at least 1,782 COVID-19 outbreaks at
meatpacking and food processing plants and farms to date. At
least almost 88,000 workers have tested positive for COVID-19,
and at least 375 have died.
Many meatpacking and agricultural companies have blatantly
put profits over people, and few are being held to account. A
study of California workers by occupational sector found that
food and agriculture workers have experienced the highest and I
quote, ``excess mortality during the COVID-19 pandemic with a
39 percent increase in mortality compared to past years.''
In other words, as Debbie Berkowitz will explain in more in
her testimony, more workers have died from COVID-19 in meat and
poultry plants from date during the pandemic than died from all
causes in the industry in the past 15 years.
Instead of implementing commonsense social distancing
strategies to prevent the spread of COVID-19, meat, poultry,
and agricultural companies continue to pursue faster production
practices such as accelerated line speeds to protect their
bottom line. Stunningly, during the first few months of the
pandemic, over a dozen poultry plants, including Tyson were
given permission from the USDA in the form of waivers from
existing regulation to actually increase their production line
speeds, making it impossible to move workers further apart.
Tyson then had the audacity to take out a full-page ad in
the Washington Post in April 2020 trumpeting their ineffective
half measures for worker health by placing the highest priority
on the company's meat processing productivity. And I have a
copy of that ad right here, which I will get put into the
record.
The Chair. To add insult to injury, some of these companies
while they say that they are feeding America, they have
recently been exporting more of their products to China while
American consumers have faced shortages. According to data from
the U.S. Department of Agriculture shipments of American pork
to China more than quadrupled since March when the pandemic
began.
The Occupational Safety and Health Administration, OSHA, is
the agency responsible for promoting the health and safety of
these workers. But throughout most of this pandemic, OSHA has
been largely asleep at the while, allowing meatpacking and
agriculture facilities to become deadly COVID-19 hotspots and
failing to hold companies accountable.
Under the leadership of the previous administration, OSHA
waited 6 months to take any action to protect meatpacking and
agricultural workers from the spread of COVID-19. Any action
they did take amounted to nothing more than a light slap on the
wrist to big corporate meat, poultry, and agriculture interest.
In September, OSHA issued two small financial penalties
totaling $29,000 to a Smithfield and a JBS plant. For context,
in 2019 JBS' annual revenue was $51.7 billion. Smithfield's was
$14 billion. The more reason why urgent action is needed for
OSHA to hold these industries accountable, to protect meat,
poultry, and farmworkers.
Fiscal year 2022, what we need to do is to prioritize
additional resources to OSHA to increase inspections on the
ground, to protect workers in the most dangerous workplaces. We
should place emphasis on workplaces where workers are deemed
essential and also face a higher risk of infection, as--such a
slaughterhouses, poultry processing plants, and agricultural
workers.
In the interim, I am working with Chairman Bobby Scott to
secure, $150 million for worker protection activities at the
Department of Labor as part of President Biden's American
Rescue Plan. Of this amount, 75 million will go to OSHA to
support additional enforcement at dangerous workplaces such as
meatpacking plants, poultry processing plants, and farms.
OSHA must issue clear, effective, comprehensive
requirements for employees to guarantee all workers, including
meat, poultry, and farmworkers receive the protection from
COVID-19 that will keep them safe. That should start with
issuing an Emergency Temporary Infectious Disease Standard.
Already, the Biden administration has taken a strong first
step toward protecting our most vulnerable workers with COVID-
19 through its executive order on protecting worker, health,
and safety, which calls on OSHA to quickly decide on whether it
will issue an Emergency Temporary Standard and to revise its
guidance to employees.
From these revisions, it is clear that the administration,
the Biden administration, intends to hold employers including
meat, poultry, and agriculture accountable. I was pleased to
see stronger language communicating that employers should
implement prevention programs to reduce COVID-19 transmission.
Specifically, the guidance calls on employers to increase
quote, ``physical space between workers at the worksite to at
least 6 feet.'' This may require modifying the workspace or
slowing production lines.
So for its offenders such as Tyson's, Pilgrim's, Cargill,
JBS, and Smithfield should be on notice. I expect OSHA to hold
you accountable to protect your workers from unsafe conditions.
The country, including this subcommittee will be watching,
and we will not overlook these companies' track records, many
of which include guilty pleas related to violating the Foreign
Corrupt Practices Act and price fixing.
Finally, and very quickly, I would like to shine the light
on the obscure but harmful rider that has been included in the
Labor H. Appropriations bill since 1977. The rider prohibits
OSHA from conducting standard workplace health and safety
inspection an enforcement on small farms. This means a worker
could die on the job, and OSHA would be prohibited from
conducting an onsite investigation. There is no reason to
continue to carry this rider at a time when farmworker safety
has never been more important. OSHA must be able to protect
workers at all farms.
Some might say this rider merely follows a precedent sent
by agricultural exemptions in other Federal labor laws. The
argument is even more pernicious. Agricultural exemptions and
new deal worker protection laws were included as compromises to
secure the votes of southern lawmakers who opposed expanding
labor rights for Black farmworkers and sharecroppers.
Since becoming chair of the Labor H. Subcommittee, I have
fought to remove this rider, and I am going to work with my
colleagues across the aisle to join me in examining the
implications that this language has on worker health and safety
and racial equity.
We cannot continue unfair, unjust language just because it
is what we have done in the past. And with that, I would like
to yield to the ranking member of the subcommittee Congressman
Cole for opening remarks.
Mr. Cole. Thank you very much, Madam Chair. Thank you. I
appreciate you holding this hearing, and I look forward to
learning from your considerable expertise in this area, given
your previous service on the Ag Subcommittee of the full
Appropriations Committee. And, of course, I want to express my
appreciation to all of our witnesses for being here today.
Obviously, COVID has been a tremendous challenge for our
Nation and the entire world. The disease is highly
transmissible and has shown it can quickly threaten lives,
seriously strain our economy. As we are discussing today, it
presents new challenges to the production and distribution of
food and essential supplies.
Like most sectors of the economy and our society at large,
food producers and their workers were forced to adapt quickly
to changing circumstances. An evolving understanding of the
virus, developing guidance from the medical community, and
early shortages of personal protective equipment were among the
challenges that they faced.
Producers had to take innovative steps to protect their
workers. The effective protection of workers' health and safety
is critical job one. Employers are concerned about the welfare
of their workforces and their workers and value the fact that
each is someone's mother, son, sister or spouse. And,
certainly, we on our side of this have a special responsibility
to see that those workers are taken care of. We are all
partners together in the workplace and often neighbors within
single tight-knit communities.
A safe workforce also helps to meet the Nation's imperative
goal to maintain a safe and accessible food supply. As we all
saw and probably experienced firsthand empty shelves during an
uncertain times, such as a frightening pandemic caused panic
and hoarding only worsening the situation. And certainly all of
us are grateful to those in the food production industry who
stepped up to the challenge and made sure that our temporary
inconvenience never became a crisis.
The production of meat and poultry products also depends on
tight schedules, adjusting time delivery systems from farm to
market. Disruptions at any point in the chain can compound a
problem, wasting food and sometimes forcing destruction of
thousands of animals resulting in economic and environmental
disasters.
Along the way, our country has learned much as we faced our
first serious pandemic in generation. With helpful science-
based guidance from the Centers for Disease Control and
Prevention and the Occupational Safety and Health
Administration, we saw processors and workers take adaptive
steps through administrative and engineering controls to
maintain a safe work environment. Adjustments to shifts,
processing line configurations, cleaning, and facial coverings,
for example. Even guidance on committee practices were commonly
provided.
Congress has also played a part. Emergency funds relevant
to today's topic were provided to the U.S. Department of
Agriculture, the Department of Labor Health and Human Services,
the Centers for Disease Control, and directly to the States to
help in the cause.
Obviously challenges remain, and the virus is still
prevalent, and concerning new variants have emerged. I know we
are all hopeful that with continued vigilant sound practices
and mass vaccination under way, we will further mitigate the
threat.
There were indeed serious problems and deficiencies in some
locations in the meat and poultry processing business, as we
will hear more about shortly. Wherever worker safety and health
are jeopardized, it must serve as a wake-up call and demand
swift response and correction.
However, I think we can be proud as a Nation as a whole of
the dedication and ingenuity of the workers and the industry
itself and the regulatory agencies in helping us meet food
demand under unprecedented circumstances in a safe and
responsible manner.
Thank you again to all our witnesses today. And to you,
Madam Chairman, I look forward to hearing the testimonies on
this important topic.
The Chair. I thank the ranking member. If I now may, I
would like to--delighted to welcome our witnesses this morning.
Deborah Berkowitz, Worker Safety and Health Program director
with the National Employment Law Project. Dulce Castaneda,
founding member of Children of Smithfield. Iris Figueroa,
director of Economic and Environmental Justice, Farm Worker
Justice. And Carmen Rottenberg, the managing director,
Groundswell Group.
Let me remind witnesses that the entirety of your testimony
will be entered into the record. And with that, Ms. Berkowitz,
you are recognized for 5 minutes.
Ms. Berkowitz. Good morning, and happy birthday, Chairwoman
DeLauro----
The Chair. Thank you.
Ms. Berkowitz [continuing]. And Ranking Member Cole, and
members of the subcommittee, I am grateful for the opportunity
to testify today. I am the Worker Safety and Health Program
director at the National Employment Law Project. NELP is a
nonprofit research and advocacy organization that for more than
50 years has sought to strengthen protections and lift labor
standards for workers in low-wage industries.
We have known from the beginning of the pandemic that
workplace exposures to COVID-19 could be and are a significant
driver of the pandemic. To mitigate the spread of COVID-19 to
the public, we must also mitigate the spread in the workplace.
COVID-19 began spreading in meat and poultry plants right
from the beginning of the pandemic. Yet as supermarkets
restructured and as factories nationwide retooled to protect
workers, workers in meat and poultry plants were still required
to work elbow to elbow, shoulder to shoulder. They were crowded
together as they clocked in on the production lines, in locker
rooms, in bathrooms, and in break rooms.
While the entire country was told to practice social
distancing, the CEO of Smithfield announced that social
distancing is a nicety that makes sense only for people with
laptops. Instead of implementing the basic CDC guidance for
social distancing, the industry hung flimsy plastic sheeting on
the sides of workers where they were crowded together. CDC told
the industry there is no evidence these work, and they had to
be used in addition to keeping workers 6 feet apart. That was
ignored.
Instead of assuring that sick and exposed workers were
quarantined, the industry incentivized and intimidated sick
workers to come back to work with a bonus that only they could
get if they did not miss a day of work in a month or three
months. So this was not a hero's bonus for hours worked.
Workers also learned getting adequate math or the ability
to work their hands a couple of times a day. The result of that
in hundreds of millions of meat and poultry plants around the
country, tens of thousands of workers were infected, and many
workers were hospitalized and died.
The meat industry framed their choice, their actions as a
choice. They could even feed America, or they could protect
workers. This is a false choice. The industry can and must do
both, and we as a society must hold them accountable when they
fail to do both.
The overwhelming majority of meat and poultry workers are
Black, LatinX, and immigrant workers. These workers were also
disproportionately impacted by COVID-19. The CDC estimates that
87 percent of all infections in the meat industry occurred
among racial and ethnic minorities.
Meat and poultry plants were among the harshest and the
most dangerous working environments in U.S. manufacturing even
before the pandemic hit. With injury rates running twice as
high as the national average. So it was that much more
devastating when COVID-19 hit the industry.
The National Academy of Sciences published a study finding
that in just the first few months of the pandemic, the
unmitigated spread of COVID-19 in meat and poultry plants was
associated with between 236,000 and 310,000 COVID cases and
4,300 to 5,200 deaths just as of July 1.
The industry has been successful at hiding the full extent
of its COVID outbreak. They have not published their data. And
many big meat and poultry States are not making any of the
plants infection or desk data available. So even with the
limited data we know, just from, you know, less than half the
States, we know that more meatpacking poultry workers died of
COVID-19 in the 12 months of the pandemic than died from all
work-related causes in the last 15 years.
We know how to mitigate the spread of COVID-19 in our
workplaces. This is not rocket science. And the failure of this
industry and the billion-dollar companies that dominate the
industry shows an absolute reckless disregard for the lives of
workers.
To make things worse, the agency in charge of ensuring
worker safety, OSHA, advocated all responsibility under the
last administration. OSHA failed to issue any COVID-19-related
requirements that companies would have to implement, and they
decided to stop almost all enforcement.
Thirteen thousand COVID complaints were filed with Federal
OSHA, and the agency closed almost every single one of them
without an inspection. In many of these workplaces, outbreaks
had followed these complaints. Had OSHA stepped into these
plants and done its job, the spread of COVID-19 would have been
mitigated.
It is important to understand that when OSHA fails, workers
are on their own. When a worker files a complaint and OSHA
decides not to inspect, workers don't have the right to go into
court and sue the company to enforce their OSHA rights.
OSHA is not only the government agency whose actions
jeopardized the lives and health of packing house workers in
this pandemic. The USDA, including the Food Safety and
Inspection Service also intervened, repeatedly, to ensure that
the meatpacking industry could place profits for a few over
workers' health.
But it is a new day in the government. On the first full
day of the Biden-Harris administration, the President issued a
new executive order to protect worker health and safety. OSHA
must follow the President's directive, and they must issue a
comprehensive Emergency Temporary Stand and start enforcement.
It is not inevitable that those who harvest and produce our
food must also be subjected to risk to their health and safety.
We can choose to change this. Thank you.
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The Chair. Thank you. And, now, Dulce Castaneda, you are
recognized for 5 minutes. And so, go for it.
Ms. Castaneda. Chair DeLauro and members of the
subcommittee, thank you for having this hearing and for the
opportunity to testify today. I come before you as the proud
daughter of a meatpacking plant worker and immigrant parents to
share the appalling working conditions which I and many others
have witnessed.
I come from a small rural community of 7,000 people in
Crete, Nebraska. My father has worked at Smithfield Foods in
Crete for a quarter of a century, and I know of no greater
loyalty and commitment than that of his and his colleagues to
keep food on everyone's table. My father enjoys his job. He is
a model employee and takes pride in his work.
But over the last year, I and some close friends heard from
our parents who have worked in these plants for decades that
they had no personal protective equipment and were not being
told when they had been exposed to COVID-19.
It came as no surprise that COVID would ravage meatpacking
plants as workers have always worked shoulder to shoulder, and
common areas are small and congested. Ventilation systems are
old and outdated, and toilet paper and soap are always in short
supply in the restrooms. However, in the year 2020, as we heard
companies like Tyson, JBS, and Smithfield pride themselves in
feeding America and feeding the world, we witnessed continued
blatant disregard for the lives of frontline workers who make
that happen.
Accordingly, our parents were too scared to speak out. They
were afraid they would lose their jobs, their source of income,
and their health insurance all in the middle of a pandemic.
Instead, we, their children, organized and spoke out on their
behalf. We called ourselves the Children of Smithfield.
And while you should be hearing what I am sharing from
workers directly, we must recognize that the largely immigrant
and refugee workforce making up this industry often experiences
language barriers, has less access to technology, has fears
about legal status, and cannot leave work in the middle of a
day to attend a public hearing, not to mention the retaliation
they would likely face from their employer.
That is why I am so honored and humbled to come before you
representing worker families to share the raw, honest truth of
what so many have experienced this year.
Let's rewind to April of last year when my father told me
the company had given him and his colleagues hairnets
attempting to pass them off as PPE. If its use had not meant
endangering the lives of workers like my father, it would have
been laughable. Later when workers were issued disposable face
masks, we heard chilling accounts from workers saying they had
to work with blood-soaked masks because they were not replaced
after becoming soiled with blood from animal meat.
In addition, when Smithfield failed to conduct contact
tracing, workers had to turn to each other. But when H.R.
Representatives got word that workers were conducting their own
tracing, they ordered workers not to disclose their test
results to one another. To make matters worse, in May,
Nebraska's governor ordered public health departments to
withhold data regarding COVID cases at plants.
But on top of the lack of PPE and transparency, many
workers have been forced to go to work even while sick. In
fact, they were incentivized to do so. Companies like
Smithfield offered their employees what they called a
responsibility program. And during this time, OSHA was absent
while workers suffered.
In late May of last year, at least 139 Crete Smithfield
workers had tested positive for COVID. I filed an OSHA
complaint and received a call from an official who told me that
OSHA did not see a reason to inspect the plant, because
according to the information that Smithfield had provided, the
company was doing everything possible to contain the virus. He
said that workers should be washing their hands constantly and
sanitizing often. While completely ignoring the fact that
workers are often denied bathroom breaks and have limited time
during breaks to remove and put on their work gear, use the
restroom, eat, and use that time to actually rest. Instead,
they are expected to work like machines. The OSHA official
instructed me to tell my father to quote, ``wear his mask and
keep his distance,'' end quote.
As you can see, the agency effectively ignored my complaint
without conducting an inspection or talking to workers. It is
unfathomable that our communities have lost members because of
corporate negligence, and yet many of the horrifying conditions
you heard us mention remain true today. So many of our loved
ones have been deemed essential, yet treated as expendable.
So today my only request is that moving forward you
consider the safety of American workers and ensure that each
day when they clock into work, whether that is for an early 5
a.m. shift, as I watched my father do for my entire 27 years of
life, or a late night 11 p.m. shift, they walk into a place of
work that is safe and uphold human dignity.
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The Chair. Thank you. Thank you, very, very much, Dulce.
I would now like to introduce Iris Figueroa, director of
Economic and Environmental Justice of Farmworker Justice.
Ms. Figueroa. Thank you, Chairwoman DeLauro, Ranking Member
Cole, and members of the subcommittee. Thank you so much for
the opportunity to testify about health and safety protections
for agricultural workers. The approximately 2.4 million people
who labor on this country's farms and ranches.
My name is Iris Figueroa, and I am the director of Economic
and Environmental Justice at Farmworker Justice. Farmworker
Justice is a national advocacy organization that seeks to
improve farmworkers living and working conditions.
We urge the subcommittee to prioritize the health and
safety of farmworkers and their families, by providing the
necessary resources to respond to the COVID-19 pandemic
disproportionate impact, as well as the high rate of
occupational injury, illnesses, and deaths among our
agricultural workers that already predated the COVID crisis.
COVID has had a devastating impact on farmworkers. A Purdue
University tracker estimates that almost 500,000 agricultural
workers have contracted COVID thus far. The study that
Chairwoman DeLauro cited found not only that food and
agriculture workers have experienced the highest excess
mortality in the pandemic compared to other workers, but that
increase was even higher, 20 percent higher for Latinos who did
agriculture workload.
Although, the data we have as well as multiple media
reports and accounts from workers themselves are alarming, we
are still likely underestimating the full impact of the
pandemic. For example, farmworkers have reported that they were
hesitant to be tested or to disclose a positive result because
they cannot afford to miss work or risk losing their job.
The majority of farmworkers are Latino immigrants. Many of
whom are undocumented. Few farmworkers receive health insurance
or sick leave from their employer. They also face numerous
challenges accepting healthcare. At the same time, farmworkers
face multiple other occupational safety and health risks, such
as pesticide exposure and heat stress. These stresses can in
turn lead to chronic health conditions. So that there is not
just a risk of contracting the virus but if possibly having
more severe symptoms if they do.
Farmworkers that often work in close proximity to each
other may have limited access to handwashing stations or
sanitation and are transported in shared vehicles. Some
farmworkers, including visa workers program under the H-2A
program, live in employer-controlled housing.
Thus, for farmworkers to remain safe, adequate protections
must be put in place. One of the measures we have been calling
for is the Federal OSHA Emergency Standard for COVID that
includes agricultural workers, including employer-provided
housing and transportation.
Mere guidance has been insufficient. Many farmworkers
continue to report that their employer did not provide them
with basic protections, such as masks, handwashing facilities,
hygenic supplies, or the opportunity to socially distance in
the field or in transportation.
We ask this subcommittee to assure that OSHA has the needed
resources to not just issue but also effectively implement and
enforce a Federal COVID standard. We have also been advocating
for farmworkers to be prioritized for vaccines. However,
vaccination is just one element of the COVID solution. It is
not a substitute for effective workplace protection.
Worker protections against occupational hazards beyond the
current COVID crisis are also needed. Increased funding is
needed for OSHA's development of safety standards, educational
outreach to workers and employers, inspections, and
enforcements.
OSHA needs to take a proactive and committed role in worker
safety and be acceptable to workers on the ground. There are
many organizations who are already trusted partners for
farmworker communities who can aid in this effort.
Another longstanding issue our organization has advocated
for is the removal of the appropriations rider, which
Congresswoman DeLauro referenced, which prohibits inspections
and enforcement of small farms.
Simply put, we believe all farmworkers deserve a safe
workplace, regardless of the size of their employer, their
immigration status, or which State they happen to be in.
Essential workers, including farmworkers have born the
threat of the COVID crisis, which is far from over. This
terrible moment should serve as a call to action to remedy some
of the many longstanding and unfair exclusions of farmworkers
from basic workplace protections.
Farmworkers are proud of their hard work and their role in
feeding this Nation and the world. They should not have to
choose between their job or their health or worse their lives.
It is not hyperbole to state that the need for worker
protection is a matter of life or death. We look forward to
continuing to collaborate with the subcommittee to assure a
food system that treats workers with dignity and respect.
Thank you.
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The Chair. Thank you very much. I am now pleased to
recognize Carmen Rottenberg, managing director of Groundswell
Group. And, Ms. Rottenberg, you are recognized for 5 minutes.
Ms. Rottenberg. Thank you, Chair DeLauro, Ranking Member
Cole, and members of the subcommittee, thank you for the
opportunity to testify today.
My name is Carmen Rottenberg. I am the managing director of
Groundswell Strategy, a consulting firm I founded upon leaving
USDA Food Safety Inspection Service last March after 13 years
of career public service, most recently, having served as
agency administrator.
FSIS is a public regulatory agency responsible for ensuring
the U.S. commercial supply of meat, poultry, and processed egg
products stay wholesome and properly labeled.
From the very early days of this pandemic, I have been able
to witness a meat industry that has been focused on the health
and safety of its workforce while working hard to ensure the
continuity of food production, which is critical to our
national security. And, yet, there is still no wide-scale
effort by the government to vaccinate food and agricultural
workers.
Vaccinating our frontline workers now is the only way to
eliminate the hazard and protect them from COVID-19. The
Federal Government must take the lead in ensuring this happens.
In March, as current and former government health officials
began to warn that the U.S. was moving past the point of
containment of the virus into a posture of mitigation, trade
associations and many individual meat companies reached out
early and often to CDC's National Institute of Occupational
Safety and Health, OSHA staffed at all levels, the Department
of Agriculture, State and local public health departments, and
State departments of agriculture.
The industry used this early informal guidance and began
implementing control, employee health screenings before and
during shifts, education and training to employees on the
importance of staying home if sick, notifying the health
department if they became ill with COVID-19 symptoms, and
constant reminders about the importance of handwashing at work
and at home. All of this was consistent with what our Nation's
public health experts knew about how to mitigate the spread of
coronaviruses and what career scientists and medical
professionals in the Federal Government were advising.
In the early days, there were few experts more relied upon
than Dr. Douglas Trout, the 30-year veteran of NIOSH. His
steadfast availability to stakeholders early in the pandemic is
illustrative of the cooperation and collaboration between
dedicated career public servants and industry that has led to
illness reduction in the meatpacking industry.
In November, MeatingPlace published an interview with Dr.
Trout about the meat industry's response to the pandemic. Here
is what he said, ``We actually, months ago, going back into
early March with providing technical assistance to State and
local health departments, and also to the companies while we
were attempting to develop our guidance. I think they responded
in the appropriate way which is to reach out to local
resources, the guidance which was created with NIOSH and OSHA
as a collaborative document was formally issued on April 25.
But prior to that, we were interacting with the companies and
health depositions with best available knowledge at the time.''
When asked about key weaknesses that he saw in touring
these pork and poultry plants during this pandemic, Dr. Trout
said this, ``I wouldn't call it a weakness because there was no
reason necessarily to have the occupational, safety, and health
controls to prevent person-to-person spread of a virus like
SARS-CoV-2 prior to this epidemic.
As we went out into the field, the data that we gathered
from touring plants, from talking to health departments, from
talking to companies, those are the things that led to the
published guidance from the CDC and OSHA.''
And his guidance for what to do next protect workers?
``I would say continue, rather than more needs to be done.
Right now, we don't have any evidence of other intervention
other than what we have already put in our guidance--need to be
done.''
After spending an estimated $1,500,000,000 on comprehensive
mitigation control measures, we see the success of the meat and
poultry industry COVID-19 response when we look at the
reduction in illness in meatpacking plants over time.
New daily COVID-19 case rates for meat and poultry workers
are nearly 95 percent lower than at the pandemic peak in the
industry in May. Cases rates in the general population are now
more than four times higher than rates from meat and poultry
workers.
The industry's effect with multilayered approach to
protections include temperature checks and healthcare
screenings before and during shifts. Information and education
in multiple languages for workers on safe practices at work, at
home, and in the community, face masks, face shields, and
personal protective equipment, enhance sanitation in break
rooms, lunch rooms, and locker rooms, high-touchpoints, and
other common areas, physical distancing, and physical barriers
between work stations, state of the art air sanitation
ventilation system, on-demand testing, and increased access to
health services.
The updated worker safety guidance issued by OSHA in
January of this year reaffirms the protections the meat
industry implemented. Most of the meatpacking industry has
implemented these measures and more.
This is not a pandemic of the industry's making, but I have
witnessed first hand the investment the meat industry has made
in working towards elimination.
While the meat and poultry industry sustains its commitment
to investing in employee safety, it is time for the Federal
Government to show that same commitment to health and safety by
ensuring immediate vaccinations to the essential frontline
workers who show up every single day so we can eat. Thank you.
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The Chair. Thank you very much, and I thank all of you for
your testimony. We will now proceed to, to questions, and I
will start off, and then we will deal with the 5-minute rounds.
In listening to the meat industry's testimony, you would
think that they were exemplarious for workplace health and
safety, but we have got some recent OSHA complaints that tell
another story. And let me just be quick with this.
November 2020, Georgia meatpacking plant, sick workers are
not isolated. Exposed employees are not checked or quarantined,
and masks are not in use.
December 2020, Mississippi poultry plant. Employers tested
positive for COVID-19 were allowed to return to work without a
negative test result. Employees who tested positive were
allowed back on site after 2 days.
January 2021, West Virginia poultry plant. Concerned
employees were refused testing and temperatures taken after
several co-workers were diagnosed with COVID-19.
Ms. Berkowitz, do you share the meat and poultry industry's
view that their COVID-19 mitigation strategy have been a
success? What is the current state of worker, health, and
safety in these plants around the country?
Ms. Berkowitz. Thank you. The industry's response, I would
just say in one word, has just been disgraceful. You know,
there are still outbreaks happening. You know, thousands and
thousands of workers are still getting sick from ongoing and
new outbreaks in meat and poultry plants. And I just want to
make a point that the data that the industry is citing showing
the declining cases is not their own data. They are relying on
a nonprofit who are trying to collect as much data they can
from newspapers and other sources because most States aren't
reporting this. Most big meatpacking States aren't reporting
any of the data, and the companies aren't reporting any of the
data.
Workers are still crowded together. They are still shoulder
to shoulder, elbow to elbow on production lines. How is that
possible that they are the only industry that seems to think
that they can still sacrifice worker health? Masks are not
adequate. Workers, you know, are--the masks are wet. They are
not being replaced. They still don't have time to wash their
hands more than once in a work shift.
And, you know, they use these plastic barriers on the sides
of workers that they say--that even CDC told them it is not
going to work. Workers lean forward to cut the meat. There are
people in front of them. You know, you get COVID from people
breathing. The breath goes out in front and goes all around. So
no, it has just been really a disgraceful response by the
industry.
The Chair. Let me get another question in if I can Ms.
Berkowitz, and you made reference to aerosol inhalation. The
industry appears to think these plastic barriers, these flimsy
plastic barriers while only requiring quote ``distancing when
feasible is adequate.''
A few weeks ago, physicians, scientists, experts in aerosol
science, occupational industry wrote a letter to the White
House calling for stronger protective measures to prevent COVID
infection. So inhalation, such as higher-quality masks and
better ventilation system. Yesterday, my colleagues and I sent
a letter urging the Biden administration to adopt the
recommendations.
Given what aerosol and occupational illness sciences are
saying about the risk of inhalation, are the plastic barriers
installed by any industry effective? Is the industry's
commitment to quote ``distancing when feasible'' adequate
protection for the workers?
Ms. Berkowitz. Well, we--thank you for your letter, and I
hope this administration listens and hears it, and is reflected
in the new OSHA standard. But, you know, the incredible
outbreaks in the industry the wildfire spread is true positive
that these flimsy plastic barriers between workers do not work
to protect workers. And, you know, with all the new information
about the small aerosolized particles, they clearly don't do
that at all. Remember, they are on sides of most of these
workers who are working shoulder to shoulder, elbow together,
you know, their breaths are out in front of them. It goes all
around. And, you know, it is really a travesty, because what
needs to happen is what CDC said in the middle of March, and
that is we need to do physical distancing and get workers
masks. And what the industry needs to do is spread workers 6
feet apart, and they need to improve and enhance their
ventilation system.
And, you know, they can't not just protect workers and say,
we are not going to do physical distancing. If that is the
case, then they have to find respirators for workers, because
we cannot sacrifice workers, especially Black, Brown, and
immigrant workers to make a profit.
The Chair. Thank you, and I don't have much time left, but
I want Ms. Figueroa--you referenced the rider. And this is
about small farms and agriculture. The Bureau of Labor
Statistics found data that agriculture, along with forestry,
fishing, and hunting have the highest fatal work injury rate at
any sector. RAND also showed robust injury and fatality.
1977, we have had to carry this rider in this bill here.
With the rider in place, do employers have any incentive to
protect their workers? What are the consequences of denying
workers on small farm protections from OSHA?
Ms. Figueroa. Thank you for that. As you said, I believe
the data speaks for itself in terms of what the impact of the
rider has been, knowing that OSHA does not cover them.
Undoubtedly, it covered some employers to figure that they have
little respite or facing consequence for dangerous statistics--
conditions, and so we have seen injuries, we have seen deaths,
everything from poultry machinery livestock. And the bigger
issue as well we have seen repeated incidents at the same
worksite, but because the situation was not remedied, workers
continue to be injured.
The Chair. Thank you. Congressman Cole.
Mr. Cole. Thank you very much. I want to first move to this
area of vaccines that we are talking about. I know in my own
State, in the initial phases of the pandemic, the three
populations I heard about and saw the most were nursing home
populations, frankly, incarcerated populations, and certainly
people working in food processing plants. We had them all over
western Oklahoma, much more higher incidents, much more
difficult circumstances.
In most of the areas, certainly, in our State, but I think
probably this is true, nursing home folks were made a priority
in terms of vaccination, both the workforce and, obviously, the
clientele. We did the same thing, a little bit of public
uproar, but the incarcerated population, obviously, more
exposed. I am, frankly, surprised that we have not seen the
same thing for people working in meat processing plants and
food processing of all kind.
So I will start first with Ms. Rottenberger--Rottenberg,
excuse me, and ask her why in her opinion that is, and then I
would like to move to Ms. Berkowitz, the same question.
Ms. Rottenberg. Thank you for the question. You know,
vaccines have been recommended. CDC came out with
recommendations on how vaccines should be distributed to
certain populations, certain vulnerable populations. And then
States have carried out the vaccination programs in very
disparate ways.
And so, we see media reports on certain States have decided
that anyone over 65 can get the vaccine. Of course, some of the
meat and poultry workers then are able to get the vaccine
through that category. But there has not been a coordinated
uniform effort. And these are frontline workers who work in
critical infrastructure.
You know, it is hard to imagine a workforce more deserving
of this vaccination than the people who put food on our plate.
And they are desperate to get the vaccination. I mean, in
touring these meat and poultry plants, these workers are
desperate, the plant managers are desperate to provide that.
And many of these companies have the ability, they have
hired entire medical teams that can distribute these vaccines
to employees. So why as a country have we not done that.
When we look at CDC guidance, you know, any time there is a
workplace hazard, the first thing to do in the hierarchy of
control is to eliminate the hazard. But that thing eliminates
the hazard. And so I am very troubled that there has not been a
uniform approach. And if anything can come out of this hearing
today could be that we could get workers vaccinated. I think
that that would be an excellent outcome.
Mr. Cole. Thank you. Ms. Berkowitz.
Ms. Berkowitz. Hi, well, you know, we have totally
supported prioritizing vaccines for our essential workers,
especially essential workers in meat and food processing, in
supermarkets, all the heroes that have been out there. And, you
know, I know in my State of Maryland, I see grocery store
workers are now getting it, and that is really super important.
But I also just want to make one point and that is that is
not a substitute right now for implementing safe practices. We
need both. It is going to take a long time for the meat and
poultry industry to vaccinate all of its employees. Remember
Congressman Cole said they have between 50 and 150 percent
turnover in these plants. There is a constant influx of new
workers. So they have a big job to get these essential workers.
We have a big education job, a lot of these workers are,
you know, you know, communities of color that have faced really
disparate impact on their whole healthcare and the history of
it. But I think we have to do both. We have to prioritize
vaccination, and we have to keep workers 6 feet apart, and we
have to make sure these workers are protected, and industries
must implement those----
Mr. Cole. If you think I am suggesting and either/or
approach, I am not. I am just shocked that we did not have that
particular group higher up on the scale for vaccination, given
the critical nature of the work and, frankly, the exposure they
have compared to a lot of other populations.
I don't have a lot of time left, but Ms. Rottenberg, I want
to ask you real quick. You know, you had an interesting set of
data that said this population hit much worse at the beginning
than the average population and much better. Ms. Berkowitz
addressed a little bit about why that may not be completely
accurate data.
So I want to ask you, is that--is there other data we
should be looking at and then any insight you can give us about
that, because it does suggest an improvement over time. I am
just, again, I am wondering about the accuracy of the data.
Ms. Rottenberg. Yeah, I mean, certainly, and in my full
testimony I indicated that it was taken from the Food and
Environmental Reporting Network, the data that I cited. You all
had a wonderful hearing last week on public health
infrastructure, and I think that there is a real question about
how data is collected through the States during this pandemic,
and moving forward how that can be improved. It is true that
FERN is the data source that most folks are pulling from right
now.
But certainly, the meat and poultry industry was an early
industry that--early had really significant impacts from COVID-
19. And there wasn't a lot known about the spread at the time.
We didn't know it could be spreading symptomatically. And so
what was commonplace for dealing with coronavirus didn't work
for this coronavirus.
And so the industry had to work with the public health
partners in order to develop, honestly, the approach it sees
today which is a multilayered approach of physical distancing,
physical barriers, and that is clearly in line with the current
CDC/OSHA guidance.
Mr. Cole. Thank you very much. Thank you, Madam Chair.
The Chair. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. And Ms. Figueroa I would like to raise
an issue that I think really brings shame to this Nation.
Children in agriculture are the only group of children not
protected under our U.S. child labor laws. Agriculture is the
only American industry that permits children as young as 12 to
work with no restrictions on the number of hours they spend in
the fields outside of the school day. The fact is that high
school dropout rates of child farmworkers quadruple the
national average.
According to the CDC'S National Institute for Occupational
Safety and Health, agriculture is the most dangerous industry
in this county for young workers. Children work long hours in
hot temperatures and sharp tools and heavy machinery. They
climb tall ladders, lugging heavy sacks and buckets, risking
serious injury and even fatality.
A recent GAO report found that over 50 percent of all the
work-related child fatalities in the U.S. occur in the
agriculture industry. Since 2001, I have introduced legislation
to bring the age and work hour standards for children in
agriculture up to the standards for children working in all
other industries, and to provide children working in this
industry with greater protection against toxic chemicals.
Amazingly, there has never been any appetite in either
Republican or Democrat run Congresses to fix this unacceptable
double standard in child labor protections, even though I have
amended my bill to address issues that have been raised such as
exempting family farms or age groups and future farmers of
America.
With more children dying or being seriously injured than in
any other industry, Ms. Figueroa, what will it take to make the
protection of the U.S. farmworker children a national priority?
Ms. Figueroa. Thank you for that question and for your
legislation and all your work in this space, which we strongly
support. I think the COVID crisis which is what--the main thing
that brings us here today really should serve, as I said, as a
moment to highlight some of the many exceptions and unique ways
in which agriculture is treated. And child labor is one of
those examples that advocates have been working on for decades.
I think if this crisis does not finally allow folks from
both sides of the aisle to see their reality of farmwork, not
just for children but for adults, I am not sure what will. It
should be a call to action, like I mentioned. And these
children are facing all of these occupational health and safety
risks that I mentioned before, and many times more so because
the impact can be even worse for children.
Ms. Roybal-Allard. It is my understanding that other
developed countries have much stricter child labor laws in
agriculture. How are they able to accomplish getting these
labor protections for children in their agricultural industries
and we cannot?
Ms. Figueroa. So, so, I am not that familiar with some of
the work that has been done in other countries. I know we work
with a child labor coalition that is a partner on these issues,
and they work a lot on those international issues.
But I think at the end of the day, it is a matter of
political wealth really, and an understanding that agriculture
is, in fact, an industry like any other. There is no reason why
workers should be less protected just because of the nature of
the industry.
Ms. Roybal-Allard. Well, I know that one of the arguments
that has always been made was, well, then produce will--the
cost of produce will go up. But it just seems to be with
Americans having no problem paying $5 to $10 for a cup of
coffee, paying a few dollars more in produce to protect the
lives and well-being of children shouldn't be a major problem.
And I yield back my time.
The Chair. Congressman Harris.
Mr. Harris. Thank you very much. And let me, let me follow
up a little bit on what Ranking Member Cole was asking about
with regards to vaccines. Because it is becoming very clear for
the entire COVID crisis that vaccines are actually the way out.
That Operation Warp Speed was tremendously successful in
delivering vaccines in record time. Something never done before
in U.S. history.
And given the data that we have in the last couple of weeks
that it seems that a single shot of Pfizer and Moderna vaccines
are almost as good as two shots, and, hopefully, the FDA the
will revise the EUA to allow that, we could be freeing up 20 or
30 million vaccines in the next month, some of which could go
to these workers. Now, since I [audio malfunction] Have poultry
no [audio malfunction].
The Chair. Andy, you are going in and out.
Mr. Harris. [audio malfunction] Decreasing the output of
the plant, which would result in deep [audio malfunction]. What
is that? [audio malfunction.] to require their workers to be
vaccinated if, if the [audio malfunction.]
Ms. Rottenberg, if you could just tell me where do they
stand with regards to the ability of employers to require the
vaccines, if and when they become available?
Ms. Rottenberg. Congressman Harris, I have to say that your
audio was going in and out. And so I missed a lot of what you
said. In terms of whether the vaccines--I think the last part
of your question is are the vaccines--can the companies make
the vaccines mandatory? I really don't have a basis on which to
answer that.
I know that there are Federal agencies that do regulate
the--you know, what you can require. The meat and poultry
industry, many of the companies that I have talked to are not
mandating the vaccine, but they notice the vast majority of
their workers have an interest in getting the vaccine, and they
know that through surveys that they have conducted.
Mr. Harris. And do you know--because I know the United Food
and Commercial Workers Union is pushing for vaccinations, do
you know if they would agree to mandatory vaccination, of
course, with the usual exceptions for, you know, people who
have religious objections or disability objections?
Ms. Rottenberg. Well, you know, UFCW is not here today with
us, but they did sign on with the meat industry on a letter in
December to the governors, to all of the governors, really
advocating for getting these vaccines to food and agricultural
workers, especially meatpacking employees. So I know UFCW is
very supportive of getting these vaccines to this population.
Mr. Harris. Do you know if, given the data in the last
couple of weeks that a single dose of Pfizer and Moderna may be
just as effective or almost as effective as two doses, have
these companies approached the administration or the Secretary
of HHS to change the EUA to free up tens of millions of doses
that could go to these workers to protect them?
Ms. Rottenberg. Certainly, HHS and FDA are responsible for
making those approvals. I think that the meat and poultry
industry is happy to get any vaccines that they can to
employees. You know, there has not been a widespread effort.
Companies have had to work individually with local health
departments, plant by plant, in order to try to get some
prioritization for their workers, and that is not just true of
the meat and poultry industry. That is true of the produce
industry also. That is true of the retail industry. And so this
sector has just not been given the attention on vaccines.
Of course, mitigations are important. They are going to be
with us for a long time, I think, masking and social distancing
and physical barriers, because there are some people who won't
be able to get the vaccine. But vaccination is the way out of
this, as you indicate.
Mr. Harris. Sure. And I would also suggest that, even with
turnover in these plants, the fact of the matter is that if you
can achieve 70 to 75 percent vaccination rate, you probably
achieve herd immunity in the plant, and you greatly decrease
the risk. So, again, vaccination appears to be the way out of
this, and I would hope that the administration agrees and the
unions agree that getting as many of the food processing
workers vaccinated as possible is the--is really the light at
the end of this tunnel, the one that preserves our ability to
process all the meats we need to do and to keep economies like
the economy in my district going if we don't have to deflock
our poultry population.
Anyway, I yield back, Madam Chair.
The Chair. Thank you.
Congresswoman Lee.
Ms. Lee. Thank you, Madam Chair. Thank you very much to our
witnesses for being here.
Let me just say a couple things. First of all, even before
the pandemic, meatpacking, poultry, and the ag sector have been
very dangerous industries for workers, and the pandemic only
exacerbated these dangerous conditions, and, of course, we know
that the majority of workers are workers of color.
Now, Ms. Rottenberg, let me just ask you in terms of the
industry. We knew early on--Dr. Fauci and our scientists
indicated what mitigation efforts we needed to follow. It is
obvious that because of the deaths and the transmission of the
virus, that evidently the meatpacking industry did not believe
what mitigation efforts would be necessary to put into place
early on.
So I am asking you, in terms of the fact that--it is clear
the data shows that the industries didn't follow the science.
OSHA failed the workers in terms of providing guidance and
oversight. Also, the industry failed to provide proper
protection. Workers don't have a right to sue.
So what protections do workers have? And I will ask, given
that, do they receive hazardous pay?
And, Ms. Berkowitz, I would like for you to respond also.
But let me just hear, what kind of efforts is the industry--has
the industry put in place that allow for workers to be
protected, and if they are not protected by the industry, to
have some recourse based on what we know has taken place?
Ms. Rottenberg. Thank you for the question. It is an
excellent question. You know, when we look back at masks or
face coverings, which are now, as you know and referenced, the
single greatest way to stop the spread of COVID-19----
Ms. Lee. But they were last year also.
Ms. Rottenberg. But last year this time----
Ms. Lee. They were last year.
Ms. Rottenberg. Last year at this time, you had public
health officials saying--telling everyone outside of
healthcare, do not buy masks. Masks are not effective. They
said, you know, stay safe by washing your hands, covering your
cough, stay home if you are sick.
Now, ultimately, on April 3, when arguably the COVID-19 had
already taken hold in our communities in a way that, you know,
we were somewhat ignorant as a Nation as to how COVID-19 had
taken hold in our communities, because we didn't have the early
testing that we would have needed, and so certainly the country
was behind at that point.
So food processors followed government guidance from the
beginning. They didn't--a year ago, they did not require or
recommend employees wear masks. The same is true at USDA FSIS,
because the government said they were not helpful.
Now, later, we heard public health officials say,
everything we knew about coronaviruses up to that point told us
that people were not likely to spread it when they were
asymptomatic. So science at the time suggested there was not a
high degree of asymptomatic----
Ms. Lee. Okay. I only have a minute left.
That is what the government said, and you all believed the
government.
Ms. Rottenberg. That is right.
Ms. Lee. Ms. Berkowitz. Okay. Okay. We know----
Ms. Rottenberg. That is correct.
Ms. Lee [continuing]. What the government was saying, and
it caused so much death and destruction of workers in this
industry.
Ms. Berkowitz.
Ms. Berkowitz. You know, actually, the history is a little
bit different. First of all, in my testimony, I talk about how
during the Bush administration, which was over a decade ago,
the meat industry was warned that they need to prepare, because
they keep workers so close together and they are so labor
intensive, that they need to prepare if there is some kind of
virus outbreak. And they totally ignored that.
Second of all, by the second week of March, everybody knew
that you had to be 6 feet apart. That was the first guidance
that came out of CDC. The meat industry decided to just keep
workers working closely, you know, shoulder to shoulder, elbow
to elbow. The auto industry was shut down to retool.
Supermarkets, everybody was retooling.
By the end of March, it was clear that asymptomatic spread
was a significant, you know, source of spread of the virus.
And, in fact, CDC, because of that, had recommended that all
exposed workers should, you know, be quarantined because we
know there is asymptomatic spread.
The meat industries lobbied the previous administration and
got CDC to weaken its guidance, which they just reversed right
after the election, that allowed them to bring back exposed
workers. And because of that change, they actually had the CDC
Director--JBS--call the local health department in Greeley,
Colorado, and say, you can--it is okay if they bring back
exposed workers. And the county health department head there
quit over this. But, you know, the industry has known.
And then, of course, everybody was told to be in a mask
during the first week of April. I wrote my first FAQ sheet on
all this, that everybody should be in a mask and 6 feet apart,
and none of that was really followed in the industry.
So thank you, Congresswoman.
Ms. Lee. Okay.
Thank you, Madam Chair. Thank you.
The Chair. Thank you.
Congressman Fleischmann.
Mr. Fleischmann. Thank you, Madam Chair and Ranking Member
Cole, for this hearing. And I want to thank the witnesses as
well.
Of course, our country is trying to move through this
incredibly difficult, arduous COVID situation, and we look and
applaud improvements in all industries in all sectors of our
society as we move forward.
Consistent with that, Ms. Rottenberg, I was pleased that,
on January 29 of this year, OSHA issued updated guidance. We
have heard some testimony here that there needed to be updated
guidance, and they have done that.
That new guidance encourages 6 feet of physical distancing
between workers, but it also recognizes there can be fixed
workstations where workers are not able to remain at least 6
feet away from other people. In that circumstance, OSHA
encourages the use of other control and mitigation measures,
like the installation of transparent shields or other solid
barriers, such as Plexiglas, flexible strip curtains, et
cetera, to separate workers.
My question, ma'am, is: Was it your observation that
companies and plants waited for OSHA and CDC's April 26
guidance or were they taking precautions and implementing
controls well before the guidance was issued?
Ms. Rottenberg. Thank you for the question. Companies
absolutely did not wait until the April 26 guidance was issued.
And, in fact, the April 26 guidance was based on the
mitigations that the plants had implemented.
So when NIOSH and CDC--CDC, NIOSH, and OSHA evaluated the
kinds of interventions and mitigations that establishments had
used, and I sort of ticked those off in my testimony, certainly
there is the utilize the social distancing, physical distancing
where possible.
And I don't know how many folks on the subcommittee have
been to a meatpacking plant, they are busy places. There is a
lot of workers, and certainly we hear a lot about positioning
on the line. But there are, you know, other challenges. Having
to--the time clocks. I was at an establishment a couple of
weeks ago that has installed dozens more time clocks around the
facility to allow distancing, you know, one-way traffic in the
hallways, always wearing masks, utilizing social distance
monitors or safety monitors to ensure that people are following
the rules.
And then, of course, the physical--where physical
distancing can't be maintained, then installing those barriers.
And that is consistent with the CDC and OSHA guidance.
In fact, last week, CDC published a study that was
completed by University of Nebraska Medical Center, in which
they looked at the effects of initiating universal mask
policies and installing physical barriers, and that was done
over the summer. And they found significantly reduced COVID-19
cases in 62 percent of the facilities. And that was over the
summer.
As we have learned more through this process, the meat
industry has implemented additional controls. So I would say
that, you know, proper mask use, social distancing, other
administrative controls really rely on people adhering to the
policies. Where you can put physical barriers in, we know that
this is a multilayered approach that works in the industry. We
have seen a reduction over time--a significant reduction in
illness over time.
I think you are muted.
The Chair. Congressman Fleischmann, can you unmute?
Mr. Fleischmann. Okay, thank you. I did that.
The Chair. Thank you.
Mr. Fleischmann. So sorry. Thank you for that answer.
Ms. Rottenberg, in your testimony, you just alluded to the
industry's multilayered approach taken to COVID-19. Can you
elaborate a little bit more on that approach, especially when
it comes to masks and physical distancing?
And I will say this: I am so pleased to see that we have
seen improvement from the inception moving forward. But, with
that, I will ask you to answer that question.
Ms. Rottenberg. Now I am not unmuted.
Absolutely. So, to begin with, you know, social distancing
doesn't eliminate the hazard. It is a tool that we can use as
an administrative hazard, and the industry has certainly
implemented that physical distancing where it is possible, and
then employed other control measures when, as the CDC calls
about 6 feet of distance is not possible, is not always
possible.
As I mentioned before, there is a lot of movement in the
plant. It is a busy place. This is not unique necessarily to
the meatpacking industry. There are a lot of people in a
building.
And so the approach is consistent with the new OSHA
guidance where, at fixed workstations, where workers are not
able to maintain at least 6 feet from other people, transparent
shields or solid barriers--for example, Plexiglas, flexible
strip curtains--should be installed to separate workers from
other people. That has been the new guidance from January, and
that has been implemented in establishments.
Then, also, utilizing masks, upgrading ventilation systems,
staggering the start-stop times, providing single assigned
seats at lunch and break times, investing in additional clocks,
all of these things are part of the multilayered approach.
Everything--the vast majority of the industry has
implemented these controls.
Mr. Fleischmann. Thank you. I yield back.
The Chair. Congressman Pocan.
Mr. Pocan. Thank you very much, Madam Chair.
I have to say, as an employer of small business, I am
rather disgusted by the greed and guile by a number of these
companies and the actions that we have seen happen, whether it
be Tyson having the managers betting on how many workers would
get COVID, whether it be Ms. Castaneda's testimony about
handing out hair nets as PPE and not replacing bloodied masks,
to so many of the stories. It is really disgusting to watch an
employer treat their employees like the product rather than the
people that are actually earning them the profit.
I guess my question for Ms. Berkowitz--this hasn't been
brought up yet--is around the--the OSHA fines, I think, has
been part of the issue. We know, in 2019, the average fine for
a serious violation was $3,700. Last night--Last Week Tonight
by John Oliver, a comedy show, did a better job of covering
this issue than most probably cable networks, talked about how
JBS in September was fined $15,000 for their lack of COVID-19
safety protocols after six workers died at one of their plants,
yet they made 50 billion in revenue in 2019. That is 0.00003
percent of their profit. One person's funeral was more than
that fine.
And when you look at that issue of the inability of OSHA to
do what they need to do--and we had that company in Wisconsin
too where they gave them a letter instead of any kind of a
fine. Can you talk about that, Ms. Berkowitz, the problem with
OSHA and the fines that they have done on this?
Ms. Berkowitz. Oh, yeah. Thank you very much for this
question. You know, I am a big believer in OSHA. I have worked
there for 6 years. And I know that, you know, OSHA inspections
can make a difference. They can save lives.
And, you know, even Ronald Reagan, that ran on a platform
of limited government, the largest fines that he issued in his
administration were to the meatpacking industry, because he
knew that you have to go after bad actors and you have to send
a message. You know, OSHA is a small agency. It would take them
162 years to get into every workplace once.
So what happened in this pandemic, instead of OSHA doing
its job and its mission and going after industries that were
not following the basic CDC guidance for business on their
website, right at the beginning, of masks and 6 feet apart, and
making sure that sick workers were taken out of the workplace,
and that--instead of, you know, doing inspections, OSHA just
went AWOL.
You know, the last administration said, we are not going to
issue any specific requirements, and we are not going to do
enforcement. And workers filed complaints and never got
inspections. They just--you know, the industry just said, okay,
we will do what we can.
And, you know, I think if you talk to the workers at
Smithfield in South Dakota, where a thousand--over a thousand
workers were sick, and JBS in Greeley, Colorado, where so many
workers died--and workers died also in Smithfield from COVID.
You know, the fact that OSHA gave them what was like the lowest
fine they could have for a serious violation, the maximum,
$15,000, for all these workers' deaths, was worse than a slap
on the wrist.
They felt that it was worse than issuing no fine, because
it green-lighted to the industry that there are no consequences
for you for not implementing safe conditions. And that--it was
a real travesty, which is why it is a new day, and we really
have to get OSHA sort of back out there----
Mr. Pocan. Thank you.
Ms. Berkowitz [continuing]. And get back out there
enforcing.
Mr. Pocan. Well, I appreciate it. Thank you.
Ms. Rottenberg, I know you are now with the Groundswell
Group. I know you represent--or your company represents Jaguar
and Maserati. Do you represent any food companies, specifically
meat industry companies, with your firm?
Ms. Rottenberg. So, actually, as I indicated on my truth in
testimony form, in terms of the companies that I represent that
would have an interest in today's hearing, it includes Holland
& Knight on behalf of Smithfield. I serve in an advisory
capacity on NatureSweet and Bell & Evans.
Mr. Pocan. That is good enough. Thank you. I think I won't
ask you the next question because, honestly, I don't know if
you will be the best person to answer given where your paycheck
comes from.
So let me go back to Mrs. Berkowitz. I have a question. You
started to talk about the low number of inspectors. We are at a
45-year low, which is why it would take, as you said, 165 years
to inspect every workplace. But, also, there is a weird OSHA
minimal accountability about companies don't need to report
injuries if it is at a first-aid level, so many companies have
had first aid on site, kind of as a Band-Aid, no pun intended.
Could you please address that, Ms. Berkowitz?
Ms. Berkowitz. Sure. And the meat industry was actually
cited for turning their first-aid stations into a station that
prevents workers from getting medical care, which--from
doctors, which is when an injury becomes recordable to OSHA, is
when you have to get medical care beyond first aid. And so, you
know, the poultry industry has been very successful with gaming
the system.
Mr. Pocan. Thank you very much.
I yield back, Madam Chair.
The Chair. If I can just make a point before recognizing
Mr. Moolenaar.
JBS that we have been talking about, understand that this
is a Brazilian company that has received from the USDA, the
prior USDA, $100,000,000 in terms of bailout, and yet they have
been in violation of the Foreign Corrupt Practices Act, and
they have entered into a plea agreement with the Department of
Justice, just to talk about who we are dealing with.
Congressman Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair. I appreciate the
chance to be here and hear this important topic.
I wanted to begin with--I appreciate all our witnesses
today, but I wanted to begin with Ms. Rottenberg. And we
started off the hearing kind of talking about The Jungle and
the meatpacking industry. And there has been a lot of talk
about corporations and--and I just wondered, since she
represents some of the firms, I just wondered if she could talk
a little bit about what kinds of resources some of the firms
have put into personal protection equipment. Because I know
early on, you know, it was almost impossible to get N-95 masks,
and I know companies even sent, you know, planes over to get
those kind of masks and protective equipment.
And I also know that there was a lot happening where
employees would ride together in vehicles and, you know, things
passed that way.
So I wondered if she could talk a little bit about that.
Ms. Rottenberg. Thank you for the question, Congressman. I
think you are absolutely right that once the CDC sort of made
an about-face on masks on April 3, there--it was fairly
difficult to obtain masks. In fact, we saw USDA Food Safety and
Inspection Service at that time go out with a directive to its
employees that they would reimburse the employees up to $50 for
making their own masks.
There was a mask shortage, face covering shortage. I am not
talking about anything fancy, but there was a face covering
shortage. And you did have companies that went to extraordinary
measures to fly--in one case, fly to China to get PPE, because
there just was not a way to do that.
I think that the Meat Institute absolutely--and other trade
associations absolutely aided companies in trying to find
supply chain streams for that kind of equipment. But certainly,
the companies worked as quickly as possible to secure masks for
the employees, and then adhere--ensure that employees were
adhering to that mask wearing.
I will say, you know, I have toured the country, to plants
during this pandemic, and I will say that it is really stark
the difference between--you walk into a facility--from the time
that you get to or arrive at the facility and make your way
through, your--you have--your temperature is taken, and you are
going through questionnaires, and you are going to the plant
with masks on, and all the other employees have it, and you see
all of these--this multilayered approach that I have talked
about.
Then I would drive around the community and see that there
is--the community is not masking. And this is not true of all
places in the country, but it is true of some places in the
country, where, when you have the general community surrounding
the establishment that is not employing the kind of mitigations
that we know stop the spread, it makes it very difficult for us
to be able to protect our workers. And by ``us,'' I mean the
United States.
Oh, I think you are muted.
The Chair. John? John, unmute.
Mr. Moolenaar. All right. I got it. Thank you.
You mentioned, you know, the community spread, the spread
in the workforce. I mean, is there statistics or studies or do
you have any data that has shown kind of how--because my sense
is a lot of these protective measures are probably helping
within the workforce, but in the community, maybe some of those
protective measures aren't quite as significant.
Ms. Rottenberg. So the CDC has done a couple of reports
on--specifically on the meatpacking industry, and what they
have found is that it is very difficult--they can't come to a
conclusion about--certainly, the meatpacking industry isn't
creating the coronavirus. There--it is not starting in the
plants. So somehow it is brought into the plant through a human
vector and then spreads.
Now, whether it spreads in the plant or whether it spreads
in the community and the people who work in the plant live in
that community, I think there is a lot that remains to be seen
on that. We don't have enough data yet to know the answer, and
we may never know the answer. The fact probably is that it was
spreading in both places early on before there were mitigation.
Mr. Moolenaar. Okay. Thank you. And then I wondered if you
can just comment on--it seems like the goal should be to get
everyone vaccinated. We have talked about kind of how quickly
that could happen, if maybe there was a higher priority on
this. Obviously, the union that represents the meatpacking, you
know, industry, you know, is the UFCW. And I am wondering, have
they taken a position on this?
And, Madam Chair, as this is answered, maybe we could
figure out if there is a way to have them come and give
testimony on this as well.
The Chair. Yeah. I don't--yeah. I would be more than happy
to have them give testimony on this effort as well, because
they have been trying to protect the workers, and, in fact,
have found it very, very difficult to do. But more than happy
to have that side of the----
Mr. Moolenaar. Okay.
The Chair [continuing]. Coin as well. Sure.
Mr. Moolenaar. Thank you.
The Chair. Thank you. And I would----
Mr. Moolenaar. And I yield back.
The Chair. Congresswoman Clark.
Congresswoman Clark.
Ms. Clark. Thank you. Thank you, Madam Chairwoman. Thank
you for this important conversation today.
I want to go back to the line of questioning started by
Congressman Pocan about OSHA. And to Ms. Berkowitz, can you
tell me--my understanding is that we are at the lowest number
of inspectors since 1975. Is that correct?
Ms. Berkowitz. Yes. That is correct.
Ms. Clark. And with your testimony that OSHA received more
than 13,000 COVID-related complaints from workers about
dangerous workplace conditions, how--at the current staffing
levels, was it your testimony, would take 160 years to inspect
every workplace, clearly a capacity issue?
Ms. Berkowitz. Totally.
Ms. Clark. What can you tell me about the impact on the
last 4 years of OSHA's staffing and inspection, not only on
COVID relief, but how it ties into the changes we have seen in
line speed?
Ms. Berkowitz. Oh, yes, that is a great question. First of
all, I want to say that, during this pandemic last year, you
had two things happening. One is OSHA, that had already been
hollowed out by the previous administration, so 42 percent of
its leadership positions were never filled, they let the
inspector numbers drop to the lowest level. The number of
inspections done during the whole Trump administration was
lower than--I don't know--the last 30 years.
So, you know, that is what, you know, faced OSHA as they
went into the pandemic. And then, of course, they were sort of
shut down by their leader so that they really couldn't do
enforcement.
But also at the same time, you had the United States
Department of Agriculture Food Safety Inspection Service, who,
under the previous administration, did more to decrease worker
safety in meat and poultry than any other government official,
they allowed line speeds to increase in hog slaughter plants,
which are some of the most dangerous industries in our country,
as fast as they want so every worker would work harder and
faster. And during the pandemic, when you need to spread
workers far apart, which means that you have to sort of reduce
production, here they are incentivized to just keep them all,
you know, shoulder to shoulder.
And, also, in April, stunningly, big packing house
company--Tyson's, you know, Wayne Farms--asked for and received
last April permission to violate, you know, current regulations
and increase their line speeds, when we know that poultry
workers were dying from COVID. And, you know, it is because,
you know, they just wanted to increase their profits, when they
should have been moving workers 6 feet apart and trying to
protect them.
I mean, had the industry implemented protections early on
in the pandemic, a lot of these plants, they had to close down
entirely because they had no workers. And, you know, I just
think that, you know, implementing safe practices and getting
the vaccine is now how you are going to prevent this spread in
the poultry industry. It has got to be both.
And you can't still have workers working shoulder to
shoulder and, you know--and most of these line speed increases
are really detrimental. And I hope the new USDA leadership
takes a really hard look at them and prevents any more line
speed increases and rolls back what has already been done.
Ms. Clark. Thank you so much.
I have a question related to Ms. Figueroa. Given the
farmworkers' challenges, such as language barriers or
transportation access or healthcare access in many rural parts
of our country, what do you think this committee can do to
improve the quality of care and access to vaccines for these
workers?
And, also, in--I see my time is short. Also would like to
ask Ms. Rottenberg specific advocacy that she can point to from
the meat industry to get essential workers in our meat
processing plants vaccines. Very interested in specifics.
Thank you, Ms. Figueroa.
Ms. Figueroa. Thank you for your question, and that is
advocacy that we have been doing as well. There is a variety of
factors. As you mentioned, language access is a huge one;
socially appropriate treatment; just the practical access to
healthcare centers. So funding and support for migrant health
centers, which serve a lot of these communities and are trusted
partners on the ground for farmworkers.
Also, to that practical piece, there are solutions like
mobile health units, increased use of telehealth, which
obviously, for vaccines would not work, but for other types of
healthcare and preventative healthcare.
And then there is issues of broadband access that are
broader than this, but make it difficult for workers to even be
able to access the information about where to get the vaccine,
which is why we really need to be bringing it to their
communities instead of just waiting for them to come to it.
Ms. Clark. Thank you so much. I see that I am out of time.
Maybe we will be able to follow up with Ms. Rottenberg on her
advocacy for vaccinations.
Thank you.
The Chair. Congressman Cline.
Mr. Cline. Thank you, Madam Chair. I thank the subcommittee
for having this important hearing on this issue. And as someone
who represents a very rural district, I am so pleased to hear
all the questions from my colleagues about all the different
issues facing farms and farmworkers and farm families. I hope
we can continue this conversation.
In Virginia, in my home State, the poultry industry is the
largest agricultural sector, contributes billions of dollars to
our economy and provides thousands of jobs. It has been
classified within one of the 16 critical infrastructure sectors
in which operational continuity is deemed essential by the
Department of Homeland Security.
And as we saw shifts in our supply chains during the early
days of COVID-19, farmers, essential workers across the
industry stepped up to ensure Americans remained fed and store
shelves were stocked. As a Nation, we owe a debt of gratitude
to all those involved in the food and agriculture industry.
Without their tireless efforts, we could have seen much darker
days at the onset of the pandemic.
The work done by meatpacking, poultry, and other
agricultural workers is vital to the rural communities in my
district, across America. Successful workforce response to
COVID-19 requires government to work with industry in
supporting employees.
And as Ms. Rottenberg shared in her testimony, companies in
this industry have been consistently taking proactive steps to
ensure the safety of their employees to the best of their
ability while standing--while standards were being developed
and further research was being conducted on the virus. As the
response to COVID continues, we need to be focusing on the
dynamic nature, preventative measures, and best practices that
are being updated.
In May of 2020, I toured a poultry processing plant in my
district virtually to see firsthand the lengths that were being
taken to increase the safety of employees and slow the spread
of the virus. And, additionally, many in the industry have
focused on the importance of education regarding the virus,
incentives for best practices, and flexibility for employees.
Many in the industry were taking care to go above safety
standards as they were being rolled out to further protect
their workers, and these practices should be encouraged.
Congress should prioritize funds in relief measures to
ensure that these essential workers who support our critical
supply chains are able to continue to provide food for the
Nation and take care of their own families.
So I want to allow Ms. Rottenberg to respond to the
exchange between Congresswoman Clark and Ms. Berkowitz about
OSHA and about trends within the industry. The most recently
available BLS data shows that the incidence of occupational
injuries and illnesses within the poultry sector slaughter and
processing workforce has fallen by 84 percent over the last 25
years. The most recent data showed that the industry had 3.5
total recordable illness and injury cases per 100 full-time
workers per year.
Comparatively, industries like golf and country clubs had a
rate of 5.2 cases, pet supply stores had a rate of 7.5 cases,
and skiing facilities had a rate of 10.7 cases per 100 full-
time workers per year. So, comparatively, 3.5 per 100 is pretty
low.
Now, while the poultry industry has been safely increasing
line speeds over the past 25 years, their injury and illness
rate has fallen 86 percent and is now at an all-time low,
according to the most recent data from the Department of Labor.
So, Ms. Rottenberg, can you please discuss the industry
trends toward a safe and productive workplace even prior to
COVID-19?
Ms. Rottenberg. Absolutely. Thank you for the question. So
you are right that in late last year, in November, Bureau of
Labor Statistics released data from 2019. So they publish their
data reports a year in arrears. And based on that--you have
cited the poultry data. I would say that for the whole meat and
poultry industry shows a decrease in worker injuries by about
77 percent since 1999. So that is going back a little further,
I think, than you have cited.
But also found that the U.S. meat and poultry packers have
reached a record low of four cases per 100 full-time workers.
And as you indicate, this does follow years of dedicated safety
improvements in plants and a sustained downward trend of
injuries.
Part of this also is implementation. I do know, in your
district, implementation of automation equipment and really
significant capital investments that companies have made. I
have witnessed that firsthand in the 13 years that I was at
USDA's Food Safety and Inspection Service. So appreciate the
question.
Mr. Cline. Absolutely. The automation going on in the
processing facilities, the innovation going on is outstanding.
And I would encourage all my colleagues to tour a facility. If
one is not available in their districts, we could organize a
brief jaunt out to the Shenandoah Valley and tour one in my
district.
Ms. Rottenberg. Absolutely.
Mr. Cline. So, with that, Madam Chair, I yield back.
The Chair. I would like to tell the gentleman that--and it
was a few years ago--I have been to several of the poultry
processing plants in your district and have come to a quite
different conclusion in terms of the safety of the workers and
of the kinds of protection that they really do require,
especially during a pandemic.
Ms. Frankel.
Ms. Frankel. Hello. Thank you, Madam Chair. Let me get my
lighting correct here.
Okay. Well, you know, for those of you who suffer in the
winter from coldness, it is hot here in Florida. So I want to--
I have some questions to Ms. Figueroa really about farmworkers'
life here in Florida, because they often face brutal heat
conditions.
And, if you could, what kind of health consequences could
this have, and how does OSHA need to do--what do they need to
do to mitigate these conditions? That is question number one.
Ms. Figueroa. Thank you so much for that question. And, in
fact, one of the other issues, or one of the broader issues
that our organization and other advocates have been pushing for
is a Federal OSHA standard on heat stress, which we believe is
long overdue. It causes injuries, illness, and even death in
farmworkers, and is completely preventable. And with climate
change, we can only expect that threat to increase. So that is
something that we absolutely need action on.
Ms. Frankel. Thank you for that.
And would you like to comment on how a guaranteed paid
leave policy would help farmworker families and reduce the
spread of COVID-19?
Ms. Figueroa. Tremendously. I mean, that is one of the main
practical barriers. If workers that are already making
extremely low wages know that they are not going to have the
money that they need because of taking sick leave, that is not
the--that is going to be a huge disincentive for them to
actually come forward, be tested, et cetera.
And I have to say, the sick leave provisions that have been
passed in some of the past COVID relief, although it is great
that we have some provisions, they had exceptions based on
employer size that were very problematic for some workers. And,
also, the education and outreach about the availability of sick
leave was virtually nonexistent in farmworker communities, so
workers didn't even know that they might have that right.
Ms. Frankel. Well, you know what? That leads me to my next
question, because here in south Florida, there is a lot of
family owned and small community farms. And what kind of issues
do you see at the smaller farms versus the more industrial
facilities, and how can we address them? I think you just named
one of them.
Ms. Figueroa. Yeah. I mean, I think that COVID and other
issues really see across farm size, which is why we think all
workers should be protected. I think people might have the
mistaken notion that because it is a smaller firm, conditions
might be better, but workers are also more isolated and have,
you know, fewer resources and ability to get together with
other workers and figure out what the situation is. And, of
course, there is also very tangible regulatory prohibitions on
certain protections on small farms, which makes the reality
very dire for them.
Ms. Frankel. And next question. Thank you. What, if
anything, can we do from Congress or in other--if there is
other avenues, to provide a pathway to union membership for our
farmworkers? Excuse me. And how would that--what would that
mean for their health and safety?
Ms. Figueroa. So that is another huge issue that, again, is
broader than COVID. One of those very historical New Deal era
exclusions is that farmworkers are not covered by the NLRA and
in many States are--don't have collective bargaining and union
rights. And so we have seen that some of the best measures by
UFW, by other unions, have been when workers are able to come
together.
So at the Federal and State level, being able to get rid of
some of those barriers to worker organizing is really--building
that worker power is really the number one way that we can help
improve conditions on the ground.
Ms. Frankel. Thank you, Madam Chair. I yield back.
The Chair. Congresswoman Herrera Beutler.
Ms. Herrera Beutler. Hi. Thank you.
Everybody has to be quiet.
I wanted to ask about, you know, kind of a little bit of a
followup to Representative Clark's question about the advocacy
for vaccinations, specifically, obviously, among farmworkers.
You know, my home State of Washington, ag workers are not
eligible for vaccines until Phase 1B, Tier 2, which might not
occur until summer. Like, we will be lucky if we get that by
summer. We are currently in Phase 1B, Tier 1.
Have agricultural workers in other States been prioritized
for vaccines, and how is it working? Can--I do agree--I think
it was Congressman Cole's comments about it doesn't have to be
either/or. How can we facilitate that?
And that is a question to you, Ms. Rottenberg. Thank you.
Ms. Rottenberg. Thank you for the question. It is really
important to both get workers vaccinated in order to eliminate
the hazard, and then also to continue with the mitigations that
we know work, these multilayer mitigations that work.
So in response to Congresswoman Clark's question about the
advocacy, UFCW and the Meat Institute in December, just before
Christmas, they sent a letter to all 50 Governors requesting,
emphasizing that quickly vaccinating the workforce across the
country would maximize health benefits, especially in rural
communities that often have limited health services. It is
just--it is absolutely critical. And so that letter went in
December.
The trade associations have been in regular contact with
governors' offices, their individual advisers and lobbyists,
who have been in--have had conversations with individual
States. Every State is handling it a little bit differently,
but it is the case in many States, the agricultural workers are
in the 1B Phase, except that, as more and more vaccines have
come online, it seems like there are--there are new
modifications being made to who can get into the 1A group.
And so I am just very concerned that we are skipping past
these essential workers. It is the employees that work in the
plant, it is also the employees that work at retail, and the
farmworkers. It is absolutely critical to get these folks
vaccinated. And the companies have the resources to help with
the vaccination.
So there has been a significant amount of advocacy
involved. I personally have been involved with some of it, but
I know that there is much more that has been done in individual
localities from plant managers who are working with their local
health departments, and, honestly, have been since last March.
Ms. Herrera Beutler. Madam Chair, I yield back.
The Chair. Congresswoman Bustos.
Mrs. Bustos. Thank you very much, Madam Chair. I appreciate
it.
I am going to address this question for Ms. Berkowitz. In
your testimony, you noted that some of the lapses in judgment
in leadership at the CDC, the USDA, and OSHA under the Trump
administration. Meat processing facilities didn't seem to have
the guidance they needed to protect workers while maintaining
the food supply chain, and OSHA was noticeably absent when
workers needed them most.
So, Ms. Berkowitz, in your opinion--hold on one second--in
your opinion, what does the Federal Government need to do in
order to prevent something like this from happening again? Is
it better communication? Is it more staffing? Maybe just talk
through what you think should happen so we don't go through
this again.
Ms. Berkowitz. Thank you for that question. So what
happened in this pandemic is, you know, CDC started issuing
guidance, and guidance is voluntary. You can follow it or not.
But what happened right at the beginning of the pandemic, at
the very beginning of March, is OSHA decided not to turn that
guidance to some kind of requirement. They decided not to
issue--Federal OSHA--not to issue any requirements for
employers to implement.
And, second, they then decided that they weren't even going
to use the CDC guidance in enforcement as previous
administrations have done when there has not been, you know, a
standard.
So I think it is imperative that OSHA, within the next 2
weeks, as the President directed, issue emergency temporary
standards that are like the standards issued in Virginia or in
California or Michigan or Oregon and Washington, which have
various emergency standards already in place, that OSHA issue
emergency temporary standards, and that they start working on a
permanent standard so that there will be procedures in place
that companies know they have to follow, and they can't say,
Oh, well, CDC tells me this, but it is just guidance, and I
don't have to follow it.
I mean, I think that, you know, there are many industries
that knew what to do, and they complied--the auto industry,
other industries, or unionized industries, like the
supermarkets, like here where we live in. In Maryland, in D.C.,
the unions made a huge difference in getting the supermarkets
to move people 6 feet apart and to give masks and face shields
and hand sanitizers.
But we need also requirements. And that is why the--you
know, OSHA needs to issue requirements and get them so
employers know legally what they have to do.
Mrs. Bustos. Thank you.
Ms. Castaneda, you have been sitting there very patiently,
and you were kind enough to come here and share the story of
your father and others. Very dramatic. Hair nets used as PPE. I
mean, it is unfathomable. Blood on masks that had to be used
and used again.
You were limited to 5 minutes in your remarks. Just I want
you to, if you can, paint a picture of your father and what he
was facing day in and day out in addition to those graphic
details that you shared with us earlier.
Ms. Castaneda. Absolutely. Thank you for that question. So
as I noted, there were many instances where a lot of our
parents, like I said, many of the members of our group, all of
our parents have worked there for decades, and they have been
nothing but loyal to these companies. They are responsible
employees. They--you know, they are rooted in the community.
And so, yes, their jobs were at stake.
But, you know, some of the things we heard--one of the
parents of one of our members said that she wanted to be
tested, because when one of her coworkers immediately next to
her tested positive, to call and tell her that she had tested
positive, encouraged her to get tested, she went to the HR
department and asked if she could. She was allowed to, but they
told her explicitly not to disclose her test results to anyone
besides the HR department.
And so, you know, you have workers in the situation where
the company is telling them that they can't disclose their test
results to each other, and it--you know, the company themselves
is not telling workers when they have been exposed. And you had
a situation in Nebraska where public health departments could
also not tell workers and give information as to the number of
positive cases in each plant. So just a total lack of
transparency.
In addition to that, a lack of responsibility and
accountability on behalf of the companies. You know, workers
are often given information in language that they cannot
understand. You know, many workers of color, English is not
their first language. It is not their primary language. It is
not even required that they know English to be hired by these
companies. So to give them information in a language that is
inaccessible is appalling and it is irresponsible.
Mrs. Bustos. All right. Thank you, Ms. Castaneda.
And, with that, Madam Chair, I yield back.
The Chair. Thank you.
Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you very much, Madam Chairwoman.
I have a couple of quick questions, I think. Ms. Figueroa,
you may be able to answer this question. What is the definition
of a small farm that is exempt from OSHA? Can anyone answer
that question?
Ms. Figueroa. Yes. So it is less than 11 workers, so 10 or
less workers.
Mrs. Watson Coleman. Thank you.
Ms. Rottenberg, I think you mentioned something about safe
distancing being practiced in the plants, and I was wondering:
At what point during any shift is safe distancing happening if
individuals are working side by side on conveyor belts with
just flimsy screens between them? So exactly when is the safe
distancing accomplished?
Ms. Rottenberg. Thank you for that question. There are
certainly parts of the plant where distancing is possible, and
that is either in the further processing sections of the plant.
In some plants, you have more distance available there.
Certainly, when employees first come into the establishment and
in lunch rooms and things like that, there have been major
reconfigurations in establishments that I have visited.
There are some positions on the line that it is not
possible, given the manufacturing equipment, to separate, and
then you have those physical barriers.
Mrs. Watson Coleman. Is there anything that happens between
shifts to sort of sanitize, clean up, and get ready for the
next shift?
Ms. Rottenberg. Yes. An excellent question.
Mrs. Watson Coleman. Or is that impossible?
Ms. Rottenberg. No, that is an excellent question. And so
there has also been really significant--you know, this is a
highly regulated industry given that it is a--you know, has
food safety inspectors in it every single day from USDA. And so
there are really significant sanitation requirements that
companies have to abide by. This is prepandemic.
But there--in many--many plants will operate two shifts,
and then the third shift is the cleaning shift. But they also
have cohorted employees. Many establishments have cohorted
employees so that you know, you know, who has been working with
each other. And that has evolved over time so, you know, to the
point where we know what measures work.
Mrs. Watson Coleman. Thank you.
Ms. Berkowitz, what has been your observation as to the
improvements in the safety and security provisions at the
plants? Do you see the actual happening of safe distancing and
other measures to make it a safer environment?
Ms. Berkowitz. Thank you for that question. You know, I
talk to workers or their representatives all over the country
from meat and poultry plants. I have spent, like, decades as a
worker safety advocate in this industry. I came out of the
United Food and Commercial Workers Union. I was their health
and safety director.
Workers are crowded together everywhere. They are crowd--I
mean, the biggest parts of the plant are the sort of cold, you
know, processing part as opposed to the kill side. They are
shoulder to shoulder, elbow to elbow, with these flimsy plastic
barriers that the workers hate because they bang into. They
don't protect their breath from going to one another. They are
still crowded in break rooms and locker rooms. And, in fact,
workers just went on a strike in the end of December at a
poultry plant because they were so crowded together in hallways
as well.
Mrs. Watson Coleman. Someone testified to the fact that I
think the USDA had given the poultry industry, I think, a
waiver to make the conveyor belt or the line faster. So if USDA
does that, does then OSHA look at that recommendation and see
if it in any way impacts safety and security in the job? And,
if so, how do they work out what might be a contradiction
between the two agencies?
Ms. Berkowitz. Well, you are exactly right. Under the
previous administration and, you know, my fellow person
testifying led this drive, they decided not to look at worker
safety issues, because they said we can't regulate it. And so
what happened is they issued these waivers under cover of
darkness. Nobody had any input--not the public, not the workers
in the plants, not OSHA--to increase waivers.
And the problem is you have one agency then sort of telling
companies to violate the OSHA law, and that really can't be.
Mrs. Watson Coleman. Thank you. That was my concern.
So in addition to needing more OSHA workers and in addition
to needing more investigations taking place, do we need
different and more legislation to protect workers? And, if so,
what would that involve, Ms. Berkowitz?
And that is the end of my questions.
Ms. Berkowitz. Yes, we definitely need more legislation
directed at the USDA, directed so that there is no more line
speed increases in meat and poultry plants.
Mrs. Watson Coleman. Thank you, Madam Chair. I yield back.
Thank you.
The Chair. Yes.
Congressman Harder.
Mr. Harder. Thank you so much, Madam Chair. And thank you
to all of our witnesses for their testimony today.
I wanted to focus especially on what we have seen happen
among farmworkers. I represent the California Central Valley,
sort of the fruit and nut basket of the world. And, of course,
like everywhere else, we have seen a disproportionate COVID
impact upon our Latino community, and especially among our
farmworkers.
We have done a number of things to try to mitigate that.
Things have gotten a little bit better over the past few
months, but it has still been really heartbreaking to see.
And, Ms. Figueroa, I wanted to ask a little bit. From your
testimony, you talked about some of the things that you think
could be done to improve testing, improve protections among
farmworker populations.
I am curious what areas you have seen the most success.
What locations or which farm areas have really had the best
success in mitigating COVID among farmworkers, and what might
we be able to learn in terms of opportunities to scale those up
on a national level?
Ms. Figueroa. So thank you for that question. And, of
course, you know, COVID has been widespread across the country.
I think California is a good example, because California, being
a major agricultural State, passed some of these protections
that we talked about, like heat stress protections, an
agricultural labor board.
And so that has helped to actually put workers in a much
better position, not to mention an emergency standard that was
also passed in California. So I think the regulations
themselves, the union activities that I mentioned earlier, and
workers' ability to organize, and then in terms of vaccination,
as well as safety, collaboration.
So there was just a New York Times article, just 2 days
ago, I believe, about the Coachella Valley and an initiative
that is taking place to vaccinate workers, where they are
bringing--they are working with growers, with health centers,
with community partners, to bring that to the community so that
workers have the information about the vaccine safety and are
able to access it.
And so those are just some examples of some of the models
that we would like to see across the country. Not to say that
it is all perfect, right? There is still challenges, and we are
still hearing, like I said--and I really want to emphasize,
what we are hearing from workers about not getting basic
equipment or having basic protective measures is not a year ago
or 6 months ago. It is still very much ongoing. This crisis is
not over for these workers.
And I also want to address something that was mentioned
before in terms of workers contracting the virus and that
somehow being disconnected from their workplace. What we have
seen and with the data and the surveys we have seen show is
that workers, when they have the tools and the information,
they do take the safety measures. They wear the masks, they
wash their hands, et cetera. But if they don't have those tools
at their work sites or in their housing or in their
transportation, then they are not able to take those
precautions.
Mr. Harder. Thank you.
One of the other challenges that we have seen here
especially is the implications of lack of paid leave through
farmworkers, and so--and we had a program in Stanislaus and San
Joaquin Counties which offered to essentially help quarantine
workers if they tested positive. And we saw very low uptick of
that program, because folks were very reluctant to actually get
tested because they were afraid they were going to lose their
earnings, especially at the peak of the harvest season.
I am curious if you could talk a little bit about what you
have seen on that and what opportunities you think we might be
able to do to mitigate that impact and the lack of paid leave
for farmworkers today.
Ms. Figueroa. So, first, having sick leave protections
during the pandemic, which I know is something that is part of
the broader discussion about COVID relief.
Second, having adequate outreach to these farmworker
communities in languages and formats that they understand, so
that they understand what their rights are that they can claim.
And, third--and this is a piece we haven't talked about a
lot, but it is such an overarching piece for farmworkers and
low-wage workers in general, which is the fear of retaliation.
And this is a place where OSHA really needs to step up and make
very clear that they are not going to tolerate retaliation
against workers, whether that is in the work site or through
immigration enforcement or both. That is a super strong
deterrent for workers.
So workers want to know what their workplace rights are,
but they also want to know that these governments and State
agencies are going to have their back if they are brave enough
to come forward to claim those rights.
Mr. Harder. Thank you. And I see my time is up, so I will
yield the remainder. Thank you so much for your testimony and
all you are doing.
Over to you, Madam Chair.
The Chair. Thank you.
Congresswoman Lawrence.
Mrs. Lawrence. I want to say good morning and thank each
and every one of you for coming today. In my previous life in
my career as a Federal employee, one of the jobs I had, I was a
safety and health administrator and participated in the OSHA
inspections, training, and also the accountability to
management.
So I want to ask this question to Ms. Berkowitz. One of the
things that I saw in the previous administration was the lack
of staffing at OSHA, and sometimes painfully taking 6 months to
address a deadly issue. Can you talk about the benefit of
staffing and getting people on board so we can have timely
responses to issues as they arise?
Ms. Berkowitz. Thank you. And this is a wonderful question.
OSHA is really underresourced. They haven't had a real increase
in their budget in the last 4 years. And it was already a small
agency, relatively speaking. So, you know, it didn't have the
ability to really carry out its mission.
They really need twice as many inspectors, not only health
and safety inspectors, but also the kind of inspectors that
deal with retaliation complaints, which--they get so much of
it. And they got 1,700 of those just in the first few months of
the pandemic and dismissed like 70 percent of them. They just
had to process them so quickly.
So, I think it is really important that OSHA have the
staffing that the American workers need to assure their
protection, because it is only OSHA. There is no right to sue
under the OSHA law.
Mrs. Lawrence. All right.
One of the other things I wanted to highlight was the
refusal to promptly address dangerous work environments at a
facility which was--which is an affront. Because when employees
say that, ``I feel my life is at risk,'' we are now in a new
administration and one that has a real sensitivity to workplace
environment.
Can you tell me, Ms. Castaneda--am I saying that right--
when you came forward testifying before this committee about
what your father's colleagues experienced--I am so sorry to
hear about it--but how can we as this committee ensure that we
are making OSHA responsive to the cries from the workforce?
Ms. Castaneda. Thank you so much for that question,
Congresswoman. You know, in my quite limited interaction with
the OSHA official, it appeared to me that he had sort of been
instructed to close my complaint and sort of prioritize, you
know, putting out small fires and sort of actually--instead of
actually addressing the issues at hand.
So I think that is a clear indicator that, you know, he
wasn't even aware of some of the statistics or even what the
guidance actually was for these companies. So it wasn't a
priority. I think that is an indicator that, you know, we need
enforceable standards that are consistent across different
plants so that officials can prioritize that.
Mrs. Lawrence. I just want to be on the record today
through my amazing chairwoman who is one year younger and more
beautiful and more intelligent, happy birthday.
But I want to be on the record that OSHA fulfills such an
important role in the workforce. No one should go to work to
die or be injured or to risk their life. You are going to work
to have a livelihood for your family.
And so I just want to pledge my support through
Appropriations and all that I can do in Congress, knowing I
have investigated some situations and workplaces and know the
history of people who have died in the workplace--and why OSHA
was even established.
So I thank you all so much, and I will yield back.
The Chair. Thank you very, very much. And thanks for the
birthday greetings that is to all of you. I know that they have
called the vote, so I--so we will not get to a second round. So
I want to yield to Congressman Cole for some closing remarks,
and then I will make some closing remarks.
Mr. Cole. Well, thank you very much, Madam Chair. First of
all, Madam Chair, I am smart enough to associate myself with
Mrs. Lawrence's remarks about you. And thank you for speaking
eloquently for every member of the entire committee, Mrs.
Lawrence. I appreciate it very much.
But I seriously want to thank you for this hearing. I think
this really is an important topic, and I certainly learned a
lot and enjoyed our witnesses. I want to thank each one of them
for their testimony and their insights and what they brought.
I am troubled, as I suspect all of us are, by the lack of
prioritization for vaccination for this particular workforce. I
am at a loss to understand. Again, just thinking back to the
beginning of the pandemic from my own State where we saw the
worst outbreaks, and this was a group of workers that were very
much subject to that. And we certainly have a lot of the food
processing facilities in a rural state like Oklahoma. I just
assumed that they would be at the top.
I just--and I am embarrassed that I didn't know better. And
I think that is something that we need to think about because
it is interesting both folks looking at it from an industry
standpoint and looking at it from a worker's standpoint at
least in that area have the same opinion. And I think that
would be a good thing for us to work on.
The second thing which we unfortunately didn't get to, but
I know--I know you, Madam Chair, will focus on this going
forward. If Ms. Rottenberg's data is correct, and I assume it
is, I have no reason--we have seen a great improvement here.
What I would worry about is once this pandemic is in the
rearview mirror, would we backslide? In other words, would a
lot of the procedures that have been put in, you know, be
forgotten about? I think that is something we need to think
about going forward. Because--and that is not to say more
doesn't need to be done. I am not suggesting that at all.
But I am suggesting, I don't want to go back to where we
were, to where this particular worker group, you know, was
particularly vulnerable given the work situations that we have.
And I also take with some--I would also say this, there was
a great deal of confusion at the outbreak of this pandemic. I
remember when the CDC was telling all of us not to wear a mask.
And so it takes a while to actually get to where you want to
be. But if indeed we have made progress, we need to figure out
how to institutionalize that progress and make sure that it
is--it is permanent, and in what we can do process-wise going
forward.
But, again, let me just thank our witnesses. I thought all
of you really had valuable things to say. I think that the
committee benefitted from your respective points of view and
insights.
And, Madam Chair, I want to thank you again. I thought this
was a very important topic for us to discuss, and I appreciate
you putting it front and center for this committee to consider.
And with that, I yield back.
The Chair. Thank you very, very much. I want to thank the
ranking member. I want to thank all of our witnesses for your
testimony.
I think it is important to note and--well, first of all,
what I would like to do is to put into the record--unanimous
consent put into the record a Washington Post article that
says, more than 200 meat plant workers in the U.S. have died of
COVID-19. Federal regulators just issued two modest fines. And
an OSHA severe injury data from 29 States, 27 workers a day
suffer amputation or hospitalization. Poultry processing among
most dangerous industries.
[The information follows:]
******** COMMITTEE INSERT ********
The Chair. And this is a fact prior to a pandemic and has
been said here that COVID-19 exacerbated the conditions in a
pretty incredible way. So even before the pandemic, we had
meatpacking poultry and agriculture were dangerous industries
for workers.
I also want to mention this, and this has to do with
Congresswoman Roybal-Allard, we requested a GAO report which we
received in 2018, a report confirming that in agriculture labor
where children as young as 12 years old can be found working in
the fields, substantial health impacts on minors, as well as
the highest rate of work-related deaths out of all industries
in which children are allowed to work. Something that we ought
to take up as well, and that is in terms of workplace safety
and OSHA and its ability to go on these small, small farms.
Let me just mention two or three things here. More workers
have died from COVID-19 in meat and poultry plants to date
during the pandemic than died from all causes in the industry
in the past 15 years.
Tyson's hog producing plant in Waterloo, Iowa, which
produced pork for China, 1,500 workers sick. The managers had a
callous betting pool on how many workers would get infected.
Plants were shut down, yes, but that didn't have to do with
safety precautions, it mostly had to do where they didn't have
the workers because the workers were ill.
The meat companies are denying workman's compensation cases
for sick workers with medical bills and help to families whose
loved ones have died. The USDA did provide in the past
administration to--waivers from existing regulations increasing
the production of line space.
And I just realized very, very quickly, Ms. Rottenberg,
were you at FSIS when the line speeds were increased?
Ms. Rottenberg. So the modernization of poultry happened in
the Obama administration in 2012. The rule was finalized, but
there was----
The Chair. But you were there----
Ms. Rottenberg [continuing]. I was not administrator.
The Chair [continuing]. And leading the charge on--well,
actually, I will answer my own question because I know the
answer to the question, is that you were whether when we did
increase the line speeds there.
And I might add that with USDA, which flew in face of CDC's
recommendations to industry, said CDC in fact at--with pressure
both from the Vice President and through Director Redfield,
they weakened the guidance on the meat industry, if one could
imagine during this period of time.
I am going to finish up with something that may be viewed
as self-serving, but I am going to do it anyway. In a book that
I wrote in 2017 called, The Least Among Us: Waging the Battle
for the Vulnerable, I wrote, and this is a quote, ``It bears
repeating that the reason companies do not feel free to poison
us, sell us spoiled meat, lock our daughters up in ninth floor
sweatshops with no fire escapes, employ our underaged sons in
coal mines, force us to work 13-hour shifts without overtime or
a break, or call in private armies to fire rifles at those who
dare strike for higher wages. It is not because companies
experience a moment of zen and decided to evolve, no. They were
forced into greater accountability and social concern by the
legitimate actions of a democratic government''--and that is
small ``D''--''a democratic government.'' In other words, if we
depend on good will, we will all be screwed.
Those words continue to ring true today as I reflect on the
lessens that we have learned during this hearing. Even before
the pandemic, meatpacking, poultry, and agriculture were
dangerous industries. The pandemic exacerbated the occupational
hazards which are disproportionate felt by workers of color.
OSHA's mission, OSHA's mission to promote the health and
safety of workers included--including from COVID-19, but during
the pandemic under the previous administration, OSHA was asleep
at the wheel, which is why urgent action is needed by OSHA to
hold these industries accountable to protect meat, poultry, and
farmworkers from COVID-19.
Again--and I believe that the vaccines are critical and
important, but that is we have some problems that have existed
before that continue to exist. And, yes, we should prioritize
essential workers with vaccines.
So we have some good suggestions from our witnesses today--
provide OSHA with sufficient funding to increase health and
safety inspectors and expand enforcement, to protect workers.
Urge OSHA to develop and adequately enforce a COVID-19-
related Emergency Temporary Standard, including requirements to
limit airborne transmission in meat and poultry plants, robust
protections for agricultural workers, increase support for and
improve oversight over OSHA's whistleblower and State programs,
remove the harmful appropriations rider, limiting inspections
and enforcement on small farms.
And let me just conclude with this quote and that comes
from Ms. Castaneda, ``So today, my only request is that when
you consider the safety of American workers and ensure that
each day when they clock into work whether that is for an early
5 a.m. Shift, as I have watched my father do for my entire 27
years of life, or a late night 11 p.m. Shift, they walk into a
place of work that is safe and upholds human dignity.''
That is what our legal and moral responsibility is it do
for workers in these industries, and yes, for all workers.
And with that, this hearing is adjourned. Thank you.
Thursday, March 11, 2021.
COVID-19 AND THE MENTAL HEALTH AND SUBSTANCE USE CRISES
WITNESSES
LISA AMAYA-JACKSON, CODIRECTOR, UCLA-DUKE UNIVERSITY NATIONAL CENTER
FOR CHILD TRAUMATIC STRESS
ARTHUR EVANS, JR., CHIEF EXECUTIVE OFFICER AND EXECUTIVE VICE
PRESIDENT, AMERICAN PSYCHOLOGICAL ASSOCIATION
VERNA FOUST, CHIEF EXECUTIVE OFFICER, RED ROCK BEHAVIORAL HEALTH
SCIENCES
MARK STRINGER, DIRECTOR, MISSOURI DEPARTMENT OF MENTAL HEALTH
The Chair. This hearing will come to order. As the hearing
is fully virtual, we need to address a few of the housekeeping
matters. For today's meeting, the chair or staff designated by
the chair may mute participants' microphones when they are not
under recognition, for the purposes of eliminating inadvertent
background noise.
Members are responsible for muting and unmuting themselves.
If I notice that you have not unmuted yourself, I will ask you
if you would like the staff to unmute you. If you indicate
approval by nodding, staff will unmute your microphone.
I remind all members and witnesses that the 5-minute clock
will apply. If there is a technology issue, we will move to the
next member until the issue is resolved, and you will retain
the balance of your time.
You will notice a clock on your screen. That will show how
much time is remaining. At 1 minute remaining, the clock will
turn to yellow. At 30 seconds remaining, I will gently tap the
gavel to remind members that their time is almost expired. When
your time has expired, the clock will turn red, and I will
begin to recognize the next member.
In terms of the speaking order, we will begin with the
chair and ranking member; then members present at the time the
hearing is called to order will be recognized in order of
seniority; and, finally, members not present at the time the
hearing is called to order.
Finally, House rules require me to remind you that we have
to set up an email address to which members can send anything
they wish to submit in writing at any of our hearings or
markups. That email address has been provided in advance to
your staff.
With that, I want to acknowledge Ranking Member Congressman
Cole and all of our colleagues for joining us today.
Before I begin, I would just like to take a moment to
recognize that today is March 11th. It marks exactly 1 year
since the World Health Organization declared COVID-19 a global
pandemic.
Since that day 1 year ago, almost every aspect of American
life has changed. Our economy has floundered. Cities have shut
down. Thousands of businesses have closed. Rates of food
insecurity and poverty have grown, and more than 525,000
Americans have lost their lives.
And with each passing day, the wide-ranging, enduring
consequences of this terrible catastrophe are becoming horribly
and more devastatingly clear. For example, not too long ago, an
11-year-old girl came into the Connecticut Children's Emergency
Department. She was there for something unrelated to mental
health, but recently the hospital had made it a policy to give
all patients as young as 10 years old a universal suicide
screening. When doctors asked the girl if she had any thoughts
about killing herself in the past few weeks, she said yes. She
said she had been thinking about suicide for quite some time
but did not know who to talk to about it. Her mother was
shocked by it.
The issue of mental health and substance abuse was already
a growing concern in this country before the COVID-19 pandemic,
but the isolation, the school closure, the economic anxiety,
and challenges to obtaining childcare have only exacerbated
these already existing problems and created new barriers to
treatment.
In 2019, 1 in 10 adults reported symptoms of anxiety or
depression. In 2020, that number increased to 4 in 10. Some
surveys have shown over 50 percent of people reporting that the
pandemic has negatively impacted their mental health. And it is
our Nation's most vulnerable who are the most at risk.
According to data published in the official Journal of the
American Academy of Pediatrics, suicidal thinking among young
patients is up 25 percent or more from similar periods in 2019.
Another CDC report found that, in 2020, pediatric emergency
admissions for mental health problems like anxiety and panic
have increased by 24 percent for young children, 31 percent for
adolescents compared to 2019.
In addition to our Nation's children, this pandemic has
been especially difficult for minorities, young adults, and
essential workers. Women with children are more likely to
report symptoms of anxiety and/or depression than men with
children. Black and Hispanic adults are more likely to report
symptoms of anxiety or depression than White adults.
Those who are essential workers are particularly affected.
In addition to reporting symptoms of anxiety and depression
during this pandemic, essential workers are also more likely to
say they are starting or increasing substance abuse and have
suicidal thoughts compared to nonessential workers.
Finally, young adults are reporting higher than average
levels of anxiety, depression, and substance use as a result of
this pandemic.
Certainly, the COVID-19 pandemic has been difficult for all
of us, but it has been especially difficult for these groups,
and it is leading to even greater problems, like substance
misuse, drug overdoses, and domestic violence.
For example, there has been a double-digit increase in
domestic violence hotline calls since the beginning of this
pandemic, and the kids in those families are experiencing
ongoing trauma without the respite and support they might
previously have gained through school.
Meanwhile, drug overdoses are up 42 percent; overdose
deaths are up 24 percent in 2020 compared to 2019. Alcohol
sales and consumption have skyrocketed. And while it is too
soon to know how the pandemic has affected suicide rates, we do
know there have been considerable increases in the number of
people who report thinking, thinking about committing suicide,
just like that 11-year-old girl in my home State of
Connecticut.
But we are not sitting on the sidelines. For quite some
time, we have been working to provide more funding and
resources for mental health and behavioral health programs. We
have, this committee has provided significant funds--and we
have done this on a bipartisan basis--significant funds for the
Substance Abuse and Mental Health Services Administration to
address this emergency through the CARES Act, the December
emergency bill, and the American Rescue Plan, which we passed
yesterday.
That includes additional funding for both the National
Child Traumatic Stress Network and certified community
behavioral health clinics. I look forward to President Biden
signing the American Rescue Plan into law tomorrow so that
these resources can get out the door to our communities.
I also want to note that the Affordable Care Act was
integral in expanding Medicaid, which in many States is the
most significant source of coverage and funding for substance
treatment.
And working together with my colleagues on this committee,
we have supported a number of investments to improve the mental
health of children and young people. This includes a landmark
new Federal investment in social-emotional learning,
investments in the so-called whole child approach to education,
and investments in community schools.
We have also invested in Project AWARE and Healthy
Transitions, which were part of the, quote, ``Now is the
Time,'' end quote initiative following the tragedy in Newtown,
Connecticut.
And I am particularly proud to say we have increased
funding for the National Child Traumatic Stress Network by $25
million over the last 5 years, an increase of more than 50
percent. As part of the investment in the National Child
Traumatic Stress Network, we also directed resources to provide
counseling and trauma services to unaccompanied immigrant
children. We need to do more.
I also agree we must recognize these issues that do not
exist in isolation from each other, which is why we created a
new pilot program last year to help State and local health
departments develop plans to address the social determinants of
health in their communities.
But while these investments are a step in the right
direction, the behavioral health system has been underfunded
for years. We need to be thinking on a more long-term scale,
provide the funding, the resources needed not only to help
weather the immediate effects of this pandemic, but also to
help treat what I expect will become an exponentially
increasing mental health crisis in the next few years.
This simply is not something that is going to go away as
soon as everyone gets a COVID-19 vaccine. Without proper
treatment, trauma and complex trauma like the kind we are
seeing in so many kids and adults during this pandemic can last
and compound for years, even generations.
Our kids, our essential workers, our most vulnerable are
suffering. We owe it not only to them but to the health and
resilience of our economy, our workforce, and our society to
ensure these people get the mental as well as the physical
healthcare that they need.
We are fortunate to have an incredible group of experts
with us, and I look forward to hearing your recommendations on
how to build a stronger behavioral health system that is
capable of meeting those needs in the years to come.
In many respects, you all seem to be in general agreement
on the need for greater investment in the Substance Abuse
Prevention and Treatment Block Grant and to expand the
behavioral health workforce so that we can meet the demand for
services.
We look forward to hearing how you have responded to the
crisis over the past year and what you see as our top priority
as we move forward.
What I want to do now is to yield to our ranking member,
and then we will go to the introductions of the panel. And,
with that, I yield to Congressman Cole.
Mr. Cole. Thank you very much, Madam Chair. I would be
remiss not to tell you I really like those glasses this
morning. They are pretty sporty. They make a strong statement.
I want to begin by thanking the chair for holding this
important hearing today. Much attention has been given to the
economic toll of the pandemic and the impact on physical
health, and rightly so. However, we all know those are far from
the only impacts. In fact, some of the more subtle effects are
just being brought to light, and we may not know all of the
consequences for years or even decades to come.
However, the information that we have on some of these
secondary impacts is concerning. Based on recent surveys,
symptoms of anxiety and depression have increased considerably
in our population. In addition, survey respondents also
admitted having started or increased substance use to cope with
stress or emotions related to the pandemic.
Suicide is also increasing, particularly for adults aged 18
to 24 and for minority groups. Overdose deaths, which had just
begun to show a small decline, have marked a reversal and are
now on the rise again. Life expectancy is decreasing, reversing
progress over generations.
After a year of lockdowns, isolation, and physical
distancing, the mental health impact is apparent. Families
having financial distress are further burdened by feelings of
exhaustion, frustration, and mental strain from coping for so
long. Sadly, too many families are also dealing with the loss
of a friend or a family member. Many children are deprived of
the emotional support and social learning provided by in-person
schooling.
Compounding these issues is a lack of providers to address
mental health and substance abuse. The United States continues
to have a shortage of qualified providers, particularly for
rural and other underserved areas.
Addressing these problems is at the core of several
programs in the jurisdiction of this subcommittee. In addition
to our annual appropriation, the fifth coronavirus supplemental
passed just 2 months ago included more than $4 billion in
funding for these issues. Much of that funding has yet to reach
local communities but, over the next few months, should become
available to address the rising rates of substance abuse and
the need for mental health services.
As States begin to reopen, businesses start the path of
recovery, and schools resume in-person instruction, we can
begin restoring some of the stability needed to return to
normal.
I am encouraged by the continued efforts to vaccinate as
many adults as possible and the news that the timeline for
widely available vaccines continues to shorten. We may be just
a few short months away from having the necessary vaccine
supply to meet all demand. Again, such an accomplishment speaks
to the perseverance and resilience of the American spirit.
I would like to extend a special welcome to Verna Foust
from my home State of Oklahoma. Ms. Foust has worked in
community mental health for over 30 years and runs one of the
largest behavioral health and substance abuse facilities in the
State, with 26 locations across Oklahoma.
As a certified community behavioral health clinic, Red Rock
provides a range of services, including outpatient, crisis
stabilization for adults and youth, substance use residential
treatment, prevention and housing. Red Rock was recently
recognized as one of the top workplaces in Oklahoma, and
Newsweek ranked Red Rock as one of the best addiction treatment
centers in the United States.
I also want to thank the chair for taking such a bipartisan
approach in this hearing. I have enjoyed the panels put
together, and I know members appreciate the ability to have
input on the topics covered and the joint selection of
witnesses.
I have always said that we may not agree on everything, but
the chair and I have always worked well together on the many
areas where we have bipartisan agreement. And I appreciate her
thoughtfulness and will always work with her on our shared
priorities.
With that, I want to thank all our witnesses for speaking
today, and I yield back the balance of my time, Madam Chair.
The Chair. I want to thank the ranking member about the
comment, first of all, on my glasses. Thank you very much.
What I need to do, because I am in the office in the
Capitol, I have got to get to work in putting some color into
this effort here, so--but a work in progress or it has not even
started yet.
But I do, I think this is a critically important hearing.
And I think we both thought when we listened to the hearing on
public health infrastructure that we noticed the consistency of
information from all of our witnesses. And I felt that same way
in reading the testimony of our witnesses this morning, with
the emphasis on mental health and what we should be doing. So
looking forward to the testimony, recommendations, and how we
proceed forward. So thank you.
With that, I am delighted to welcome Arthur Evans, Jr.,
Ph.D., chief executive officer and executive vice president of
the American Psychological Association. I want to note that, at
one point in his distinguished career, Dr. Evans served as the
deputy commissioner for the Connecticut Department of Mental
Health and Addiction Services.
Mark Stringer, director, Missouri Department of Mental
Health, who also serves as immediate past president of the
board of directors of the National Association of State,
Alcohol, and Drug Abuse Directors. He brings 35 years of
experience in the substance use disorder and mental health
fields.
Dr. Lisa Amaya-Jackson, codirector, UCLA-Duke University
National Center for Child Traumatic Stress. Dr. Amaya-Jackson
also cofounded the Center for Child and Family Health in North
Carolina, a tri-university community collaboration, that
provides state-of-the-art trauma treatment and prevention
services and a statewide training curriculum to serve children
exposed to traumatic events.
This is a program that is very, very near and dear to my
heart, and the ranking member knows that. I think we were able
to provide some funds for this for our Native American
youngsters, those who have experienced trauma and violence.
But, Dr. Amaya-Jackson, I have worked closely with Dr. Steven
Marans at Yale Child Study for years to build this program, and
it is wonderful to see how it has spread.
I was also interested in your work with youngsters at the
border, and I think now we need to be thinking about how we
increase the opportunity for your services with youngsters at
the border, since many, many more are coming these days.
And the ranking member introduced Verna Foust, but I also
want to say that I am pleased to have you as a witness and
representing the community of behavioral health clinics. And we
have worked hard to match our community health centers with the
behavioral centers. People, you know, in the Senate, like
Senator Stabenow, Congresswoman Alma Adams, and others on both
sides of the aisle understand the benefit of coupling the
community health centers with the behavioral health centers.
So thank you all very much. I will remind the witnesses
that the entirety of your written testimony will be entered
into the record.
And now, Dr. Evans, you are recognized for 5 minutes.
Mr. Evans. Chairwoman DeLauro, Ranking Member Cole, and
members of the subcommittee, thank you for the opportunity to
testify today. I am Dr. Arthur C. Evans, and I am the CEO of
the American Psychological Association, the Nation's largest
scientific and professional organization, representing the
discipline of professional psychology, with over 122,000
members and affiliates, who are clinicians, researchers,
consultants and students.
Just this morning, we released results of our latest Stress
in America survey, which shows that the pandemic has taken a
particularly difficult toll on Americans' psychological health.
Sixty-seven percent of adults said that their sleep had been
adversely affected by the pandemic. Sixty-one percent of adults
reported experiencing undesired weight gain or weight loss,
with those who reported weight gain gaining an average of 29
pounds.
The survey also showed that some groups have been
particularly impacted. Essential workers are more than twice as
likely to have been diagnosed with a mental health disorder
during the pandemic. Nearly half of mothers who still have
children home for remote learning reported that their mental
health has worsened over the course of the pandemic. And 66
percent of African Americans and 65 percent of Hispanic adults
said that they have used more--they could have used more
emotional support during the pandemic.
Without a doubt, our Nation is experiencing psychological
trauma and distress, and we know from previous research that
this will continue and that we will continue to have problems
in the months and years to come. If we are going to effectively
and equitably address the mental health impact of this
pandemic, we must use an approach that is based on population
health.
For most of our Nation's history, we have approached mental
health treatment with a model that is passive, that is
reactive, and doesn't take into consideration people's social
context. There are multiple problems with this way of working.
First of all, it assumes that people will proactively seek out
treatment, when the research consistently shows that people
often do not reach out for help and, when they do, they often
face a multitude of barriers.
Second, this approach focuses primarily on individuals in
crisis or with more severe mental illnesses, essentially
ignoring people who are having milder and earlier symptoms,
when it would be much easier to intervene.
Additionally, this model fails to consider the critical
effects that communities, systems, and social determinants play
in people's mental health.
To address this, we must add prevention and early
intervention strategies to the approach we take for mental
health. We must move upstream and use the best available
science and explore solutions at the community level to prevent
unnecessary suffering.
This population health model has proven instrumental in
saving lives and also in having saved money. Recently, I
coauthored an open letter to President Biden with a former
colleague, Dr. Gary Belkin, who was the commissioner in New
York City. And we talked about our experiences as
commissioners, I in Philadelphia and he in New York City.
During our tenures, in our letter, we talked about
strategies that we employed, like making investments in
evidence-based clinical care and making investments in more
preventative and early intervention care, like enlisting
educators, law enforcement officials, and employers as well as
staff and neighborhood anchors, like churches, childcare
centers, and community centers and train them to identify the
people who are in need of mental health treatment.
We implemented school-based services to reach children
experiencing social and emotional problems much earlier and
more consistently. We made self-care tools and screening
available through public kiosks, community outreach events, and
call centers.
These preventative interventions, along with traditional
clinical care, delivered results and mitigated the risk for
people which would have required more intensive treatment
later. For example, the creation of an enhanced State treatment
program by our team resulted in a 36-percent drop in the city's
use of crisis services.
It is essential in both the short term and the long term
that we take this kind of population health approach to address
the growing prevalence of mental health challenges and promote
mental wellness across the Nation. In doing so, we can provide
both safe and effective clinical care and reduce the risk of
people developing more significant problems.
I applaud the committee for examining the long-term mental
health impact, and I would urge you to support funding for a
future system that really prioritizes our mental health as a
Nation.
Some of the recommendations we would make is that we need
to continue to make investments in interventions that both
address the social determinants of health and target Federal
resources to evidence-based disease prevention strategies.
We need to continue to increase the Substance Use and
Mental Health Block Grants that allow systems administrators to
implement more prevention and early intervention strategies.
We need to increase funding for programs critical to the
mental health workforce, such as the Graduate Psychology
Education Program and the Behavioral Health Workforce Education
and Training Program.
We need to increase funding for programs to strengthen
school-based mental health services, including funding for
programs like IDEA, Project AWARE, and Title IV-A.
The Chair. Dr. Evans, I have to ask you to wrap up, okay?
Mr. Evans. Okay. APA stands ready to work with you and
address inequitable access to care and the ever-worsening
mental health impact of the pandemic, and I want to again thank
you for this opportunity to testify today.
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The Chair. Thank you. Thank you very much.
Mr. Stringer, you are recognized for 5 minutes.
Mr. Stringer. Thank you. Chairwoman DeLauro, Ranking Member
Cole, and members of the subcommittee, my name is Mark
Stringer, and I am director of the Missouri Department of
Mental Health. I also serve as chair of the Public Policy
Committee of the National Association of State Alcohol and Drug
Abuse Directors, or NASADAD. I really appreciate the
opportunity to testify before you today and will be focusing on
the impact of the pandemic on substance use and substance use
disorder.
Since COVID-19 was first identified in Missouri a year ago,
we have seen some really troubling trends related to substance
use and substance use disorders. For example, drug overdose
deaths increased by 21 percent in the first three quarters of
2020 compared to the same three quarters in 2019.
Of particular concern is the disproportionate impact those
overdose deaths are having in the Black community. While deaths
among White people increased 16 percent, deaths among Black
people increased 37 percent. A survey done by the Missouri
Institute of Mental Health in August and September 2020
revealed increases in substance use since the beginning of the
pandemic.
For example, of those surveyed, 56 percent said they were
drinking more alcohol than usual; 60 percent reported an
increase in smoking; and a little over 60 percent indicated
increased misuse of prescription drugs. These issues and others
present distinct challenges.
As a result, my department worked to develop a model of
treatment called the Medication First Model for people with
opioid use disorders. This model removes barriers to evidence-
based care being delivered in a prompt manner and ideally the
same day that a person presents for treatment.
Thanks to the quick action at SAMHSA and CMS, our
department offered treatment providers the flexibility to
deliver services using web-based video application, email, text
and telephone. We also offered providers flexibility on certain
paperwork requirements and timelines.
In addition to actions at the State level, we received a
lot of help from Congress. The December 2020 package and the
COVID-19 relief package cleared by the House yesterday included
critical investments in NASADAD's number one priority, the
Substance Abuse Prevention and Treatment Block Grant.
The additional investments from Congress in the block grant
allow agencies like mine to direct funds where they are needed
most. Further, an investment in a block grant is an investment
in much-needed primary prevention. The block grantprevention
set-aside is a critical component of our prevention system in
Missouri and countrywide.
Moving forward, here are my recommendations: First, we
still need the support of this subcommittee. We are fighting an
urgent and very steep uphill battle. As much as the generous
Federal grant dollars have helped, resources are still needed.
Second, I recommend a transition over time from opioid- or
drug-specific resources to investing funds in the SAPT Block
Grant. While we are incredibly grateful for our opioid-specific
grants, like the State Opioid Response Grant, States would
benefit from more flexibility to address all substances of
concern. This very subcommittee embraced this approach in
fiscal year 2019, and we hope it can be done again in fiscal
year 2022.
Third, please ensure that Federal funding for addiction
flows through State alcohol and drug agencies. These agencies
play a critical role in planning, overseeing, and implementing
a coordinated and comprehensive system of care, and they
promote effective and efficient systems through oversight and
accountability.
State alcohol and drug agencies like mine promote and
ensure quality through standards of care and technical
assistance to providers. Federal policies and programs that do
not flow through or at least coordinate with the State agency
run the risk of creating parallel, duplicative, or even
contradictory publicly funded systems and approaches.
Finally, please support and bolster the role of the
Substance Abuse and Mental Health Services Administration,
SAMHSA. We support maintaining investments in SAMHSA as the
lead agency within HHS, focused on substance use disorders. The
Nation benefits from a strong SAMHSA, given the agency's
longstanding leadership in the field.
NASADAD appreciates the role of the Assistant Secretary for
Mental Health and Substance Use, who promotes a unified
approach across HHS. And we are particularly grateful for the
leadership of the current Acting Assistant Secretary, Tom
Coderre, whom I have known and respected for a long, long time.
In the end, SAMHSA should be the default home of the substance
use disorder discretionary grants and related programming.
I thank you for this opportunity and look forward to your
questions.
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The Chair. Thank you very much.
Dr. Amaya-Jackson, you are now recognized for 5 minutes.
Thank you. Dr. Jackson.
Dr. Amaya-Jackson. Sorry. I was on mute.
The Chair. It is okay. I do it all the time. Please go
ahead. You are recognized for 5 minutes.
Dr. Amaya-Jackson. Thank you.
Chairwoman DeLauro, Ranking Member Cole, and members of the
subcommittee, thank you for this opportunity to testify today
regarding the mental health and substance use crises associated
with the pandemic.
My name is Dr. Lisa Amaya-Jackson. I am a child and
adolescent psychiatrist and codirector of the UCLA-Duke
University National Center for Child Traumatic Stress, the
coordinating center for the National Child Traumatic Stress
Network, also known as NCTSN.
And, as you know the NCTSN was created by Congress in 2000
to raise the standard of care and increase access to services
for children and families in the U.S. who experience traumatic
events. This premier, federally funded child trauma initiative,
administered by the Substance Abuse and Mental Health Services
Administration, includes 116 current grantees and over 200
former grantees working in hospitals, universities, and
community-based programs in 43 States and DC.
Americans living under prolonged threat of danger
associated with this pandemic have reported emotional reactions
that include anxiety, depression, grief, substance use, and
thoughts of suicide. Disrupted feelings of safety are
tragically exacerbated by death of a loved one, illness,
intermittent partner violence, child abuse, and poverty.
For children with trauma histories, new loss and adversity
can result in nightmares, outbursts, school challenges, and
complicate trauma and grief reactions. Overburdened caregivers
struggle to buffer the effects of our children's suffering.
On behalf of the NCTSN, I will identify several stressors
we are observing, highlight efforts to mitigate these, and
offer priority recommendations.
First, children and families are at increased risk for
traumatic stress and loss. Over 500,000 pandemic-related deaths
in the U.S. are overwhelming our bereaved families, unable to
even observe their mourning rituals. Quarantined families risk
increased conflict while economic strain increases risk for
substance use, neglect, and family violence.
Next, racial and ethnic minority families are
disproportionately impacted. COVID-19 compounds the impact of
racial discrimination and systemic disparities in the quality
of and access to essential resources. Limited access to
culturally and linguistically responsive mental healthcare,
fear of institutional bias, and historical trauma create a
troubling context for COVID-19 among these families.
Third, our Nation's schools are facing unprecedented
challenges. School routines, milestones, and critical social-
emotional learning have been disrupted. Students may lack
access to trauma-informed, evidence-based mental health
services, and it has been difficult to identify students
experiencing child maltreatment or suicidal ideation. Many
school personnel could also use staff wellness programming.
Finally, the pandemic impacts child maltreatment risk and
child welfare. Professionals believe abuse may be increasing,
given children may be sheltering where abuse is occurring and
not reported. Contact between children in placement and their
families has been reduced while services supporting parents
seeking reunification has been disrupted.
The NCTSN response to the traumatic impact of COVID-19 on
children and families has focused on several key priorities. We
are tracking the pandemic's impact on our NCTSN centers,
including secondary traumatic stress among child-serving
providers.
We are bolstering NCTSN members' provision of trauma
treatment, training, and other services, often through
telehealth and virtual training. We are disseminating trauma-
informed COVID-19 resources to caregivers and child-serving
personnel and providing trauma-informed training and
consultation to Federal, State, and local organizations.
And, finally, we are documenting lessons learned and
practice innovations, including those that should be maintained
post pandemic.
While we await further evidence of the totality of mental
health and substance abuse consequences of the pandemic, I will
conclude with six recommendations: one, ensure children and
families have resources to meet basic needs essential for
overall mental health, resilience, and violence prevention;
two, increase access to evidence based, trauma-informed
services for children and caregivers experiencing mental health
and substance use challenges resulting from the complex
interplay between the pandemic and other national crises and
disasters; three, support schools in implementing trauma-
informed programs to address gaps in their education,
development, and mental health through and post pandemic; four,
support essential child-serving systems, such as child welfare,
juvenile justice, and the Unaccompanied Alien Children Program,
to implement trauma-informed practices and policies; five,
support research to delineate mental health, substance use, and
traumatic stress consequences of the pandemic on children and
identify effective interventions; and, last, prioritize needs
of at-risk youth, including racial and ethnic minorities,
youths with disabilities, immigrants, LGBTQ persons, and those
living in poverty.
On behalf of the NCTSN, I would like to thank the
subcommittee for your longstanding commitment to the needs of
children and families who experience trauma. We stand ready to
assist as we all work together to address mental health and
substance use crises associated with this pandemic.
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The Chair. Thank you so much.
And, Ms. Foust, you are now recognized for 5 minutes.
Ms. Foust. Good morning. And thank you, Chairwoman DeLauro,
Congressman Cole, and distinguished members, for the
opportunity to speak today. My name is Verna Foust. I am the
CEO for Red Rock Behavioral Health Services, a certified
community behavioral health clinic in Oklahoma.
For many years, I worked closely with the Oklahoma
Department of Mental Health and Substance Abuse Services that
plays a critical role in overseeing the Public Behavior Health
System. One of the benefits of making Federal funds, such as
the Substance Abuse Prevention and Treatment Block Grant,
available to this agency is that we develop relationships; they
understand what we do; they offer technical assistance; and
they hold us to very high quality standards.
We are also grateful for SAMHSA's role as the lead Federal
agency for substance abuse and mental health disorders and hope
that ongoing COVID relief efforts further bolster SAMHSA's role
in administering these critical service grants.
Red Rock was one of the first agencies in eight States to
become a CCBHC under the Federal Planning and Demonstration
Program in 2017. This program has been a lifeline for community
treatment. Prior to this initiative, fee-for-service payment
models did not cover the true cost of the services nor provide
the funding for the services that were truly needed.
The proven success of the CCBHC has led Congress repeatedly
extending the demonstration and appropriating over $1.5 billion
for the expansion of the program since 2018. Today, there are
340 CCBHCs in 40 States, Washington, D.C., and Guam. The CCBHC
model provides integrated care coordination for physical,
mental health, and addiction treatment, in an effort to move
the needle on the fact that Americans with severe mental and
addiction disorders die 10 to 25 years younger than the general
population.
However, this CCBHC model will end on September 30, 2023,
for States in the demonstration unless Congress extends the
program. In my opinion, extending and supporting the CCBHC
model to all 50 States and territories, with funding well into
the future to allow for growth and planning, could be the
single most significant factor in improving behavioral
healthcare in our country.
There has been a shortage of mental health professionals in
the U.S. for many decades. The National Survey on Drug Use and
Health has consistently shown that over half of adults and
youth who need treatment do not receive it. While demand for
care is rapidly growing, the number of mental health
professionals is barely holding even. A 2016 report by the
Health Resources and Services Administration projects a
shortfall of 250,000 mental health professionals by 2025.
The CCBHC model is a great start in mitigating this
shortage. Another helpful strategy would be broader access to
student loan repayment through HRSA by broadening this benefit
to all CCBHCs, regardless of geographic area.
Since COVID, the rate of young adults age 18 through 24
that have seriously considered suicide in the last 30 days has
increased from 10 percent in 2018 to over 25 percent in 2020.
Before the pandemic, 1 in 10 adults reported symptoms of
anxiety or depressive disorder. Today, it is 4 in 10.
Included in the December 2020 COVID relief package was an
investment of $1.65 billion for the Substance Abuse Prevention
and Treatment Block Grant. These block grant dollars are vital,
and we are very appreciative of the work this subcommittee has
done to include supplemental funding for the block grant.
A bright light during this pandemic has been Congress'
approval of services to Medicare and Medicaid recipients
through the use of telemedicine. I urge Congressman to
permanently allow the use of telemedicine and that any further
Federal efforts to address the pandemic's long-term impact will
take into account the benefit of multiyear investment.
In summation, the Federal block grant to the State is
critical to provide services to the vulnerable. The CCBHC model
is transforming our system. It has resulted in improved access
to care, high-quality treatment through the use of evidence-
based practices, better staff training, enhanced care for
veterans, and is saving lives through the coordination of
mental and physical healthcare.
We must quickly address the workforce shortages to keep up
with the demand that is so desperately needed, and understand
that COVID has had a significant and lasting impact on the
mental health of Americans.
Again, thank you for this opportunity.
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The Chair. Thank you. Thank you very much.
And I want to say thank you to all of our witnesses. Once
again, I think it is striking that all four witnesses have not
only identified the problems and very descriptive of what the
issues are and what this pandemic has caused, but also again
just really stunned at the consistency of the recommendations
of how we should go forward and what are the kinds of things
that we ought to be doing.
And I would just say to you that your testimony is very
valuable in having an impact on, when we put together the
appropriations bill, what are the directions that we should go
in.
And, with that, let me just ask. I will start the
questioning, and I will just focus on children's mental health
for a second. The impact that the pandemic has on everyone's
mental health is stunning. As I said, let me focus on children.
We have worked hard to improve mental health for young
people, particularly in schools, but now these children are at
home with parents who are stressed and anxious. In some cases,
they are experiencing trauma in the home, and they don't have
the same access to teachers, coaches, counselors, friends, the
entire support system that may have been there in the past.
And, particularly, we have children with special needs, I
think, who are really suffering from the effects of the
pandemic.
Dr. Amaya-Jackson, because children are still developing,
they are particularly vulnerable to the stressors of the
pandemic. We know how important the early years are. Can you
explain how these current events can impact a child's
development and what we need to do to keep them healthy?
I am going to ask with a followup, what kind of long-term
impact do you think this will have on this generation of
children? What do you think are the longer term needs for
children and families after the pandemic is contained?
Dr. Amaya-Jackson. Thank you, Chairwoman.
Children, I think we have to always remember, are not just
little adults, and we have to understand their experiences of
stress and trauma within a developmental framework. For
example, they experience stressors of the pandemic in a
different way than we do as adults.
Challenges such as quarantine and social isolation can have
a significant developmental impact, and if you think about
where they are supposed to get that in schools with their peers
and interaction with their peers, those are very important ways
of moving their developmental progression forward.
What are they doing now? Well, they are really turning to
their cell phones, to social media, to gaming. They have much
more increased vulnerability in that way to bullying, not just
bullying, but they are having increased exposure to sexual
material. This is reducing the quality and appropriateness of
their social engagement.
We are hearing about the broadcasting of suicide attempts
and self-injury through the media and in the internet. So, as
we, you know, think about these issues, we have to be
recognizing that we are setting patterns into play that are
going to probably continue long past, you know, the ending of
this pandemic.
Our parents really need assistance. We need community
programming. We need access to services as they look to ways to
think about strategies to work with their children, to engage
with them outside of the internet, to be involved with them
when they are on the internet, to be looking at apps that are
involved with education, thinking about time limits, things
like that.
I think the issues around structuring peer interactions, as
we move towards a time when we are all going to be safe
together, we have to be thinking of developmental-oriented
activities. And to be honest, we are probably going to have to
learn a little bit about how we interact again.
We have been in isolation for a long time, and I think
children are going to need some help. And they are going to
need some structure and, you know, really emphasis on no
shaming, no blaming in the way they interact with each other
and with the adults around them.
The Chair. And do we have, in your view, the kinds of
resources or the adequacy of the current structure to be able
to deal with the short-term issues that you are talking about
and the longer term issues when the pandemic is contained?
You mentioned some of the things. Who are the best segment?
Is it organizations who can help out? Is it physicians, mental
health physicians? What are the tools in which we can begin to
deal short term and long term, in your view?
Dr. Amaya-Jackson. So I think this is an issue of looking
at everybody in the child-serving system, from pediatricians to
schools to mental health providers, assistance in child
welfare, juvenile justice, schools, as I mentioned. And, you
know, the criticalness of putting children back into the
routines.
We have our jobs. Children have their routines. While they
are at school and they are being educated, they need that
social-emotional learning to be able to move forward. But the
thing is they are going to be dealing with new traumas that
have occurred, cumulative risk on past traumas that have
occurred, and dealing with grief, grief reactions and stressed-
out parents.
What the NCTSN is doing is we are bringing together an
initiative that will pull together national stakeholders, our
NCTSN experts, to define the impact of the COVID-19 on children
and families. We are looking for identifying some key
challenges for longer term planning and generate
recommendations for agency leaders, child-serving systems, and
policymakers.
And we look forward to sharing our findings with you. I
think that we have to be in this for the long haul. This is
going to be very big. And the question of whether we have
sufficient resources, I really question that. I feel like there
are families who have not been known to the mental health
system who will now need to be known to the mental health
system.
And one important thing I will mention is that our parents,
who are very stressed, whether they are essential workers,
unemployed workers, or remote workers who have been trying to
multitask as they take care of their young children and their
children who are in remote school, you know, they have been
heroes, and they are doing their best, but there has been lots
of room for some neglect that they are endorsing in some
surveys and violence in the home.
And they are going to need some support, and I think they
are going to be carrying a lot of scars moving forward. Many of
them are grief-related scars; many of them are having not been
able to provide for their family.
And one point I will make that has been clear is that, you
know, when we as in my therapist past, we are seeing children,
we often recognize that parents need help too. And just because
a child has Medicaid, it doesn't mean a parent does too. So a
parent can seek care for themselves, but if you are asking a
parent to seek care so that they can be the best parent they
can be to their child, they may not have access to Medicaid and
the resources to do that.
The Chair. Thank you very, very much. And my time is
expired.
I will just say to Dr. Evans and Mr. Stringer, at some
point in any of your comments, the issue of Medicaid and its
expansion, I would love to get your thoughts on how that has
helped to deal with the access to behavioral healthcare.
With that, let me recognize the ranking member, Congressman
Cole.
Mr. Cole. Thank you very much, Madam Chair.
I too was struck by the consistency of the recommendations
and, frankly, the consistent strong advice that we have
sustained investment over time here to be able to deal with the
problems.
I want to quickly ask each of our witnesses in order if
they could just very quickly, because I have a limited amount
of time, give us what you think the two or three greatest
impacts of the pandemic in your respective fields have had, for
good or ill, I mean really places where we need to focus as a
committee. And I will start, if I may, Dr. Evans, with you.
Mr. Evans. Sure. Thank you, Congressman. Well, I think the
impacts are going to be widespread. I would really prioritize
the number of people who are having their first episodes with
mental health challenges. Prior to the pandemic, we had a
problem in this Nation, as I noted in my testimony, that there
are too many people in our Nation who experience mental health
problems and don't access care until they are in crisis. And
often when they are in crisis, in many communities, it is still
even hard and difficult to reach them.
So I think we have to put a big emphasis on early
identification, identifying people when it is much easier to
treat them, when we can prevent them from having more
difficulty, and put a lot of emphasis on that particular
population.
Mr. Cole. Thank you.
Ms. Foust, let me go to you next. Are you there? You may
well be on mute.
Ms. Foust. Sorry. I was on mute. I would say much of what
Dr. Evans just said. And not to repeat his words, but as far as
something good that has come out of the pandemic, I really want
to say that I think telemedicine has been a godsend. I think we
have learned how to do it really quickly. We know much better
what works.
It is incredible how some of the clients have embraced
technology. We are seeing lower no-show rates with
telemedicine. And I, again, would just ask that this be
considered to be permanent in the future.
Mr. Cole. And for the court, we hear a lot of that in a
whole range of fields. It is clearly something we need to focus
on from a regulatory standpoint.
Let me go, if I may, next to Mr. Stringer, and if you would
give us, again, your thoughts on the one or two or three
greatest impacts the pandemic has had in the areas that you
focus on.
Mr. Stringer. Yeah. Thanks for the question. You know, what
this has done, and especially early on, has created conditions
of isolation, certainly unemployment, difficulty accessing
services, hopelessness. Those kinds of things are all enemies
of recovery, and those kinds of things all create opportunities
to take substances in order to feel better or to relieve the
pain.
And so, you know, those are the main factors I think that
have contributed to this. The other one, of course, is the
availability of drugs. The cartels, others, always figure out a
way to get the product in, no matter what the conditions, even
in a pandemic.
So, Ranking Member, that is probably the best I am going to
do with that.
Mr. Cole. Okay, thank you very much.
And, Ms. Amaya-Jackson, from your standpoint, particularly,
I guess, focused on young people. You covered quite a bit of
this, but, again, two or three of the biggest impacts, for good
or ill, that you have seen the pandemic had.
Dr. Amaya-Jackson. Yeah. I would say, you know, the
traumatic nature and grief of the mental, you know, in
particular on parents and providers, is very significant. It
reduces their capacity to do what they need to be able to do.
And I would also say, you know, a very, very significant
impact on child-serving systems, be they schools, mental health
centers, hospitals, pediatricians, et cetera. Those are busting
at the seams. We know people have stepped up in a major way to
be providing, you know, critical care.
But when the pandemic is over, I think where they will be
at and where the future need will be at is going to be a
mismatch. And I think that is a very significant issue we have
to face. And telehealth will be something that we have to
consider, I think, thinking about. I think we need data on
where virtual learning and telehealth has been helpful and
where the role is for hybrid versus, you know--as mechanisms
that help access the services.
Mr. Cole. Well, I can certainly tell you in a State like
mine, which, as Ms. Foust knows, is heavily rural, it has been
absolutely great over the last year to deal with the problems
we have had.
With that, Madam Chair, I have limited time. I am going to
disappear for just a minute. That is just because I am going to
go vote, and I will be right back.
The Chair. Okay. Thank you.
Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Thank you, Madam Chair.
Dr. Evans, I would like to raise an issue that is extremely
serious but gets very little attention. As co-chair of the
bipartisan Maternity Care Caucus, I am very concerned about the
impact COVID-19 has had on the mental health of expecting and
new mothers.
As you may know, maternal mental health, including
postpartum depression and other mood and anxiety disorders, are
the most common complications of pregnancy and childbirth. It
affects one in five women, which translate into 800,000 new
mothers each year in the United States. And tragically, suicide
and overdose are the leading causes of maternal mortality for
new mothers.
Recent studies have shown pregnant women and new mothers
are experiencing increased anxiety and depression during the
pandemic at three to four times the rate prior to the pandemic.
And women of color and women who live in poverty are
disproportionately impacted by both maternal mental health
conditions and the pandemic.
Dr. Evans, could you please describe how maternal mental
health issues differ from other mental health disorders and if
they require different approaches and therapies to address?
Mr. Evans. Sure. Thank you for that question.
Yes, maternal mental health issues are different in some
important ways that we have to take into consideration as we
work with women. When I was commissioner for behavioral health
in Philadelphia, I funded programs specifically for women who
were going through their pregnancy.
As you noted, postpartum depression is the most common
complication within childbirth. One of the other distinguishing
aspects of postpartum depression is that many of the women who
are experiencing postpartum depression are experiencing it for
the first time during childbirth, which means that they are not
typically already connected to services.
One of the things that I think is really important is that
we have a multisystemic approach to this issue. For one thing,
we need to make sure that we have integrated within perinatal
services mental health treatment, particularly screening and
identifying women who might be at greater risk or may be in the
early stages of showing signs and symptoms of depression.
I think we have to make sure that practitioners, both
physical health practitioners, OB/GYNs, and pediatricians, are
aware of the prevalence of postpartum depression and understand
how to make connections to the mental health system.
And we need to make sure that mental health providers
understand the unique issues that women and mothers who are
experiencing postpartum depression have. For example, the level
of stigma and the issues around stigma are very different than
the general population. You are already talking about a
stigmatized condition, but it is particularly difficult for
mothers who have elevated expectations about how they should be
responding after childbirth.
So I think that the most important thing is to make sure
that we have the funding. When I funded those programs, there
were some complications, in particularly Medicaid funding,
around how many services or different types of services that
you could bill for in a particular day. And so we had to do
some very creative financing in order to fund those services.
So I would put at the top of the priority list making sure
that we have good ways of funding those services and that we
reduce those barriers so that those services are available to
women during that process.
Ms. Roybal-Allard. Dr. Evans, you touched a little bit on
what my second question was going to be, and that is, how do we
improve maternal mental health awareness, diagnosis, and
treatment in this country to ensure that we get the best
possible maternity outcomes for every mother, infant, and the
family?
Mr. Evans. Well, I think that mental health treatment,
early screening, early identification needs to be just a part
of the standard of care. You know, no woman, in my view, should
go through childbirth without the questions and screening
around mental health, and whether they are having mental health
challenges.
That is a systemic thing that we can do, but we also have
to make sure, as I mentioned earlier, that practitioners, both
physical health and mental health and behavioral health
providers, understand the unique challenges that women face,
that they have that education, and that they understand how to
treat those women, given the particular challenges that they
are experiencing during childbirth.
Ms. Roybal-Allard. Thank you.
I see my time is up. I yield back.
The Chair. Congressman Harris.
Mr. Harris. Thank you very much. Thank you, Madam Chair.
I have a question I would direct, I guess, to Dr. Evans and
Dr. Amaya-Jackson. I am a little worried about what the effect
of the school closing will be and the isolation on youth-on-
youth violence.
And let me just back up a little and say, look, what we see
in adults and what we have heard is that, you know, the fact
that someone could infect you with a virus makes you distrust
other people. They pose a physical risk to you. And whether you
like to think it right away, when you pass someone on the
street, you think, Well, this person could actually adversely
affect me.
Does that percolate down to children as well, as you remove
them from school and they hear at home about all the--you know,
about the fact that, yes, that other person could infect me,
they could, you know, cause bad things to happen to my health
or my parents' health? So does that percolate down? And is it
different at different ages?
So will this lack of the ability to associate with your
peers in a friendly, nonthreatening way, the lack of that, does
it make a difference at different ages as to when you--when
this is all over, I mean, are our children going to go to
school and go, Wait a minute, I am still afraid of that other
person? And what is the ramification of whether or not we see
more youth-on-youth violence because of this distrust?
So I will leave it at that and ask for your opinions.
Dr. Evans, if you can start.
Mr. Evans. Sure. Well, I think the point, the general point
that you are making is a very important one, and that is that
the pandemic is going to have long-lasting mental health
impacts on people. We know that. Specifically how that will
play out, we don't know. We don't have the studies. This is the
first time in 100 years that we have experienced this, and we
don't have the kind of long-term data that shows that. But the
issues that you are raising I think are good ones.
What we do know is that children have been under a
significant amount of stress over a long period of time, and
one of the things that distinguishes this pandemic from other
kinds of natural disasters is the long, prolonged chronic
stress level that we have documented in the survey that I
talked about earlier, and others are documenting through other
research. And what we know about that long chronic stress is
that the impact happened far after the crisis is gone. It is
sort of like veterans who have been deployed for a long period
of time, they actually adjust to the stress level; but when the
stressors are removed, that is when you see some of the
challenges.
We suspect that that is probably going to happen with a lot
of people in our population, probably children as well, and it
is a reason that we have to make a significant investment, as
Dr. Amaya said in her testimony, in every child-serving system
so that we can identify those issues early, and intervene with
children at the earliest possible moment.
Mr. Harris. Dr. Amaya.
Dr. Amaya-Jackson. I would echo Dr. Evans' words, and also
thank you for thinking about these kinds of issues.
What we are seeing with children is multipronged. They are
seeing, you know, parents are scared. That makes them scared.
They see parents fighting for what they perceive is right. They
are going to fight as well. So there is a role-modeling issue.
But I also think in these systems, whether, you know, it is
in schools, activities, children need to know that they can
both be psychologically safe as well as physically safe. And
the fear is going to be a lot of what will be driving some of
these, you know, aggressive and emotionally dysregulated
behaviors.
And so, I think where adults, counselors, teachers, you
know, can be given the opportunity to make sure that at all
levels of the environment, in classrooms, on the playgrounds,
in the halls at schools, that there is monitoring that can go
on so that children can feel safe, both physically and
psychologically, I think will be a critical element.
Mr. Harris. Okay. Thank you very much.
I yield back, Madam Chair.
The Chair. Congresswoman Barbara Lee.
Ms. Lee. Thank you very much, Madam Chair. And I want to
thank all of our witnesses for this very important hearing, and
it is so timely, Madam Chair.
First of all, just for context, my professional background
is clinical social work. Actually, my profession is as a
trained psychotherapist. In the 1970s, I founded a community
mental health center because we did not have any centers in the
Bay area that provided relevant culturally appropriate mental
health services for the African-American community, for people
of color.
Now, this was in the 1970s, and we had to develop treatment
modalities, and the reason I founded this is because we did not
have any treatment approaches that included the impacts of
social determinants on African Americans or people of color.
Racism, structural racism, creates stress, creates trauma,
creates physical illnesses, creates mental health illnesses,
and all of what we are seeing now again, but also it creates
early death. And so, what I am--so myself recently and Senator
Warren and Congresswoman Pressley, we introduced a bill, The
Antiracism in Public Health Bill, because it is so critical to
address racism and structural racism, both individually and
structurally, in our mental health system, because what you all
have recognized and said is that this certainly has a terrible
impact on the mental health of people of color, racism. And I
think the rest of the country after January 6 really begins to
understand how weighed down people of color are as it relates
to White supremacy.
So let me ask you: As we begin to fund our programs,
understanding this context now in terms of structural racism,
what would you suggest that we include to disrupt, first of
all, the systems that have been in place, and also to build
upon systems that we know will address the specific stress as
it relates to racism in people of color's daily lives? Because
this is an issue that has got to be dealt with right away in
this year's funding, and I want to see us put something in our
bills to suggest that our programs have this incorporated.
Dr. Evans.
Mr. Evans. Sure.
Ms. Lee. Anyone can respond who can help us walk through
this.
Mr. Evans. Sure. I think it is an excellent question, and I
remember I did similar work when I was in private practice
creating models, specifically for African-American populations,
because often, African Americans have a hard time relating to
more traditional services, and didn't acknowledge their
realities.
I think that there are several things that you have said
that I think are real critical. One of them is that I think it
is important for clinicians to understand social context and
understand those contextual issues. Often people are trained,
or not trained, to acknowledge that, and it is one of the
things that pushes people out of treatment. If people are
seeking treatment and people are not acknowledging their
reality, it is going to make it less likely for them to engage
in treatment.
From a policy standpoint, I think that there are several
things that we need to do. One of them is to make sure that we
are collecting the data, and we are aggregating the data. One
of the big challenges we have is that we don't really
understand. For example, when I was commissioner, we not only
collected data, but we would geo map that data to look at where
people lived, and where the services were. And one of the
things that explained people not getting to services was not so
much that they didn't want the services, but the services
weren't in places where they could easily access them.
So we have to have that kind of data in order to make sure
that people have access, and we have to make sure that we have
specific data, or specific funding, for populations who we know
are at greater risk and who are underserved. Generic services
are important, but often generic services don't get at those
unique issues that you have to overcome in order to reach
specific populations. So I would strongly recommend that in
terms of----
Ms. Lee. Doctor, yeah. And let me just, in the few minutes
I have left--few seconds I have let, on racism specifically,
antiracist policies, how do we get our mental health system to
incorporate those? Because if we don't do that, people who are
dealing with racism every day and the trauma that results will
still walk around with that load on their shoulders.
Mr. Evans. Well, I mean, the research is pretty clear and,
it is consistent that racism does have an impact on people's
mental health. I don't know that many--that this is a part of
most clinicians' training. You are a clinical social worker.
You probably know, how much of that--social workers are
probably actually better at that than most other mental health
professionals. But many of the mental health professionals
don't have that understanding of that connection and
understanding that we not only have to deal with people's
symptomatology, we also, as a part of our training, have to
help people with the realities in which they live and helping
them to actually navigate a life where they are experiencing
those kind of stressors.
Ms. Lee. Thank you very much, Madam Chair, and hopefully,
we can follow up and have some discussions about this. Thank
you.
The Chair. We certainly can. In a number of these areas,
you will have the opportunity to do that with this
subcommittee.
Congressman Fleischmann.
Mr. Fleischmann. Thank you, Madam Chair and Ranking Member
Cole, again, another outstanding hearing for this subcommittee
on an issue, mental health and substance abuse, that really has
affected our Nation pre COVID and now currently. So thank you
for holding this.
The COVID-19 pandemic is having a significant impact on the
behavioral health of Americans. A recent report found that
symptoms of anxiety disorder are approximately three times
higher, prevalence of depression about four times higher,
overdoses are reportedly up almost 18 percent among adults
compared to the same time last year.
Even before the current public health emergency, the
incidents of serious mental health illness had increased
significantly from 2018 to 2019. Suicide rates have continued
to increase, up 35 percent between 1999 and 2018. And drug
overdose deaths have climbed to a record high again last year.
The Mental Health Parity and Addiction Equity Act was
enacted in 2008, and requires insurance coverage for mental
health conditions, including substance use disorders, to be no
more restrictive than insurance coverage for other medical
conditions. Yet, the Medicare program limits beneficiaries to
only 190 days of inpatient care in a psychiatric hospital for
their lifetime. People with serious mental illness may easily
go over Medicare's 190-day limit during their lifetime,
especially if they gain Medicare coverage at a younger age.
When people with mental health illness cannot receive care in
the right setting, they can end up in hospital emergency rooms,
in jail, or, sadly, on the streets.
My question is for Dr. Evans, sir. Do you believe Congress
and CMS should reconsider the 190-day cap on inpatient
psychiatric services? If so, what would that do for Medicare,
patient care, specifically in light of the COVID-19 pandemic?
Dr. Evans, sir.
Mr. Evans. Absolutely. And I am so glad you are raising
this issue. It is such a critical issue.
People who have psychiatric illnesses need to have access
to the services that they need, and we shouldn't place
limitations, arbitrary limitations on people's access to that
care. It is plainly discriminatory. We don't do this for other
illnesses. We don't say if you have been hospitalized for
cardiovascular disease 190 days, you can't go in, you can't
have access on the 191st day. But we do that for mental
illnesses, and it is just discriminatory. We need to stop it,
and we need to make sure that people have access to whatever
level of care they need at that particular point.
And one other point that I will make, one of the things
that happens to people in the mental health systems, because
systems are so different around the country, that in some
communities that don't have enough outpatient and other types
of lower levels of services may, in fact, have more days than
people in other parts of the country.
So it is a double whammy for people who live in communities
who have had inadequate access to mental healthcare. They may
have maybe overutilization of those psychiatric bed days, and
then they would then have this arbitrary limit on access to
needed care later on in the course of their treatment.
Mr. Fleischmann. Yes, sir. Doctor, thank you again for your
testimony, the testimony of the other witnesses.
Madam Chair, in light of the fact that we have got votes
and time considerations, I am going to yield back the balance
of my time. But, again, thank you and Ranking Member Cole for
having this great hearing. Appreciate it.
The Chair. Thank you so much, Congressman Fleischmann.
I just--in any case, before this is concluded, I would
love, as I said, Dr. Evans, Mr. Stringer, anyone else, to deal
with the issue of Medicaid expansion as well. I think that
would be helpful for us to understand.
And with that, let me recognize Congressman Pocan.
And if people need to go vote, please do. I am going to go
to do that, and Congresswoman Roybal-Allard will take the chair
while I go to vote. So thank you.
Congressman Pocan.
Mr. Pocan. Thank you, Madam Chair. Thanks for the hearing
and thanks for the witnesses. I will try to get to two
different subjects if I can.
Last year, I worked with Chairwoman DeLauro to include
language in the fiscal year 2021 omnibus bill that required
HHS, Department of Labor and Treasury to ensure employer-based
insurance coverage is in compliance with mental health parity
laws. As you know, the law requires insurers to cover care for
mental health and substance use disorders at the same levels of
other medical and surgical care services. Yet, over a decade
later after the first year it was passed, the first law was
passed, we have seen the prevalence of mental health issues and
substance use disorders rapidly increase, and there are still
insurers that are not compliant with the Federal law.
So my question, I guess, would be for Dr. Evans and
possibly for Mr. Stringer: How has the lack of access to
insurance coverage impacted mental healthcare, and has it been
exacerbated by the pandemic, or has access to telehealth
coverage increased access to care?
Mr. Evans. Well, telehealth has absolutely increased, and I
hope, as you have heard earlier, that we continue that. Access
to healthcare is extremely important. When I was a clinician,
and I was the clinical director of a triage facility, the first
question that we asked when we were trying to figure out where
we needed to send someone was not what their diagnosis was. It
wasn't the level of intensity of their care. The first question
that we asked was what insurance they had, or whether they have
insurance because that dictates where you can go in terms of
your treatment services.
So if we--if people don't have, first of all, access to
those services because they don't have health insurance, often
people don't get the care that they need and they end up having
a lot of recidivism.
But the other point around parity I think is very critical.
What we know from the parity, our experience with parity, is
that is not just enough to have the laws, we also have to have
the enforcement. And it has been very clear that over the last
several years since the parity acts were implemented is that we
have to up the enforcement of parity, and we have to hold
insurers accountable to making sure that the full range of
services that are available to people from a physical health
side are also available on the mental health side, particularly
rehabilitative services and services that allow people to step
down and stay and maintain their care in the community.
Mr. Pocan. Great. Thank you, Dr. Evans.
Mr. Stringer, do you have a brief comment? Because I do
want to get to a second subject.
You may be on mute.
Mr. Stringer. I have only been doing this for a year now,
so I apologize. I am a slow learner.
Yes, I completely agree with the doctor. You know, it
puzzles me a bit why there isn't parity naturally, because good
mental health care means good--better physical care with fewer
costs, and so it puzzles me.
I was in this business back in the early 1980s when there
were a lot of private psychiatric facilities around the country
that were doing questionable things and making a lot of money,
and I think that that frightened the insurance companies, and
they really clamped down. What is unfortunate today is that
they are still living in the 1980s in that regard. We need that
care, so----
Mr. Pocan. Thank you very much.
Mr. Stringer. Yes.
Mr. Pocan. And then a question for Dr. Amaya-Jackson in the
time I have left. The Trevor Project, the leading organization
providing crisis intervention and suicide prevention services
for the LGBTQ community, has said that since the onset of
COVID-19, the volume of youth reaching out to their crisis
services program has significantly increased, nearly doubled
the pre-COVID level. And as you know, the LGBTQ youth are
already four times greater at risk of things at like suicide.
I was just wondering, how do we ensure these kinds have
access to mental health services, especially for kids who don't
feel safe in their own home? We are seeing that is almost three
times the rate with COVID that LGBTQ youth are feeling not safe
at home right now.
Dr. Amaya-Jackson. Thank you for that question.
Well, we know that LGBTQ youths and adults have long been
burdened by mental health concerns, from anxiety, depression,
self-injury, suicidal thoughts and attempts. Like you said,
they have higher rates of attempting suicide and they also
experience trauma at higher rates than their straight peers.
And we know where we can intervene are going to be in these
places where youth are experiencing bullying, traumatic forms
of societal stigma, bias, and particularly the family
rejection, which is very problematic often for them, and makes
their ability to cope with some of these other things less
possible.
The other problem is that historically, professionals have
been less successful in really recognizing and meeting the
needs of traumatized LGBTQs that perpetuates many of their
traumatic experiences. So I think that the issue is making sure
that our providers and our child-serving systems, yet, again,
are in recognition of this group as a high-risk vulnerable
population who needs access to evidence-based treatment, and
that they need training in their ability to work and engage
with these youths and to make--to get the conversations going
with youth so that they know that it is okay, and that they can
feel safe in accessing care and getting into care where they
can heal.
Mr. Pocan. Thank you, Madam Chair. I yield back.
Ms. Roybal-Allard [presiding]. Ms. Herrera Beutler.
Ms. Herrera Beutler.
I am going to then go to Ms. Clark.
Ms. Clark. Thank you so much, Chairwoman Roybal-Allard, and
thank you for this hearing. This is incredibly helpful and just
a topic of such importance to my constituents back home.
I wanted to ask about, sort of, the collision of two crises
that we are seeing, that of racism in mental health and how--
the impact it has, and impact on access to treatment, and also,
the rising overdose deaths. And my specific question is about
Black patients with opioid use disorder. There have been
studies that show that they are 35 times less likely than White
patients to be prescribed medication-assisted treatments that
could help prevent relapses and deadly overdoses.
What can we do, as policymakers, to combat the inequitable
treatment of addiction in communities that are already dying at
disproportionate rates from the pandemic?
I will sort of open it to anyone who might want to----
Mr. Stringer. In Missouri, we have put together a task
force in St. Louis, in north St. Louis, which is really our
hotspot for overdose deaths among African Americans, in
particular, males. We have put together a task force that is
looking at that.
And one thing that we have learned and should have known a
long time ago is that, you know, the traditional treatment
model of having a bricks-and-mortar building where people go
and something mysterious happens, and you come out and you are
supposedly cured, you got a gold coin and all; that model does
not work. It just does not work with most--in those kinds of
areas. You know, there are transportation problems. There is a
certain amount of stigma, of course, associated with getting
substance abuse disorder treatment, and African-American
people--I hate painting any group with a broad brush, but
generally--you know, historically, African Americans have been
distrustful of the healthcare system. I think that is a fair
statement.
And, so, we need to take treatment to them. We need to make
sure that it is the kind of treatment that they would welcome.
The message needs to be delivered by people that they trust. So
we have engaged a large group of clergy men and women in St.
Louis to help us reach into that community. So we are doing
everything that we can, using the evidence that we have, and I
am optimistic that we are going to make a difference.
Ms. Clark. Thank you.
And along those lines, Mr. Stringer, you know, before the
pandemic, we knew that there were an estimated 120 million
people who lived in areas without adequate access to mental
health care. The vast majority are people of color and rural
communities.
Can you elaborate a little bit on how we can target Federal
support to help State and local public health officials, like
yourself, in getting mental health care out to underserved
communities?
Mr. Stringer. You know, it is an interesting question. My
interest and approach is, again, in taking treatment to
individuals, and it is different how you take treatment to
somebody in north St. Louis compared to how you take treatment
to somebody in northeast Missouri in a very rural area. So, you
know, the technology that we are enjoying now during the
pandemic--and it is really having a big effect--if we can keep
that technology that allows us to take treatment out into rural
areas, that to me is the answer.
And then, again, in inner cities, it probably is more of a
taking treatment in person to people with mobile vans, and
things like that, mobile treatment sites so that we are taking
treatment to individuals and families.
Ms. Clark. Thank you for that.
And my last question is going back to, as we are coming
into a new administration, looking, once again, at disparate
school discipline policies, and the impact of behavioral mental
health conditions, especially on Black and Brown youth that we
know are more likely to be followed into the juvenile justice
system, than to be provided mental health services.
How can we work together going forward to make sure that we
are giving every young person, every child that access? And do
you think that we can work with these school discipline
policies to have a true impact?
Mr. Evans. I will jump in if anyone else doesn't. I think
it is a really important question. So, in addition to making
sure that there are services in schools, we have to look at
school discipline policies. The data are pretty clear that
African-American children, both girls and boys, a new study has
come out looking at the suspension rate for girls who are being
expelled from school, African-American girls, is very
significant. And so we can't talk about trying to protect
people's mental health and not dealing with the reality of the
disproportionate and often disparate discipline treatment.
And, so, those two things go hand in hand, and I think if
we really want to address children's social and emotional
health, we have to look at those kinds of issues as well.
Ms. Clark. Thank you so much.
I see my time has expired. Thank you for your indulgence,
Madam Chairwoman.
Ms. Roybal-Allard. Ms. Frankel.
Ms. Frankel.
Ms. Frankel. Hello? Is that me? I have someone talking very
loud. Hold on.
Thank you for this. Thank you, everybody. This has been
quite a challenge trying to do this on my cell phone.
Okay. So, you know what, I think--Mr. Evans, is it Mr.
Evans? Is that correct? Okay. This is going to sound like a
simpleton question. But what is the opposite of evidence-based
treatment? Could you just give an example of what is evidence-
based treatment versus what is not?
Mr. Evans. Well, I would hope that we are not doing the
opposite of evidence-based treatment. Really what evidence-
based practices recognize is that in most fields, including the
behavioral health field, there is a gap between what the
science says, where the state of the art is, and the science,
and where it is actually widely practiced in the field, and
that gap is about 17 to 20 years.
And over the last, I would say three--two decades, our
field has been really trying to close that gap. For example,
when I was commissioner, we created an evidence-based practice
and innovation center. We spent about $2 million a year trying
to train providers what the state of the art was so they were
practicing at the top of where the science is.
So, I think we are getting better at that as a field, but I
will tell you it is very, very complicated and complex, and
there are a range of issues from the infrastructure within
treatment programs, to financing issues, to how people are
trained, and you have to deal with all of those issues if you
want to increase practice and get more people using those
evidence-based treatment approaches.
Ms. Frankel. Can you give me an example of like an old
treatment that would no longer be--not be considered evidence-
based?
Mr. Evans. Well, a good one for substance use is that--when
I came into the field, we had very confrontational approaches
to substance use treatment. So you are kind of in people's
face. You were confronting them. And that helped some people,
but it also was not very effective, especially given what we
know about trauma and the retraumatization of people. It is a
very good example of a practice that was widely practiced, or
the intervention was widely practiced; but with our new
understanding of trauma and the fact that so many people who
come into substance abuse treatment, particularly women--
probably 80 to 90 percent of the women who are in our treatment
programs, our substance use treatment programs have some form
of trauma in their history. So that kind of confrontational
approach can work against us, and against them.
Ms. Frankel. So, Dr. Evans, Mr. Evans, or anybody else on
the panel, how can recommendations on how we in Congress can
influence the evidence-based treatment, rather than what would
be, it seems, treatment that, you know--I won't use old-
fashioned, but it seems like it doesn't really work. What can
we do at our end?
Mr. Evans. Sure. So, you know, in my experience, it really
takes resources. We can't assume that simply saying doing this
evidence-based practice is going to lead to practice change. In
fact, it takes a lot of effort to change traditional treatment
approaches. So there are a couple of things that I would
recommend.
One thing that I would recommend that we not do is mandate
particular evidence-based practices, or even mandate a
percentage of the evidence-based practices. What is more
helpful is to have guidelines, and then to have resources that
systems administrators, people who are running mental health
systems, can use to provide the technical assistance to
treatment providers.
In my experience, we were able to literally train thousands
of workers, of mental health clinicians and change practice in
dozens of mental health and substance use programs by using
that approach, much more effective than simply saying, Do this
practice. Most of the time providers don't have the wherewithal
or the resources to actually be successful at that approach.
Ms. Frankel. And are any of those guidelines being
presented now and by what entity?
Mr. Evans. They are not really presented as guidelines. I
think to too great of an extent that providers are left to try
and figure this stuff out. If you are in a system where you
don't have leadership by the systems administrators to guide
people and provide the support, it is very difficult.
For example, one of the things that I did as a payer, is we
paid providers to train their staff. So if you are in a highly
fee-for-service system, as many systems that are highly reliant
on Medicaid are, if they take their staff off to get the
appropriate amount of training, they lose revenue.
So that is a disincentive to actually do it. So you have to
understand how the financing works to make those kinds of
issues a nonissue so that providers can then focus on getting
their providers, their clinicians trained up in the appropriate
amount of time that is needed to get them to practice at the
appropriate level.
Ms. Frankel. Thank you very much. Again, I am going to
follow up with you on this.
And, Madam Chair, I yield back.
Thank you very much.
The Chair [presiding]. Thank you. And I am back, and I
thank Congresswoman Roybal-Allard.
I now recognize Congresswoman Bonnie Watson Coleman.
Mrs. Watson Coleman. Thank you, Chairwoman. Thank you for
this hearing.
I think I want to ask Dr. Evans some questions,
particularly concerning the issue of mental health and the
African-American community. Before we had this pandemic, the
African-American community already had a pandemic. I did some
work with mental health and suicide with Black youth. I did
some work on an emergency task force. So I was just struck by
the range of ages that were caught up in that.
I am also concerned about just access to mental health
services for African Americans in general. For instance, what
is it that we need to do to ensure that there is safety when an
African American is going through a mental health crisis, and
the police respond to their door? What is it we need to do to
make sure, to ensure that there is greater safety when the
police encounter a Black person going through a mental health
crisis? What should we be thinking about doing here?
Mr. Evans. Sure. You know, we have to train police. When I
was commissioner, we trained in Philadelphia. We trained about
40 percent of the police in the city during my tenure, and I
and the police commissioner had a very close working
relationship. The people, officers going through training, got
mental health training during the Academy, and then when they
were on the street for a certain period of time, they would get
what is called crisis intervention training. It made a huge
difference.
When I became commissioner, we were having, on a regular
basis, citizens being shot, and often sometimes killed by
police who were responding, didn't know how to respond to those
issues. And I can tell you during the last several years,
probably 6 or 7 years of my tenure, we didn't have one police
shooting of a person who had a serious mental illness. So it
tells us that the training does make a difference.
Mrs. Watson Coleman. So that is a best practice. Is that
being shared with other States and municipalities? Yes?
Mr. Evans. A lot of cities are doing it. It originated in
Memphis, Tennessee, but many States, cities, are doing it. I
think it just should be a standard. It makes a huge difference
in the safety of the community.
Mrs. Watson Coleman. Do you agree that there is a
tremendous under-resourcing of Black clinicians, social
workers, psychologists? Do you have recommendations for us in
how we can encourage more and support more going into the field
that would be more helpful in dealing with our communities with
collective voices? And why are they not going into those fields
now?
Mr. Evans. Well, absolutely, and a big part of it is just
financing and getting through graduate schools. So the Minority
Fellowship Program is extremely important. That is a program
that we really ought to be making significant investments in
now, particularly now, because it is going to take some time
for people to get through the pipeline. So, you know, we should
be looking at a doubling or tripling of the Minority Fellowship
Program.
You know, one of the other things is that we have to break
down the understanding of mental health issues. You know, we
have to deal with issues like trauma. You know, in my tenure in
working in the field, we spent time doing community events
where people talked about mental health issues. Sometimes it
was storytelling events that were things that people would be
more likely to go to than a lecture, quote/unquote, on mental
health, or doing community art projects that gave us an
opportunity to engage the community.
You know, these issues, we have to come at them in multiple
ways. Part of it is working with the community to help change
attitudes, and then part of it is making systemic changes like
increasing----
Mrs. Watson Coleman. I don't want to cut you off, but I
have so much more to ask. And I do have a bill out right now
that passed the last Congress, hopefully will pass this
Congress, of redoubling these efforts to get more practitioners
or providers in the pipeline.
I am concerned about our kids. I am concerned about how do
we deal with the trauma of the pandemic, the trauma of the
isolation, getting back to what the heck is ever going to be
normal again, having our children not fearing being treated
disparagingly in the educational system or with the law
enforcement.
What are all of the things that we need to be doing? Are
there best practices in having getting schools ready, educators
ready, to deal with and looking for the signs of trauma, et
cetera? What should we be doing? And I know that this is
expired time, but----
Mr. Evans. I will say very quickly, we have to increase the
mental health literacy of the population and of all of the
people who are in child-service assistance, so child protection
systems, the school systems. We need to make sure that all of
those professionals have a basic understanding of the signs and
symptoms of having mental health problems and know what to do
when people experience that.
Additionally, we need to make sure that we are doing the
same thing for parents, and we need to make sure that we are
having these kind of conversations that destigmatize and
normalize conversations about mental health in the African-
American community.
Mrs. Watson Coleman. Thank you. There is so much more I
would like to ask, but my time is up.
Thank you.
Mr. Evans. Yes, thank you for your questions.
Ms. Watson Coleman. Thank you, Madam Chairwoman.
The Chair. Thank you.
Congresswoman Herrera Beutler.
Mrs. Lawrence. Madam Chair, am I next?
The Chair. Congresswoman Herrera Beutler.
Ms. Herrera Beutler. Thank you, Madam Chair.
The CDC announced that there was a surge in overdose deaths
in the U.S. Over 81,000 drug overdose deaths occurred in the
U.S. in the 12 months ending in May of 2020, which is--it was
the highest number of overdose deaths ever recorded in a 12-
month period, which is hard to believe.
In my home State in Washington, there was a 38 percent
increase from the previous year with Fentanyl-involved deaths
more than doubling, and this subcommittee has taken steps to
try and curb that scourge that synthetic opioids have made in
our communities, and these numbers continue to be concerning.
So, Mr. Stringer, in your testimony, you mentioned that it
would be more efficient to, quote, ``transition over time from
opioids specific resources to invest funds in a Substance Abuse
Prevention and Treatment Block Grant.'' Could you maybe explain
for me this point further and how this transition would be
helpful to your agency's response to this crisis during the
pandemic and then after?
Mr. Stringer. Sure. Thank you for the question. It is a
very good one.
You know, the drug landscape is always changing, as you
know. I mean, you know, it will be stimulants for a while,
opioids for a while. Alcohol, of course, is always way up
there. And States are different. You know, we see patterns
across the country that vary. And so transferring these grants
over into the block grants, that go through the State agencies,
allows us to be flexible in responding to those situations. You
know, if these current opioid grants were shifted over to the
block grant, I don't think I would do anything different until
we got a handle on the opioid crisis. But when we did, that
would give me the option to shift some funds over to something
else, whatever the drug du jour is.
You know, the other thing is that that also ensures
quality. We were talking about evidence of best practices
before, but where things get squirrelly is where funds go to
agencies that are not licensed or certified or accredited, and
that we have no oversight over. That is where things get
squirrelly. And Dr. Evans was talking about practices that are
not evidence-based. That is where you find most of them.
So that is a longwinded answer to your question, but it is
a good one. Thank you.
Ms. Herrera Beutler. Thank you.
And I wanted to ask another question, switching gears a
little bit. Before the pandemic we knew that there were many
vulnerable groups that were not receiving the care they needed.
One group I focused on extensively are postpartum moms who are
at risk of postpartum depression, anxiety, and substance use.
We knew that 75 percent of maternal health issues go untreated.
One study found that untreated perinatal mood and anxiety
disorders cost $32,000 per mother and baby, adding up to $14.2
billion annually.
So my question is, how has the Federal funding been used to
target groups of individuals that we knew were struggling even
before the pandemic, and how can we build off what is working,
and how can we give providers the flexibility they need to
treat populations that may be deterred from seeking help due to
stigma surrounding mental health and substance use disorders?
Mr. Stringer. Well, certainly in Missouri, pregnant and
postpartum women are just about our top priority population. So
we get those folks into treatment as quickly as possible and
keep them as long as necessary until they are solidly into
recovery. So I think making them a priority is important. And
they are, by the way, a priority of the block grant. So that
helps.
And then, you know, Medicaid is an interesting situation,
because Medicaid coverage stops, at least in Missouri, after,
you know, 60 days after birth. And, gosh, that is not--you
know, if you are just now getting into treatment, that is not
nearly enough time.
Ms. Herrera Beutler. I am going to--on that point, we did--
I am supportive of a bipartisan piece of legislation, I believe
we voted on the House and didn't get all the way through, to
extend that Medicaid coverage for at least that first year
because we know that, like, 60 to 70 percent of problems occur
in that year-long time. I mean, that whole year is postpartum.
So we could go a long way in treating those women if we don't
kick them right off of Medicaid within a month. I mean, if all
of my problems of having a baby came within just that month,
that would be great, but that just isn't reality.
Mr. Stringer. Yes, I completely agree.
Ms. Herrera Beutler. Thank you very much.
Madam Chair, I yield back.
The Chair. Let me see. Congresswoman Bustos.
Mrs. Bustos. Thank you, Madam Chair. I appreciate you
holding this hearing.
Dr. Evans, this question is for you. I would like to ask
you about crisis care funding. Last session of Congress, I
introduced a bill called ``The Crisis Improvement and Suicide
Prevention Act.'' It is legislation that directs 5 percent of
the $750 million in mental health block grants to be used for
crisis care service. I know you know this, that crisis funding
helps mental health providers all over the country.
Specifically in my district, we have Rose Krantz in Rockford,
the Robert Young Center for Community Mental Health in the Quad
Cities where I live, and Unity Place in Peoria, Illinois, and
it funds crisis call centers and mobile units to travel to
patients who are in crisis.
I want to thank you for endorsing the legislation that we
wrote out of our office, and I also want to thank Chairwoman
DeLauro for passing this set-aside into law in last year's
funding bill.
My question is this: How important is crisis care funding
during and after--because I think we can start looking a little
bit ahead, cross our fingers, but during and after the COVID-19
pandemic? And then how much funding do you think we should
provide the crisis care set-aside as we move forward?
Mr. Evans. So, first of all, thank you for your support for
these services, which are really essential in the community.
I recently had a personal situation where I was helping a
family friend access services. And what happens for mental
health conditions, unfortunately, is that mental health systems
are different in every community. And, so, it is very hard to
figure out where you go for help, how do you get access to
help. And I think what this funding does is it provides really
a floor for mental health systems to make sure they have the
minimum kind of services in place so that when people are in
crisis, they can reach out, they know how to reach out, and
they can get help. So I think it is very essential.
I also think that it is important to think about what comes
before and what comes after crisis services. And to me, as
someone who has, you know, run mental health systems, or ran
mental health systems for many years, that is as critical as
the crisis services themselves. Often there are not enough
alternatives to crisis. Many of the people who end up in crisis
services are there because there simply is no other
alternative.
I know people, for example, who will go to an emergency
department and say that they are suicidal, just to get help for
their substance use issue, or for their mental health issue.
And then on the back end of crisis services, we want to
make sure that people have available services, because what
happens is that people going into crisis services, they get
admitted to a psychiatric facility and there is no aftercare
immediately when that person discharges, it significantly
increases the likelihood that that person is going to
recidivate.
And, so, crisis services are essential. We need to have a
basic way that everyone can access those services when they
need them, but we also need to make sure that we have
alternatives, and we also need to make sure that we have
continuity of care so that people don't have to get into that
cycle.
Mrs. Bustos. All right. Dr. Evans, a follow-up question for
you. The National Institute of Mental Health says that more
than 60 percent of rural Americans live in mental health and
professional shortage areas. Rural America is my district. It
is mostly rural geographically. And, so, just as an example, we
have 14 counties in the congressional district I serve. Nine of
the 14 are considered mental health shortage areas: Stephenson
County, Jo Daviess, Carroll, Whiteside, Henry, Henderson,
Warren, Knox, and Fulton are all rural, and there is a shortage
there.
That is why in the December funding bill, I was lucky
enough to be able to include language that encouraged Health
and Human Services to increase the Behavioral Health Workforce
Education and Training program present in rural areas. And I
also introduced something called the Rural America Health Corps
Act that supports 5 years of loan forgiveness through the
National Health Service Corps for providers who commit to serve
in rural areas.
So how else do you think we ought to be working with Health
and Human Services to combat mental health provider shortages
in rural areas, besides what I just mentioned to you?
Mr. Evans. Great. I am so glad you asked this question.
This is a high priority for the American Psychological
Association. We have been working with organizations, like Farm
Aid and other organizations, to look at ways that we can help
get more providers in those areas. Loan forgiveness is very
important, but it is also important to fund and make sure that
we have Medicaid expansion, and the reason is that,
particularly in rural communities--and you would know this--is
that hospitals often are strained by the number of people who
are uninsured, uncompensated care. When those hospitals go
away, often there is no behavioral healthcare provider in those
communities.
So, we have to look at making sure that the individual is
also covered, and that their services are going to be covered
and the providers that are in those communities.
And we also need to make sure that we train providers to
work in rural communities because there are unique issues.
Farmers, for example, have a suicide rate that is significantly
higher than the rest of the population. They have unique
issues, and generic mental health services often aren't
responsive to the unique strategies or the unique issues that
those individuals are facing. And, so, we need to have a range
of strategies to make sure that we shore up those services, and
that those services are appropriate for the people in those
communities.
Mrs. Bustos. Dr. Evans, thank you very much, especially for
your grasp of these issues that are so important.
Madam Chair, I yield back.
The Chair. Thank you, thank you.
Congressman Cline.
Mr. Cline. Thank you, Madam Chair. I want to thank the
witnesses for participating today.
I am particularly concerned about the impact that the lag
of our local school divisions in reopening following CDC
guidelines to reopen is having on our children, on their mental
health. You know, participating in school activities, whether
it is school time, social time with their peers, engagement
with the arts, musical performances, sporting events, routine
activities, you know, these have all been drastically altered
or prohibited for in-person participation, and these types of
activities play just as important of a role as the academic in-
classroom experience, you know, affecting our children's mental
health.
So while it is important to take public health
recommendations seriously to stop the spread of COVID, we must
take a critical look at what commonsense precautions we can
incorporate into these activities so that our youth can get
back to normal.
The Virginia Chapter of the American Academy of Pediatrics
completed a survey recently, and 97 percent of respondents said
they had either seen child and adolescent anxiety increase, or
greatly increase, since the pandemic, and a majority responded
saying they had also seen a change in depression levels, with
95 percent saying it had either increased or greatly increased.
A report by the Centers for Disease Control and Prevention
showed an increase of 31 percent in children's visits to
emergency departments for mental health concerns for those ages
12 to 17, and 24 percent for those ages 5 to 11 over last
year's numbers.
I am encouraged to see the topic of mental health discussed
more openly, removing the stigma that surrounds this issue, but
there is much work to be done.
So I will ask, Dr. Evans, I recently was in touch with our
Governor in Virginia who has put through a particularly
stringent shutdown, and is lagging on reopening and following
CDC guidelines, particularly when it comes to youth sporting
events.
The Governor has only capped at 250 participants, or 20, or
30 percent capacity rate for attendance, urging people to
remain 10 feet apart at these events and masked, which is far
beyond what is recommended.
So, Dr. Evans, you stated that prolonged social isolation
due to the pandemic has placed inordinate stress on many
interpersonal familial relationships, and threatened normal
child development, which is dependent on interaction with peers
and others. You also said that children's mental health is
particularly vulnerable.
Can you elaborate on how activities like attending a local
sporting event, being in a band, or a cheerleader can impact
students?
Mr. Evans. Sure. So we know from a lot of research, decades
of research, the negative impact that social isolation can have
on our mental health. I think, in addition, for children, we
have to be aware of not only the stressors that they are
experiencing, but they are also missing important developmental
milestones that are important in our development as people.
And for children, I think we have to be concerned about two
broad areas. One is the mental health that we are talking about
today, but we also have to be concerned about cognitive
development, disruptions in learning, and the impact, the long-
term impacts that that is going to have.
So I think the implication of all of this is, yes, there
are things that we have to do in terms of protecting our
physical health, but the points that you are making about the
impacts on our mental health are really critical, and we are
going to see these impacts over a number of years, not months,
once the pandemic is over.
And that really means that we have to have the resources
there to address both of those sets of issues.
Mr. Cline. Thank you. You know, another area that I am
concerned about is the increase in domestic violence and the
impact of domestic violence on children. As a former prosecutor
of domestic violence, I understand the importance of ensuring
that victims are taken care of, and the pandemic has only made
it harder. Isolation is a major risk factor in intimate partner
violence and family violence. Unfortunately, isolation as a
result of the pandemic may have exacerbated domestic violence
cases.
So, Dr. Amaya-Jackson, you discuss in your testimony how
the economic and other strains caused by the pandemic increased
that risk for family violence. Can you expand on the factors
that are contributing to this increase and ways that we can
address that and help them get to resources?
Dr. Amaya-Jackson. Sure. Yeah. Thank you for that really
important note and question.
So children and families, when there is overcrowding, they
are in quarantine, they are isolated, they are not having the
social support, you know, these are the things that create
tensions and conflict and often lead to violence, particularly
where families already have preexisting scenarios where there
has been tension, job insecurity, potentially poor
relationships in the past. And, you know, it ends up being a
powder keg, and children are exposed to this violence and
families are experiencing this violence.
The next steps of what we can do is really going to be
making sure that community supports, that we have training to
providers so that people can be the link to bring these
concerns to their community physicians, to their therapists, so
that the therapists can address these issues, that the
communities have the support, and that there is a trauma-
informed system in place to handle these situations.
Mr. Cline. Thank you. I yield back.
The Chair. Congresswoman Lawrence.
Mrs. Lawrence. Thank you so much, Madam Chair.
I want to talk about an issue that is extremely important
to me, and that is our foster children. The American Academy of
Pediatrics and the Healthy Foster Care America initiative
identified mental health as the greatest unmet health need for
children and teens in foster care.
I have a bill that requires that we, who are the custodian
of these foster children, that these children get mental health
screenings just like we mandate they get physical health
screenings.
Dr. Evans, can you explain why it is so important that we
address the mental health needs of our children, especially
those who are likely to experience trauma? I take in foster
children every year as interns in my office, and one of them
told me the fact that I am in foster care means I have had a
trauma in my life. Why are we as a government not stepping up?
Could you please add your feelings on this issue?
Mr. Evans. Sure. Thank you so much. And I feel strongly
about this, because, you know, I worked both in the child
welfare system as a commissioner and then as a commissioner in
the mental health system. And, you know, the young person is
exactly right. You can assume that every child who is in the
foster care system has experienced some kind of trauma.
Minimally, they have been removed from their families.
And one of the things that people don't understand is that
removing a child from their family, even when there may be
neglect involved, can be just as traumatic and sometimes more
traumatic than whatever the issues are that may have led them
to be involved in the child welfare system.
I believe strongly that we have to take a multisystemic
approach to this issue, implementing programs like therapeutic
foster care, making sure that every foster care parent has some
basic understanding of mental health issues, they know how to
connect their child to those services, and that the child
protection system has adequate resources to make sure that
those services are available to not only the child but to the
child and their family.
You also have to educate judges. One of the things that we
did when I was commissioner was to work very closely with the
judges to make sure that they were making good decisions about
how to place children and what were the services that the
children needed.
And so you have to work in sort of multiple levels. You
have to work with the court system to make sure that they are
sensitized to issues and that they are making trauma-informed
decisions. You have to do that in the mental health system. You
cannot assume that just because a person is trained in mental
health, they understand the unique needs and issues related to
children who are in that system.
And you have to make sure that the people in the child
welfare system are getting the training that they need so that
they are making good decisions in terms of how those children
are treated.
Mrs. Lawrence. Dr. Jackson, can you please respond to this
as well. Because the things that were just touched upon are
part of a legal system that has a major role in this and also
the parent. Do you have any comments on the foster care crisis
I feel that we have in America with mental health?
Dr. Amaya-Jackson. Yes. Again, thank you for that question.
So it is multifold, right? It is the experiences of the
children that become cumulative over time and lead to
complexities in their behaviors, in their emotions, in their
cognitive functions, whatever, that makes it difficult for both
child-serving providers and the families that are working with
them, you know, to handle that.
And so it is how do we increase the capacities of, you
know, foster parents, kinship parents, et cetera, to be better
able to take care of these children, to make them feel
psychologically safe as well as physically safe.
And the NCTSN does have programs and trainings. We have
developed full-on curricula called the Resource Parent
Curriculum that works with foster parents so that they can
understand, you know, when the children are waking up crying
and having nightmares about blood or something like that, that
they know what to do and how to handle that, how they talk to
these children.
So there are the issues that deal directly with the
children and helping the foster system and, you know, the
child-serving provider to be ready and able to work with
children with these kinds of difficulties.
But the other issue which Dr. Evans alluded to is making
sure the child welfare system is trauma-informed. And what I
mean by that is that these systems know how to screen for
trauma exposure and related systems, they know how to make
children, make resources available to them that are, you know,
on trauma exposure and its impact and treatment, and really
engage in efforts to strengthen the resiliency and protective
factors, and working with these families and the entire system,
you know, from the front door that you walk into a child
welfare program to the way the caseworkers are dealing with
them. And the caseworkers themselves are often very overwhelmed
as the numbers increase.
Mrs. Lawrence. Yes.
Dr. Amaya-Jackson. And Dr. Evans was alluding to this. You
know, they often have secondary traumatic stress reactions
themselves. So the whole system really has to be addressed to
help that be trauma-informed as well.
Mrs. Lawrence. Thank you so much, and I yield back.
The Chair. Congressman Harder.
Mr. Harder. Well, thank you so much, Chairwoman DeLauro,
Ranking Member Cole, for hosting this hearing on this
incredibly important topic. And thank you to the witnesses for
contributing their testimonies.
I have discussed provider shortages before, and I know
Congresswoman Bustos touched on some of the challenges that our
districts actually share in rural areas, but I think the mental
health shortage is just incredibly acute. I mean, for every
five mental health practitioners per 100,000 people that there
are in California, there are only three in my district.
It is close to half where we have in sort of providers per
capita. And obviously it has gotten worse during this pandemic,
as my district has seen increases in mental health needs for
many of our constituents, especially the students and family
members that we have been talking about during this hearing.
And I think that really is a profound statement, sort of
our values and being able to deliver very appropriate and
effective mental health treatment in rural areas.
Mr. Stringer, I am very curious with your experience, given
that you oversee Missouri's Department of Public Health, can
you provide some examples with how you or other State
departments have succeeded in the long-term attraction and
retention of mental health providers, and what do you think
should be done by this committee to continue to bring that to
the next level?
Mr. Stringer. Yes, thanks for the question. I wish I had a
good answer. We have done some things to make the situation
better. You know, one example is, you know, we have a critical
shortage of child psychiatrists in Missouri and around the
country.
So we worked with the University of Missouri-Columbia to
develop what is called the Child Psychiatry Access Program,
where physicians across the State can sign up for this. So a
pediatrician who has got a behavioral health problem in his
office in northwest Missouri can call and be on a phone or a
Webex with a child psychiatrist at the University of Missouri
for consultation. That is a nice model, and it is a great way
to spread our child psychiatrists.
And I think it is things like that. There are ECHO training
programs that are helpful. It is just going to involve multiple
things.
In terms of the committee, you know, you have already been
really good about educational reimbursement and things like
that. I think we have got to take a multifaceted approach to
this. Part of it is certainly helping folks, kids with tuition
and things like that.
Mr. Harder. Thank you. I appreciate that.
Well, one of the models that we have seen been very
successful for mental health in our area is the Promotores de
Salud Program, which is essentially community health workers
targeted towards our Latino community. Oftentimes, that is the
front line of attack against some of the mental health
challenges that we have seen, especially in this pandemic.
I am curious where folks have seen that model been
successful and what opportunities we might have to continue to
scale up those sorts of community health workers, especially in
communities of color, to make sure that we can cater to the
mental health needs in a real community-centered approach. That
is for any of our witnesses that have any suggestions around
that.
Mr. Stringer. In Missouri, we have certified peer
specialists, which that is a big part of the answer to the
workforce shortage, and that can be done fairly quickly. We
have certified peer specialists that work with our
professionals.
And these peer specialists are people who have had some
training, and they have lived experience with the mental
illness or substance use disorder and they work hand in hand
with our mental health professionals. And they will go into
emergency rooms, for example. They will go into a variety of
community settings for the purpose of outreaching and engaging
people in services.
Mr. Harder. Terrific. Any other witnesses have any
suggestions on provider shortages in general or that type of
community health worker model?
Mr. Evans. Well, I think what I would add to what Mr.
Stringer said is there is a movement in the mental health field
to do what is called task-shifting. There are things that we do
in the mental health world that don't necessarily need a person
who is trained at the master's or doctoral level.
And as the program--I am not familiar with that specific
program, but it sounds like that program is taking people who
may not have the higher levels of training but might be very
effective at engaging people.
So I think that those kinds of strategies and peer
services, as you heard Mr. Stringer talk about, are really
critical. I also think that telehealth is extremely important,
and audio telehealth, particularly in rural fronts and frontier
communities, which we often don't talk about, where people
don't have the broadband bandwidth to do regular telehealth. So
making sure that audio telehealth and telehealth in general is
available is one really important aspect to addressing the
shortage.
Mr. Harder. Perfect. Well, thank you, Mr. Evans.
Back to you, Madam Chair, and thank you so much for your
time.
The Chair. I thank our witnesses. We will not have a second
round of questioning, but let me ask of Congressman Cole for
any last minute thoughts or comments or a question that you
might want to ask.
Mr. Cole. Well, I will try to wrap up from my standpoint.
First of all, thank you, Madam Chair, for the hearing. I think,
you know, it is clearly a subject that the committee cares
very, very deeply about. We had a lot of great questions and
observations and comments.
I want to thank our witnesses. I also want to apologize to
them a little bit. We all had to go in and out voting, but that
is what they pay us to do up here, so I am sure you are going
to be generous in forgiving us in that regard.
I am struck, Madam Chair, as you were, with, number one,
the consistency of thinking from a variety of perspectives of
this particular panel. I am struck too, just thinking over
several hearings, about the things that we see over and over
again: the disparate healthcare outcomes, the workforce
shortages, and a variety of areas.
It strikes me that we do a very good job in probably taking
care of the research into this and maybe not as good a job in
just the delivery and the coverage area. We all know that we
have tremendous problems in terms of matching up our workforce
with our needs and having a workforce diverse enough that it
matches with our population. Just a lot of serious issues here
that are going to take sustained investment over a lot of
years.
But, you know, that may be--well, let me put it this way:
This pandemic certainly is going to cast a long shadow. It is
not a situation where we have got the vaccines and, gosh, in 90
days, we can look in the rearview mirror and put this behind
us. I think the panel made very, very clear the consequences of
this are going to live a long time and affect a lot of
individual Americans in very negative ways. We are going to
have to think that through as we try to manage expanded but
still always limited resources to cover these gaps.
But, again, I will just thank our witnesses. You were all
terrific and very, very helpful in, you know, highlighting the
areas that this committee needs to take into account and focus
on in a bipartisan way and move forward.
So, with that, Madam Chair, I yield back to you.
The Chair. I want to thank the ranking member for his
comments and cooperation in the past on these issues, and I
know we will have the cooperation going forward in these areas.
And I too want to say thank you to all of the witnesses who
joined today. And, again, really, you are laying out a
blueprint for us. And we need to be mindful of that blueprint
and look, as the ranking member said, within, you know, the
scope of the resources, et cetera, really to deal with how we
are going to prioritize this area going forward because this is
not just for the moment, short term, and it is important.
And you have elucidated, which I will mention, some of the
short-term things that we can do, but this is going to be post
this pandemic and what we are going to live with. And I say
that because we know and why today was so critically important,
we have studies of Chernobyl, Hurricane Katrina, September
11th, to show that elevated rates of mental health problems go
beyond the initial event and sometimes last for more than a
decade or beyond.
And this virus has the same similar long-term disaster. And
what you have laid out and what people are dealing with is
anxiety, depression, grief, isolation, and what that has
already translated into in overdose death, people thinking
about suicide. So I think the emergency which we recognize, I
want you witnesses to know that we recognize the urgency of the
action that we need to take if we want to make an impact.
And we also know that we had a system that was already
struggling with trying to meet the existent needs of mental
health. And it wasn't front and center, but in so many ways
what this pandemic has done is to really expose the
shortcomings in our various systems, whether it be unemployment
insurance or public health infrastructure, healthcare
disparities. All of these have been, you know, just really
exposed and exacerbated because of the pandemic.
So how we deal with improving the pipeline of providers and
how we look at the services. And I do want to mention this to
you, because, listen to this, just it pulled out some of the--
to our ranking member, most of these issues fall within the
bailiwick of this committee.
You know, it is the population health approach which Dr.
Evans spoke about, working with communities to identify someone
with a problem before it becomes a crisis and look at it in
terms of populations that we know may be potentially at risk.
We are talking about African-American communities,
underserved communities. Congresswoman Roybal-Allard talked
about, you know, the postpartum moms, you know, et cetera, a
number of areas. So which part of the population and how do we
deal with that? And it is not cookie cutter.
Increased funding for school-based mental health, increased
access to evidence based trauma-informed care, and we need to
hear from all of you about best practices on trauma-informed
training. Help us with that so we put the money in the right
places in this issue.
Resources, and you have been consistent on the Substance
Abuse Prevention and Treatment Block Grant program, which is
something that you all believe is a direction that we need to
go in. Funding for workforce programs to address the provider
shortage here, which is critical.
Prioritizing the needs of at-risk vulnerable groups,
children and adults, that goes back to the population approach.
Increased integration of mental and physical health. And I will
tell you, because these are pieces that we are funding already
and we need to take a hard look, is the certified community
behavioral health clinics, which move us towards this goal. The
National Center for Child Traumatic Stress. This is working,
and we have put funds into these programs.
And how we sustain or enable grantees to be able to sustain
themselves with funding is an important part of a long-term
response. And looking at SAMHSA, looking at SAMHSA, at their
role as a lead coordinating, you know, agency.
So how do we reduce stigma on all of this? And it may be
that, unfortunately, this is such a widespread issue at the
moment that the issue of stigma may be, you know, lessened, how
it is playing out, because we are going to see this short term
and long term, so people understand it.
And one of the things that we pay close attention to is we
don't have--at least the data now shows that the suicide rates
have not really increased. However, there has been an increase
in people thinking about suicide. And, as I understand it--and
I am not a professional in this area--but it is after the event
is over that you will see increased suicide as a result of what
happened. It may not be happening now, but we are going to see
that.
So there are a number of these issues. And a couple of
them, the telemedicine issue, Medicare, Medicaid, as we have
talked about. And, Mr. Stringer, I know Missouri voted on it,
but it has not yet been implemented, but everybody has alluded
to Medicare and the Medicaid expansion of really being helpful
because then you can take resources and use them elsewhere,
which is so critically important.
But telemedicine, Medicare, Medicaid, it is not part of our
jurisdiction, but we can certainly have, you know, an impact on
the committees and the subcommittees that do have that
jurisdiction.
I can't thank you enough, really, you know, for what you do
every single day. And what we want to do is to be partners with
you. And I don't want the conversation to end after this
hearing, but as we look toward to the appropriations bill for
2022, we would like to be able to take advantage of your
knowledge and expertise and where we place--the resources are
not unlimited, but help us to identify where we can utilize our
resources in the best way to address the short term, long term,
and use this as an opportunity to build some of the
architecture in this area that we need to have for the future.
So, again, my thanks to all of you and to all the members
of the subcommittee and particularly to our ranking member for
your interest in this area. We are going to move at it, and we
are going to be in touch with all of you, but don't hesitate to
be in touch with us as we go forward. Thank you so much.
And, with that, this hearing is adjourned. Thank you.
Tuesday, March 23, 2021.
ADDRESSING THE MATERNAL HEALTH CRISIS
WITNESSES
STACEY D. STEWART, PRESIDENT AND CEO, MARCH OF DIMES
CAROL SAKALA, DIRECTOR FOR MATERNAL HEALTH, NATIONAL PARTNERSHIP FOR
WOMEN AND FAMILIES
WENDY GORDON, ASSOCIATE PROFESSOR AND CHAIR OF THE DEPARTMENT OF
MIDWIFERY, BASTYR UNIVERSITY
LISA A. ASARE, ASSISTANT COMMISSIONER, DIVISION OF FAMILY HEALTH
SERVICES, NEW JERSEY DEPARTMENT OF HEALTH
The Chair. The hearing will now come to order.
As this hearing is fully virtual, we must address a few
housekeeping matters. For today's meeting, the chair or staff
designated by the chair may mute participants' microphones when
they are not under recognition for the purposes of eliminating
inadvertent background noise.
Members are responsible for muting and unmuting themselves.
If I notice that you have not unmuted yourself, I will ask you
if you would like the staff to unmute you. If you indicate
approval by nodding, staff will unmute your microphone.
I remind all members and witnesses that the 5-minute clock
still applies. If there is a technology issue, we will move to
the next member until the issue is resolved, and you will
retain the balance of your time.
You will notice a clock on your screen that will show how
much time is remaining. At 1 minute remaining, the clock will
turn yellow. At 30 seconds remaining, I will gently tap the
gavel to remind members that their time is almost expired. When
your time has expired, the clock will turn red and I will begin
to recognize the next member.
In terms of the speaking order, we will begin with the
chair, ranking member, then members present at the time the
hearing is called to order will be recognized in order of
seniority, and finally, members not present at the time the
hearing is called to order.
Finally, House rules require me to remind you that we have
set up an email address to which members can send anything they
wish to submit in writing at any of our hearings or markups.
That email address has been provided in advance to your staff.
With that, let me acknowledge Ranking Member Cole and our
colleagues for joining us here this morning. And I want to
thank and extend a warm welcome to today's witnesses, Ms.
Stewart, Dr. Sakala, Dr. Gordon, Ms. Asare, and we thank each
of you for being here and look forward to your testimony. And I
will introduce our witnesses further in a few moments.
Today, we are here to examine the maternal health crisis in
this country, which, frankly, I think amounts to a national
disgrace.
When Stacy-Ann Walker of Hartford, Connecticut, was
preparing to have her first child, she was 29, healthy, and
excited to become a mom. But when she started experiencing
shortness of breath, exhaustion, and swelling in her legs, her
doctor brushed her concerns aside, saying these were normal
aches and pains of pregnancy. Soon, Ms. Walker's baby developed
life-threatening complications that required an emergency C-
section that left both mom and baby fighting for their lives.
The baby weighed 2 pounds, 12 ounces at delivery, and Ms.
Walker developed heart valve problems and heart failure. Ms.
Walker, who is a Black woman, was lucky to come out of that
ordeal alive.
The CDC estimates that roughly 700 women die from
pregnancy-related complications a year in the United States.
Just very briefly, just a quick personal story. Sixteen
years ago, my daughter Kathryn went in with what was expected
to be a normal delivery of our granddaughter. When she was
ready to deliver the baby, they discovered an infection. Long
and the short of it, the infection led to sepsis and the
infection spread to both my daughter and to my granddaughter,
Rigby. Both were in the hospital in intensive care, and it
wasn't clear whether either one of them would survive. With the
grace of God, both of them survived, and Rigby today is 16
years old, and Kathryn is thriving.
I say that because oftentimes we don't think about
childbirth as with the implications that are attendant to it
and how dangerous it can be, and we just take it as a matter of
routine. And I think today's session helps us to focus on what
are the kinds of things that we need to do.
And even before COVID-19, the maternal mortality rate in
the United States was already more than double the rate of many
other industrialized nations. Shamefully, our maternal
mortality rate is higher than it is in Kazakhstan and in
Kuwait. This is partly because our maternal health outcomes
vary drastically by race.
Black women, American Indian, and Alaska Native women are
two to three times as likely to die from a pregnancy-related
cause than White women in the United States. And the racial
disparities persist, regardless of income, education, and
access to care.
Worse, for every woman in the United States who dies from
pregnancy-related complications, 71 women suffer from
unexpected labor or delivery complications that have a
significant impact on their health. However, it is important to
note that this number does not include women who suffer from
pregnancy-related mental health conditions. They are left out.
My question, and I believe our question should be, why?
The definition of severe maternal morbidity does not
include mental health conditions--depression, anxiety,
substance disorder--and maternal mental health conditions are
the most common complications of pregnancy. Suicide and
overdose are a leading cause of death for women within 1 year
of giving birth, so the mental health-related complications and
deaths are in addition.
Of course, the COVID-19 pandemic has only exacerbated these
longstanding problems. Because of the pandemic, pregnant women,
mothers, and their families are now less likely to pursue
prenatal care screenings and other postpartum and perinatal
care.
Social determinants of health have a profound impact on
maternal outcomes as well, and these issues do not exist in
isolation from each other. None of this happens in a vacuum.
Substandard housing, food insecurity, maternal healthcare
deserts, all of these challenges contribute to maternal health
disparities and can have a devastating impact on the health of
our Nation's mothers, which is why I am especially proud that
we created a new pilot program last year to help State and
local health departments to develop plans to address the social
determinants of health in their communities.
And I want to give a shout-out to Congresswoman Bustos for
her focus on the social determinants of health and where we
need to try to go with these issues.
As a proud founder of the bipartisan Congressional Baby
Caucus--and I cofounded that with Congressman Denny Rehberg
several years ago, and an inaugural member of the Congressional
Black Maternal Health Caucus--I am committed, as I think we all
are, to ensuring the health and the safety of our mothers and
our babies.
I want to highlight two members of the subcommittee for
their tireless work to improve maternal health and maternity
care. Chairwoman Roybal-Allard and Representative Herrera
Beutler are the founding co-chairs of the Congressional Caucus
on Maternity Care, which is a bipartisan congressional caucus.
This issue has been a priority for many other members of
this committee as well. Chairwoman Lee, Representative Watson
Coleman have been passionate advocates for reducing health
disparities in all areas, including maternal health and
maternal mortality.
And while she is not a member of this subcommittee, I am
excited to welcome Representative Lauren Underwood to the
Appropriations Committee. She has been a leader in assembling a
bill known as the Momnibus, which includes many new initiatives
to address maternal health and maternal mortality.
Over the past 2 years, this subcommittee has been
instrumental on a bipartisan basis in increasing funding for
grants and programs to improve maternal health. We increased
funding for the Maternal and Child Block Grant, the Alliance
for Innovation on Maternal Health maternal safety bundles, the
Maternal Mortality Review Committees, and for the Healthy Start
Program. We also provided funding for midwife training
scholarships and for State Maternal Health Innovation Grants,
to promote State-level coordination and innovation in maternal
healthcare.
Additionally, I am pleased that the American Rescue Plan
extended Medicaid coverage for low-income mothers from 2 months
after birth to 12 months after birth, an expansion that is
critical to improving access to care for vulnerable new
mothers. But there is still so much more work to be done, as 12
States have yet to expand Medicaid. And beyond that, while it
is a topic for the authorizing committees, we need to increase
reimbursement rates, and those cannot wait.
Today, we will hear from witnesses about some of the
reasons why maternal health outcomes in the United States lag
behind other industrialized countries and why disparities in
maternal health outcomes persist.
We will also hear about promising strategies to improve
maternal health, how the programs funded in Labor-HHS can
support these strategies and improve maternal health outcomes
in all communities.
Our mothers are the lifeblood of our families, our Nation,
and our world. And those 1,000 days between the beginning of a
woman's pregnancy to the second birthday of her child are
already incredibly stressful, challenging, and life-changing,
but now, for the first time in history, women are more likely
to die during childbirth than their mothers were before them.
This is unacceptable. As I said at the outset, it is a national
disgrace.
As a Nation, we are supposed to value freedom, motherhood,
and, yes, apple pie. But we have to ask ourselves, if the
United States is the bottom of the barrel when it comes to
maternal mortality rates among industrialized countries,
countries we consider our peers, then are we really a Nation
that values the lives of mothers?
Seven hundred women are dying every day. Thousands more are
suffering from either labor or delivery complications or
pregnancy-related mental health conditions. Can we really say
that our Nation values mothers or the lives of those that they
sustain?
We owe it to our Nation's mothers, to our families and
communities to ensure that not one more woman, not one more
mother dies as a result of childbirth. We are fortunate that we
are in a powerful position to help with this subcommittee. And
I hope that this hearing will give us all a better
understanding of what solutions there are and what we are able
to do, from an appropriations standpoint, to address this
inexcusable problem.
Our witnesses today are all leaders in improving the health
of women and their families. The panel includes witnesses who
will offer nonprofit, academic, advocacy, provider, and State
government perspectives on addressing the maternal health
crisis.
And, with that, I yield to our ranking member, Congressman
Cole.
Mr. Cole. Thank you very much, Madam Chair.
Let me begin with a little housekeeping, if I may. I, as
you know, serve as the ranking member on the Rules Committee,
as well as on this Subcommittee on Appropriations. In an hour,
we start a hearing on war powers, which I know people are very
interested in. So I will not be with you for the entire
hearing. I regret that very much, but I just have to discharge
my duties.
But let me begin by wishing, again, good morning to you,
Madam Chair, to the members of the subcommittee, and to our
testifying witnesses.
I want to commend the chair for holding yet another hearing
on an important issue, one that touches us all. Today, we are
here to learn about programs that seek to improve maternal and
child health. But, unfortunately, for far too many, the United
States is not the shining example that it should be in this
area.
I hope with investments we continue to make to expand
access to service and create change for expectant mothers in
the health system we can reverse course and lead the world in
quality care for all mothers and children.
I want to recognize as a leader on this issue and a proud
member of this subcommittee Ms. Herrera Beutler. She sponsored
and got signed into law the Preventing Maternal Deaths Act of
2018. In addition to this work, she launched the Congressional
Caucus on Maternity Care with Congresswoman Roybal-Allard,
another leader in this area. And I want to commend both of
these offices for helping to prepare for this hearing today.
And I would be remiss not to mention the decades of
congressional leadership by the chair for her efforts to
improve the health and welfare of children. Chair DeLauro has
spent much of her congressional career seeking to improve the
lives of children, and has been a long time chair of the
Congressional Baby Caucus.
Our subcommittee membership has led Congress in legislative
efforts and still continues this work with several proposals to
advance newborn health screening and address the unique needs
of moms in rural areas.
The United States has one of the highest maternal mortality
and infant mortality rates of all Western nations, a fact that
is simply unacceptable. My own State of Oklahoma ranks as the
fourth highest State in the entire country for both maternal
mortality and infant mortality. It is an imperative that we do
better.
To address these problems, our subcommittee has made
several significant investments to improve maternal health and
address disparities in maternal mortality. We have increased
resources to all 50 States and territories through the Maternal
and Child Health Block Grant, flexible funding that supports a
range of health services for moms and babies.
We have worked to establish Maternal Mortality Review
Committees, multidisciplinary teams that comprehensively review
deaths of women during or within a year of pregnancy. And I
know in the coming year we will do even more to support these
programs.
The leadership represented by this subcommittee in the area
of today's hearing shows how important the topic is today and
how fortunate this committee is to have such experts and
champions making critical funding decisions on these programs
for moms and their children.
We all know the new virtual environment can pose an untold
number of technical challenges. I want to acknowledge the work
of the chair and her staff, particularly Trisha--and I know I
will butcher your name, Trisha, so I am sorry--Castaneda, for
making these virtual hearings as seamless as possible. I know a
lot of hard work goes into that happening, and I certainly
appreciate those efforts.
And I want to thank all our witnesses for coming before us
today, sharing their time and expertise. We are always grateful
to have you.
And thank you again, Madam Chair, for holding this hearing.
It is a very important one as we go about our work for this
session of Congress.
I yield back the balance of my time.
I think you are muted, Madam Chair.
The Chair. Hi. Here I am. Okay. Technologically challenged.
But I want to thank the ranking member for his kind words.
But also, so much of the work and so many of the members of
this committee have been really, you know, leading the charge
and been visionary as the direction that we ought to go in, and
so much of the work has been on a bipartisan basis.
And I think, once again, we will note that even with all of
our witnesses, this is the third hearing that we have had where
there has been such a consistency of message, if you will, on
what the problem is and what we need to do about it, what are
the solutions. And so I am grateful for that effort.
And I want to apologize to my colleague, Congressman
Fleischmann. Both he and I chaired the Baby Caucus for a while
as well, so that has been a bipartisan event as well.
And, with that, let me introduce our witnesses this
morning: Stacey Stewart, president and CEO of the March of
Dimes; Dr. Carol Sakala, director of maternal health at the
National Partnership for Women and Families; Dr. Wendy Gordon,
associate professor and chair of the Department of Midwifery at
Bastyr University; and Lisa Asare, assistant commissioner of
the Division of Family Health Services for New Jersey
Department of Health.
I am going to turn it over to our colleague Bonnie Watson
Coleman to really introduce Ms. Asare.
Mrs. Watson Coleman. I want to thank you very much, Madam
Chair, and I want to thank you for holding this very important
hearing.
As the assistant commissioner in the Department of Health
in New Jersey, she has worked for this department over 22
years, so she brings experience and wisdom to the position she
holds today.
She oversees three service units which provide extensive
public health service to New Jersey families, promoting and
protecting health. And they include maternal and child health,
special child health, and early intervention services and the
State WIC program.
And in this capacity, she has led the Division's work in
addressing the social determinants of health through
multisector collaboration and public-private partnerships. And
she has also worked very closely with the first lady of the
State of New Jersey, Tammy Murphy, who has been a leader, a
collaborator, and a visionary in dealing with this particular
issue.
Ms. Asare is a graduate of the University of Toronto, and
has her master's degree in public health from Rutgers
University's Biomedical Health Services, and she has many
distinguished awards recognizing her wisdom and her
contribution to these areas. And I welcome her.
And I thank you for the honor you have given me to
introduce her.
The Chair. Thank you. Thank you.
And, with that, I am going to--I want to remind the
witnesses that the entirety of their written statement will be
entered into the record. And we will now proceed and we will
proceed with Ms. Stewart. You will begin your testimony.
Ms. Stewart. Thank you so much.
And good morning, Chair DeLauro, Ranking Member Cole, and
members of the subcommittee. Thank you for inviting me to
testify today. My name is Stacey Stewart. I am president and
CEO of March of Dimes.
We have many challenges before us as we are confronted with
a dire maternal and infant health crisis to help women before,
during, and between pregnancies. We need to do much more to
improve outcomes for moms and babies, but the reality of this
crisis that we are facing is truly startling, as you mentioned,
Chair DeLauro.
The U.S. remains among the most dangerous developed nations
in the world in which to give birth, and it is more dire for
women and babies of color.
Preterm birth is a leading cause of infant mortality, which
has slowly declined over the past few years, but, today, still,
in the U.S. two babies die every single hour and two women die
from pregnancy complications every single day.
It is not just access to quality prenatal care that makes a
difference in outcomes. Improving the health of a mom before
she is pregnant, as she is trying to become pregnant, and even
after pregnancy are essential. The fourth trimester, which is
the 12 weeks after birth, is a vulnerable time, and we must
ensure moms and babies are receiving adequate care.
The causes of this crisis are complex, but there is still
much we do not know. The Preventing Maternal Deaths Act and the
PREEMIE Reauthorization Act are enabling us to collect vital
data and translate it into meaningful action to prevent future
deaths.
We are hopeful new events, new efforts will spur further
action, including a new HHS public-private partnership that we
are undertaking to advance equity in maternal health through
hospital-based quality improvement activities. This pilot,
which is funded by UnitedHealthcare, aims to improve outcomes
for baby--for Black women in the South, and we plan to scale it
to 100 hospitals over the next 5 years.
With all this, March of Dimes offers the following
recommendations for fiscal year 2022 funding: First, the Eunice
Kennedy Shriver National Institute of Child Health and Human
Development, NICHD, carries out groundbreaking research on
preterm birth, maternal mortality, maternal substance use, and
prenatal substance exposure. We request at least $1.7 billion
for NICHD, to sustain it and enhance its existing research
programs, including efforts of COVID-19.
CDC's Surveillance for Emerging Threats to Mothers and
Babies Network, SET-NET, was designed during the Zika virus
outbreak and informs clinical guidance, educates providers and
the community, and connects families to care. And due to
chronic underfunding, CDC currently supports only 29 State,
local, and territorial health departments. Therefore, we
request funding for SET-NET at $100,000,000, to allow CDC to
provide real-time clinical and survey data nationwide on the
impact of COVID-19.
Maternal Mortality Review Committees, MMRCs, funded by CDC
in 25 States, work to identify, review, and characterize
maternal deaths and prevention opportunities. We need more
standardized data collection, which is so important and needed
to examine all the factors contributing to maternal mortality,
preventable deaths, and poor birth outcomes. We are requesting
$30,000,000 to maximize the reach and capabilities of MMRCs
nationally.
The Perinatal Quality Collaboratives, PQCs. PQCs are
currently funded by CDC in 13 States, and they work to improve
the quality of obstetric care in health facilities. However,
many lack adequate resources, and we are requesting $30,000,000
to fully scale these programs in all States.
PRAMS, Pregnancy Risk Assessment Monitoring System,
collects State-specific, population-based data on maternal
attitudes and experiences, covering about 83 percent, 83
percent of all U.S. births. We are requesting funding of
$2,000,000 to sustain this critical survey system.
Newborn screening is another one of our most successful
public health programs. Each year, 98 percent of the 4 million
infants that are screened each year--that are born each year
are screened, allowing them to receive prompt treatment and
care, saving and improving their lives. CDC's Newborn Screening
Quality Assurance Program and HRSA's Heritable Disorders
Program are also important. We urge you to provide $28,000,000
and $28.883 million for these programs, respectively.
Lastly, I will just mention HRSA's Screening and Treatment
for Maternal Depression and Related Behavioral Disorders
Program, an important program that we are encouraging more
support of. $10,000,000 we are urging to provide support to add
five State grants. And we thank the subcommittee for its
funding $3,000,000 for the Maternal Mental Health Program.
I just want to say, in conclusion, thank you for this
hearing, and I look forward to adding more information about
all these programs that we are requesting support for. Thank
you.
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The Chair. Ms. Sakala? Dr. Sakala.
Thank you, Ms. Stewart.
Dr. Sakala.
Dr. Sakala. Thank you.
Chair DeLauro, Ranking Member Cole, and members of the
subcommittee, I am grateful to testify before so many stellar
champions for women and families. I am Dr. Carol Sakala,
director for maternal health at the National Partnership for
Women and Families.
The National Partnership has been advancing economic and
health justice for 50 years. I am honored to be here today, and
encourage continued listening to those most impacted as we
develop policy.
Our Nation fails to provide many birthing families with
equitable, respectful, safe, effective, and affordable care.
What can we do about the urgent dire needs, especially of
Black, indigenous, and other people of color? Research shows
that several models offer better care and outcomes now. I will
briefly discuss three of those and one promising emerging
model, as outlined in the National Partnership's Improving Our
Maternity Care Now report.
These interrelated models contrast with much typical
maternal care, for example, by providing personalized,
respectful, effective care, and achieving remarkable outcomes
for such key indicators as preterm birth and breastfeeding.
First, midwifery care emphasizes building a trusting
relationship, promoting health, and tailoring care to needs and
preferences.
The second model is community birth settings. Demand is
rapidly growing for birth in both birth centers and at home as
appreciation for the distinctive care in those settings grows.
The third model is doula support. Doulas are trusted
nonclinical companions who help birthing people through comfort
measures, emotional support, and information. And an extended
model provides support from pregnancy through the postpartum
period.
Community-based forms of these models help meet needs of
birthing families from historically marginalized groups and a
strong evidence base supports them.
The final model is community-led perinatal health worker
groups, which generally offer a range of community-tailored
support services and may provide clinical care. They offer
dignity and respect to clients who often experience
discrimination in healthcare and everyday life.
Although many of these multifunction groups offer proven
midwifery, birth center, and doula services, their impact has
rarely been evaluated. This model could play a major role in
mitigating our maternal health crisis, and evaluation is a
priority.
We must also continue the longer term work of transforming
the maternity care system through payment reform, workforce
development, and other levers, and we must continue to expand
access to paid family and medical leave and other essential
social supports.
Here are some recommendations within the subcommittee's
jurisdiction, and my written testimony has additional
recommendations and details. Chronic underfunding hampers the
potential of State Perinatal Quality Collaboratives, which
bring stakeholders together for quality improvement. We
encourage the subcommittee's continued support of these groups.
We also encourage the subcommittee to continue to advance
maternal health through two new initiatives at the CMS Center
for Medicare and Medicaid Innovation by evaluating the
community-tailored perinatal health worker models and by
carefully designing and encouraging uptick of a maternity care
episode alternative payment model for accountable higher
quality care.
Additional Agency for Healthcare Research and Quality
funding could help fill glaring maternal health performance
measure gaps. To foster needed improvements, we encourage a
set-aside for person-reported measures of both the experience
of receiving maternal newborn care and maternal health
outcomes.
Thank you to this subcommittee's maternal health champions,
Chair DeLauro, for leading on paid leave and paid sick days;
Representatives Roybal-Allard and Herrera Beutler for leading
the Maternity Care Caucus; and the majority of members for
leading or cosponsoring priority maternal health bills,
including the Black Maternal Health Momnibus, BABIES, Midwives
for MOMS, MOMMA's, FAMILY, and Healthy Families Act.
Gratefully, the subcommittee's investments in Federal
programs target inequities, fund essential work, and are making
a difference for moms and babies.
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The Chair. Thank you very, very much.
Dr. Gordon. Dr. Wendy Gordon.
Dr. Gordon. Good morning, Chair DeLauro, Ranking Member
Cole, and members of the subcommittee. And thank you for the
opportunity to testify today. My name is Dr. Wendy Gordon, and
I am an associate professor and chair of the Department of
Midwifery at Bastyr University, a small natural health college
near Seattle, Washington.
Thanks to the work of this subcommittee, my midwifery
education program was one of the first recipients of the set-
aside funding from the HRSA Scholarships for Disadvantaged
Students grant that was earmarked for midwifery education
programs in 2020. I and several of my students are extremely
grateful to this subcommittee for that opportunity.
I have been a midwife for 16 years and am currently in
active practice at a freestanding birth center in Seattle. I
have a master's in public health, and I am among first to
receive a doctorate in midwifery from an innovative program at
Jefferson University.
I have been asked to talk with you today about the
importance of community providers in addressing the maternal
health crisis. The U.S. ranks far lower than most high-income
countries and many middle-income countries with regard to
maternal mortality, preterm birth, low birth weight and infant
mortality, yet we spend more money on healthcare than any other
country in the world. How does this make sense?
There is a framework for understanding this. To think about
it as a spectrum of care from too little too late at one end
where people who need interventions can't access them, to too
much too soon on the other end where healthy people are getting
routine interventions that they don't actually need. The risk
of bad outcomes is increased at both ends of this spectrum, and
there is a sweet spot somewhere in the middle where people only
get interventions when they need them and in a timely manner.
Midwifery care is designed for that sweet spot.
In the U.S., there are three types of midwives that vary
somewhat in their training. Some become nurses first. Some are
trained in hospitals. Some are trained specifically to attend
births at home or in freestanding birth centers. All are
aligned with a low-intervention model of care that research has
found to produce far better outcomes for mothers, little to no
increased risk for babies, and higher satisfaction with lower
costs.
There is a current shortage of obstetricians in the U.S.,
to the tune of 6,000 to 8,000, and it is only projected to get
worse over the coming decades. We cannot expect maternal health
to improve with fewer and fewer providers.
Meanwhile, midwives are severely underutilized in our
maternity care system and attend only about 10 percent of
births. In other high-resource countries with better maternal
health outcomes, such as England, the Netherlands, Australia,
New Zealand, midwives are the main providers for all women and
OBs specialize in higher risk pregnancies.
But in the system we currently have, it is hard to even
become a midwife. The systems we have just don't support
midwifery. Even though it is quicker and more cost-effective to
educate midwives than physicians, there are no dedicated
Federal streams of funding for the education of midwives in the
way that nurses and physicians are funded. I urge this
subcommittee to advocate for continued and even expanded set-
aside funding through the HRSA grant for Scholarships for
Disadvantaged Students.
Midwife salaries are among the lowest for healthcare
professionals. The cost of malpractice insurance is almost
always covered by the hospital for those who are employed
there, but for those of us working outside of institutions, we
bear that cost ourselves. Many private healthcare insurers will
not cover midwifery services in community settings, which means
that the only people who can access this care are the ones who
can afford to pay out of pocket for it.
These gaps and barriers are pervasive, and they
disproportionately impact communities of color. I urge Congress
to pass the Black Maternal Health Momnibus Act so that these
racial health disparities might finally be addressed.
All women of reproductive age should have universal access
to midwifery care and midwives who look like them. The policy
environment and healthcare infrastructure should be fully
supportive of midwifery care across all settings. Midwifery
education should be funded, especially for people from
underrepresented minorities.
And programs should have the resources to expand so that
anyone who wanted to become a midwife could do so without
incurring crushing levels of student debt. To this end, I
strongly encourage Congress to pass the Midwives for MOMS Act
to help expand the midwifery workforce.
Thank you for the opportunity to testify this morning, and
I would be happy to address any questions that you might have.
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The Chair. Thank you so much.
And now we will hear from Lisa Asare. Lisa.
Ms. Asare. Yes, good morning. Thank you.
Chair DeLauro, Ranking Member Cole, and distinguished
members of the subcommittee, thank you for inviting me to
testify on this critically important issue. I would also like
to thank especially Congresswoman Roybal-Allard, Congresswoman
Herrera Beutler, and Congresswoman Bonnie Watson Coleman, from
the great State of New Jersey, for their leadership on maternal
health issues and requesting this hearing today.
I proudly serve as the assistant commissioner for the
Division of Family Health Services in the New Jersey Department
of Health, and also as a member of the board of directors of
the Association of Maternal and Child Health Programs, also
known as AMCHP.
I am responsible for overseeing a wide portfolio of
maternal and child health efforts in New Jersey, many of which
are funded, at least in part, by the very subcommittees that
this--for the very programs that this subcommittee holds
jurisdiction over, programs such as Title V from HRSA, our
funding from CDC, our funding from the Department of Education,
and funding from the Department of Labor. But my greatest title
and biggest responsibility is mother to three children, age 24,
21, and 12.
The United States has a maternal health crisis, as does New
Jersey, with a ranking of 47th in the Nation. This crisis does
not impact all birthing people equally. It disproportionately
impacts women who look like me, Black women. In New Jersey, a
Black woman is seven times more likely to die than a White
woman due to pregnancy-related complications. This is one of
the widest racial disparities in the Nation and evidence of a
system wrought with many inequities and structural racism.
I mentioned earlier that I am a mother. Two of my children
are girls, so this work is very personal. We can and must do
better for my girls and all of our girls.
Today, I will share some promising initiatives we have
underway in New Jersey under the leadership of Governor Phil
Murphy and through the efforts of First Lady Tammy Murphy's
Nurture New Jersey initiative.
New Jersey made a renewed commitment in 2019, when First
Lady Tammy Murphy launched this initiative, which is a
statewide awareness campaign committed to reducing infant and
maternal mortality by 50 percent over the next 5 years and
eliminating racial disparities in birth outcomes, with the
ultimate goal of making New Jersey the safest place in the
country to give birth and raise a baby.
Improving maternal health in the United States must include
a focus on improving clinical care, but we also must reach
beyond the hospital and healthcare settings to address the
social determinants of health. We have considerable work to do
to reach these goals. The examples that I share will show us
how we address equity, engage community, and foster cross-
sector collaboration.
Fortunately for us, we have been able to build upon the
support of some of our longer standing programs, such as the
Title V Maternal and Child Health Services Block Grant. Some of
the signature efforts funded by the block grant include the
implementation of the Maternal Mortality Review Committee,
allowing us to move from data to action, and the Healthy Women,
Healthy Families Initiative, which is focused on providing
social supports through Centering Pregnancy, doula programs,
breastfeeding, and fatherhood support.
We have been able to develop creative strategies with our
cross-sector partners and have looked to leverage additional
dollars to maximize ways to address the maternal health crisis.
For example, we have partnered with the Department of Labor to
establish a Community Health Worker Training Institute using
apprenticeship funding.
We have also partnered with the U.S. Department of
Education on a Preschool Development Grant, which we are using
to develop a doula workforce, recognizing that preschool
readiness starts well before a child even enters the classroom.
Investing in doula support for mothers during prenatal, labor,
and postpartum periods is critical to laying the foundation for
a healthy start.
So what is my challenge and what is my ask of you?
Improving maternal health and eliminating inequities is a
complex problem that demands diverse solutions and funding
streams. I would ask that you, Congress, and Federal agencies
take a page from New Jersey's plan and prioritize racial
equity, provide opportunities for community engagement,
facilitate cross-agency collaboration and ultimately rebuild a
new maternal and child health ecosystem.
Maternal health doesn't just start when a woman becomes
pregnant. It includes all of the critical events that lead up
to this period, making it necessary to engage across the life
course and across multiple sectors.
To sum up, we do have a crisis, but we do our best to
maximize limited funding. However, additional flexibility,
coupled with increased Federal investment, will multiply our
impact.
As I close, I want to emphasize we all have a role to play
in addressing the maternal health crisis. There is no one magic
solution and no single player. There are multiple solutions
that involve all sectors, all of your subcommittees working
together, for the United States to become the safest place in
the world to be pregnant, give birth, and raise a baby.
Thank you again to the distinguished subcommittee chair,
ranking member, and members of the subcommittee for inviting me
today. I look forward to answering your questions.
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The Chair. Thank you.
I want to thank our witnesses really again. The consistency
of information on the problems and the solutions and their
admonition to all of us to move forward.
What I would like to do is, because I know the ranking
member has to leave for the Rules Committee, is have the
ranking member move forward with his questions first, and then
we will resume. Thank you.
Mr. Cole. Well, that is very generous, Madam Chair.
And let me start, since I won't be here at the end, and
just thank you again, seriously, for this hearing. I have had
the privilege of being your ranking member for two sessions,
now a third, and I think this has been the best group of
hearings we have had. You have really put a flashlight on some
problems that we need to be thinking about as a committee.
To our witnesses, our challenge as always, we are an
appropriations committee, and so we never have as much money as
we think we need. And the way approps work, I always like to
tell people is you have to move incrementally and cumulatively
over time, set long-term goals, because we are a committee
that, you know, gets some money in a good year, a little bit
more than we have, but not enough to usually address a problem
like this.
And this is a problem of enormous scope and complexity, as
all of our witnesses said. And, frankly, it is a problem that
ought to be an embarrassment to our country. It is just
unacceptable to have these levels of infant and maternal
mortality in an advanced society.
So, again, I applaud all of our members, as you pointed
out, Madam Chair, that worked on this, and I particularly
appreciate our witnesses.
I am just going to go through the witnesses quickly and ask
a question of all of you. And I will start with Ms. Stewart, if
I may, and then just sort of work through the lineup.
But, you know, one of the most shocking parts of the
testimony, of course, is the disparity geographically, in terms
of social class and certainly in terms of race, that we see in
our system. And, again, that is not acceptable.
So if you had to pick two or three things that you really
wanted this subcommittee to focus on to address that problem,
to get at the disparity outcome, what would those things do or
be? And let me start, Ms. Stewart, if I may, with you.
Ms. Stewart. Well, thank you, Ranking Member Cole, for
that. And I just want to acknowledge, again, this tremendous
opportunity and hearing.
Let me just start with addressing a couple things. One is,
you know, you mentioned that, you know, we are facing an
extraordinary maternal and infant health crisis in this
country. Even in States like your own, in Oklahoma, the preterm
birth rates are enormously high. Every year, the March of Dimes
issues a report card for every State and for the country,
looking at the rates of preterm birth.
Unfortunately, in many States across the South, some in the
Midwest, we are seeing some of the worst rates of preterm birth
of any places in the country. In Oklahoma, unfortunately, the
State's grade is an F compared to the overall U.S. of a grade
of C. That means that the preterm birth rate in Oklahoma is
even higher than it is across the country as a whole. Where the
preterm birth rate in the country is around 10.2 percent, in
Oklahoma, it is around 11.5 percent. And among Black women, it
is even higher. So the preterm birth rate for Black women is at
14.5 percent. It is 36 percent higher than as compared to White
women.
So what can we do? Well, one of the things that we have
been advocating for is that we have to make sure that women
have access to high-quality affordable care. That means that
every single woman should have access to being able to see her
doctor affordably.
We know that Medicaid covers between 40 and 50 percent of
all births in this country. Women having access to the care,
being covered by Medicaid, if necessary, before, during, and
after pregnancy. Making sure that women have coverage before
pregnancy, and making sure that women have coverage and don't
get dropped from Medicaid within a couple months after they
deliver their babies is really important.
So advocating for extending Medicaid 1 year at least
postpartum. We got some of the way there with the American
Rescue Plan, but we didn't get all the way there, to make sure
it is mandatory for all women.
The second thing we have to really acknowledge and why this
coverage is so important is because if we try to reverse these
outcomes with moms and babies just during pregnancy, we won't
succeed. We have to address the fact that there are underlying
chronic conditions for women before pregnancy----
Mr. Cole. If you could, I have very limited time. I only
have 2 minutes left, so I want to get to the other witnesses as
well. If you have another point, please make it.
Ms. Stewart. Thank you so much. Just want to end with this
to say, we have to look at the life course of women, making
sure they are addressing chronic health conditions before
pregnancy, during pregnancy, and afterwards. That would be a
great start for all of us.
Thank you so much.
Mr. Cole. Thank you very much.
Dr. Sakala.
Dr. Sakala. Yes, thank you. Very briefly, we have a data
problem, and if we can't identify how people are doing relative
to the average, we cannot improve it and address the
disparities. So I would strongly encourage better, more
consistent data disaggregation by race, ethnicity, and other
demographic categories.
And also my second point, I would call for a better
workforce development so that people are able to be cared for
by people who look like them, who understand their life
experiences, and who they can feel that they can build a
trusting relationship, including community-based providers.
Mr. Cole. Thank you. We hear both those things a lot, data
and workforce.
Dr. Gordon.
Dr. Gordon. Yes, thank you. I will advocate for the work
that the Black Maternal Health Caucus has been doing with the
Momnibus Act. There are 12 very well laid out bills that attack
the problem from multiple different angles, and that would be
my strongest encouragement for this work.
Mr. Cole. Dr.--excuse me, is it Asare? I hope I didn't
mispronounce that.
Ms. Asare. Asare. Asare. You are spot on.
I think for me, I would really speak to developing the
workforce, as some of my colleagues have mentioned, but I would
also talk about cross-sector collaboration. I think it is
everybody's issue. It is not just a health issue. And what we
are doing in New Jersey is really doing a lot of cross-sector
collaboration, maximizing other opportunities for funding,
looking at workforce development through a training initiative,
looking at developing a doula workforce through a Preschool
Development Grant, really looking to address food insecurity,
and many of the other areas.
So I would say that I would agree with what my colleagues
have said, but I would also add a cross-sector collaboration
model.
Mr. Cole. Thank you very much.
Thank you, Madam Chair, for the consideration in terms of
time. I very much appreciate it.
The Chair. We have been not been through the Black Maternal
Health Momnibus as a series of pieces of legislation, all of
which are really very straightforward and would lead us in a
different path if we wanted to change. So I would recommend
members get hold of that. We can even get that out to folks, if
you will.
Just a quick second before I ask my question here.
Geographically, I think we have to understand that the
disparities are both rural and urban, as I understand it. And
you have got rural areas where people have to drive for hours
and you have got hospitals where there are no services that are
offered.
And so we have got these--again, we have got food deserts
in this country, but we have maternity care deserts, and they
are both urban and they are rural. And there are no OB
providers in these hospitals, and it is hospitals closing in
both rural and urban areas where there is a concern.
Let me just ask, and for anyone who would like to answer,
there are some very promising strategies that you have
outlined. It is clear, though, that the country would need to
see more systemic changes in maternal and perinatal health
really to make improvements across the country in the outcomes.
How can the subcommittee support bringing these strategies
to scale, if you will, and what else should the CDC be doing in
this regard? So anyone who wants to answer, please. What are
the areas we should bring to scale, and what could CDC be
doing?
Dr. Sakala. I will answer the question about scale. We were
extremely impressed by the results of the Strong Start birth
center evaluation, 5 years, from the Center for Medicare and
Medicaid Innovation, which found that birth center care led by
midwives was effective in reducing preterm birth, low birth
weight, cesarean rates, other outcomes, and at lower cost.
And I will observe that the Affordable Care Act authorizes
the Secretary of Health and Human Services to expand
evaluations that are found by the Innovation Center to improve
care and save costs. So we would encourage you to work with the
Office of the Secretary to determine ways to scale up that
really powerful model.
The Chair. Thank you. Well, let me move on.
About the perinatal care workforce, as I understand it,
these collaboratives, there are only 13 States that have the
perinatal collaboratives. What do we need to support a
sufficient perinatal care workforce, and should we have one of
these collaborative efforts in every State?
I know you are going to say yes to that. I am going to try
to find out why we can't get them to every State. But if you
could focus in on that for a moment. And that is for the entire
panel, again, anyone who wants to answer.
Ms. Stewart. I can take that. This is Stacey Stewart.
So, yes, you mentioned the Perinatal Quality
Collaboratives, and these are really important because they are
a national network of PQCs that really look at implementing
targeted-based interventions, focusing on quality improvement,
looking at the ways in which to reduce preterm birth. And they
have done very successful programs to address early elective
delivery, promotion of progesterone therapy.
Right now, there are only a few States that are funded and
supported by the CDC at the State level. We really do need to
make sure that we have expanded funding for the nationwide
network of PQCs all around the country. That is why we are
advocating for more, an increase. These PQCs are really
important, because they get healthcare providers together to
really design interventions that can really make a difference.
We know that they have been successful. We have seen that.
In fact, our current deputy chief medical officer came from the
CDC and ran that program at CDC. We have seen it be an
evidence-based program that needs to be expanded, and we would
certainly advocate for that.
The Chair. That is great. Thank you. Thank you.
In the remaining time, what I want to try to do is to, Dr.
Sakala, you talked about--well, we have addressed the issue, I
think, of more data and the data disaggregation by race,
ethnicity, and so that we can further pursue that.
I want you for a moment, Dr. Sakala, just to explain why
paid leave and paid sick days are a maternal health issue.
Dr. Sakala. Yes, thank you very much. Maternity care is
critically important to healthy moms and babies, but many with
paid jobs face an impossible choice between going to their
provider visits or risking their jobs and income. And paid sick
days are also needed to attend to and recover from numerous
pregnancy conditions.
Similarly, after birth, paid parental leave is critical for
healthy family formation. New mothers who take paid leave have
time to recover, including the one-third these days who are
having a cesarean birth, and their children are more likely to
be breastfed, receive medical checkups, and get critical
immunizations. But only 21 percent of workers in the United
States have access to paid leave through their employers.
So for maternal and infant health, we need Federal policy
solutions, like the FAMILY Act for paid family and medical
leave, and the Healthy Families Act for paid sick days. And
thank you, Chair DeLauro, for your leadership on these
important bills.
The Chair. Thank you. Thank you. My time has expired. So
let me yield back and now yield to Congresswoman Roybal-Allard.
Let me yield to Congresswoman Harris--Congressman Harris,
and then to you, just to keep in order.
Congressman Harris.
Mr. Harris. Thank you very much, Madam Chair.
Let me just ask a related question--and I will say I am
just a little surprised that in discussion about maternal
mortality we don't have a physician or an obstetrician-
gynecologist, you know, to impart some information. Because I
am going to ask about an issue that I know when I worked for
over 20 years on the labor and delivery suite the obstetricians
always talked about was the cesarean delivery rate.
And this is not discussed very often, but there are major
differences worldwide, ranging from lower than 1 percent in
some Central West African countries to over 50 percent in Latin
and South America, Egypt, other places like that.
So my question would be, I guess for Ms. Asare, is, what is
your impression about what we can do to get our cesarean
section rate closer to what the World Health Organization says
it ought to be, which is about 10 to 15 percent? My
understanding, it is now in the mid 30s, low to mid 30s. It
varies over time.
But I think pretty clearly, maternal morbidity can be
related to our cesarean section rate. What can we do to daily
with that, and what are the trends that you are seeing both in
your State and nationally?
Ms. Asare. Thank you for the question. We certainly have
high Caesarian rates in New Jersey, so this is something that
we have been working on for quite some time. With the perinatal
quality collaborative, we have actually engaged in several aim
bundles that look at training and quality improvement are
really working with birthing and maternity hospitals, and
providers on, sort of, best practices.
One of the other things that we have done is with our
Medicaid program, we have actually said we will no longer pay
for early elective deliveries. And, so, we sort of have put in
a financial disincentive to doing that as well.
And then, I would also go back to the discussion that we
have talked about around workforce, really engaging midwives,
really engaging doulas, because some of those labor supports
can certainly help avoid C-sections as well.
So, I would say in New Jersey, our approach has been multi-
pronged, really looking at training, quality improvement,
looking at that financial disincentive, and then really looking
at additional players in the workforce that can certainly help
OB-GYNs as you have referenced.
Mr. Harris. Sure. Let me just follow up a little bit with
that, because I know that the Cochran meta analysis of looking
at the use of midwives indicates that in many places, the
Cesarean section rate is not that much different. Now, that may
be in countries where the Cesarean section rate is lower than
in the United States.
So, first of all, do you feel that going to a midwife
model, unless we change some of the other factors that might
increase the Cesarean section rate in the United States, for
instance, obesity certainly is a factor in Cesarean section
rate. The liability issue is--I mean, again, to the physicians
I talked to, that is one of their main concerns is the
liability issue. What can we do to alleviate some of those
things?
And I also want to ask you. In your Medicaid, when you
lowered the payments for Cesarean section, so brought them into
line with what it would be for vaginal delivery, did you, in
fact, see a change in Cesarean section rate when you did that?
Ms. Asare. We just started, so invite me back in a year's
time, and I certainly will have more to share with you on that.
But I think you raise a valid point about the other
determinants of what takes you to a C section. You know,
obesity, overall health, and so on and so forth. That is why I
think we are stressing so much this multi-sector approach. How
do we make sure that people are eating better? How do we make
sure that they are in their optimal state of health, prior to
even thinking about getting pregnant, because all of those
things are factors.
So we don't zoom in only on the OBs and GYNs, but we really
try to do a much more cross-sector approach, really looking at
improving maternal health overall, and not just waiting for the
period of pregnancy, childbirth, and postpartum to really
address some of these issues. So things like Medicaid coverage
for 365 days after delivery is certainly a step in the right
direction.
Mr. Harris. Thank you very much.
And I yield back, Madam Chair.
The Chair. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Thank you, Madam Chair, and thank you so
much for holding this hearing on addressing maternal health
crises, which is of great concern and of importance to me and
my co-chair of the maternity care caucus, Jamie Herrera
Beutler.
Dr. Gordon, you shared in your testimony that Bastyr
University recently received one of the fourth midwifery set-
aside grants funded by the scholarships for disadvantaged
students that this subcommittee supported. As a practicing
midwife, and director of a midwifery education program, please
explain how midwifery education is different from medical and
nursing education, and what type of further investment would be
needed to support midwifery education programs across the
country?
Dr. Gordon. Yes. Thank you for the question. Teaching
midwifery clinical practice is very labor-intensive, no pun
intended. Student midwives are usually mentored by a practicing
midwife who teaches and oversees their clinical skills in a
one-to-one relationship. This kind of teaching is time-
consuming, and usually results in decreased productivity on the
part of the mentor, and there is no current mechanism to
compensate that preceptor. Most of them do it as volunteers,
because they want to do their part to create more midwives, but
this is just not a sustainable model. In some programs, the
student is expected to pay their preceptor out of their own
pocket.
Most midwives don't have the expectation of greater earning
potential when they graduate. Nurses generally command higher
salaries than midwives, so it is harder to recoup the cost of
their education, which can run between $40,000 and $100,000 for
graduate programs. The current SDS set-aside is able to fund
scholarships for only four midwifery programs, and I am very
grateful to have one of them.
In the short run, it would be wonderful if that set-aside
could be doubled, so that a total of eight programs could be
supported with these scholarship grants. And in the long run,
midwifery needs a dedicated stream of funding, such as what is
proposed in the Midwives for Moms Act, and that would do four
things: It would incentivize the recruitment and training of a
more diverse midwifery workforce, first and foremost; it would
support the students to complete their training; it would
compensate preceptors with some sort of stipend; and it would
allow current schools to expand or new schools to open so that
we could increase the supply of midwives to address the
maternity provider shortage.
Ms. Roybal-Allard. Thank you.
Dr. Sakala, last December, the Surgeon General issued a
call to action to improve maternal health, and the Department
of HHS rolled out the healthy women, healthy pregnancies and
healthy futures action plan. As someone who has been studying
the U.S. maternity care system for decades, what do you think
are the strengths and weaknesses of that call to action? And
what can this committee do to ensure better coordination and
accountability in the action plan?
Dr. Sakala. Yes. Thank you for this question. The HHS
Maternal Health Action plan and the companion Surgeon General's
Call to Action were developed through an extensive process of
stakeholder consultation, and they create a very comprehensive
inventory of the work that is now underway across the agency.
Moreover, the 5-year targets for reducing the maternal
mortality of low risk Caesarian rates, and controlling blood
pressure in women of reproductive age, are both important and
achievable. However, conspicuously absent are mechanisms for
coordination, communication, and accountability across the
myriad initiatives.
To maximize impact, I would recommend a whole-of-government
approach. This could be accomplished, for example, through an
interagency coordinating committee that meets regularly, issues
annual reports, and works with this subcommittee to seize
opportunities. However, leadership within the Office of the
Secretary would be optimal. And the National Partnership for
Women and Families would be thrilled if there were mechanisms
to add recommendations in our testimony to this action plan.
Ms. Roybal-Allard. I yield back.
The Chair. Thank you.
Let me now recognize Congressman Fleischmann. Unmute.
Mr. Fleischmann. There we go. Thank you so much. It is good
to see you----
The Chair. You too.
Mr. Fleischmann [continuing]. And our entire subcommittee
today. Thank you to all the witnesses. A wonderful hearing.
And, Madam Chair, I also want to thank you for recognizing the
Baby Caucus. That was really wonderful, and something that was
really uplifting for me, especially earlier in my congressional
tenure.
I wanted to ask some questions, and I will leave it open to
all the witnesses. Answer whomever may wish. 75 percent of
women who experience maternal mental health symptoms go
untreated. New mothers often feel isolated and alone, and
social isolation caused by COVID-19 can exacerbate the feelings
of loneliness. Peer support can offer an opportunity to connect
with others sharing similar emotions.
My question is, can you expand on some of the experiences
and certifications held by peer support specialists, and what
are the different types of peer support available? Thank you.
Ms. Asare. I think I will take a stab at that. This is Lisa
Asare from New Jersey. Thank you for that question.
We have a maternal health crisis, and it has certainly been
exacerbated with the COVID-19 pandemic. Folks are much more
isolated than previously, and we have relied considerably on
telehealth. But I would say one of the things that we are doing
in New Jersey, having recognized the toll, we really call the
mental health crisis the pandemic within the pandemic.
We are doing quite a bit of work with our Community Health
Worker Institute, and really beginning to train community
health workers to really also address mental health. They are
not licensed practitioners, but we feel they can be peers. They
can provide peer support, and certainly make the identification
for women who need additional service, identification and
referrals. And so that is one strategy that we are using.
In addition to that, we do have legislation in New Jersey
that requires that we screen all women for close [inaudible]
Through their pregnancies, so that is something that we already
have longstanding. But certainly I would just say, again, with
the COVID-19 pandemic and the recognition that mental health is
a pandemic within it, we are really looking to train doulas and
community health workers as mental health peer counselors as
well.
Mr. Fleischmann. Thank you. Thank you for that answer.
My next question. Every woman experiences postpartum
depression differently, but understanding the facts about PPD
can help a person feel less isolated, particularly since PPD is
often more than depression. My question is, how can we better
screen for these symptoms before and during the fourth
trimester? How can we work to change the stigma surrounding
these symptoms? And how has COVID changed the way we provide
support for the women experiencing PPD? And, again, I will open
that up to whomever would like to answer that.
Ms. Stewart. I will just add a couple things about it,
Congressman. I think a couple of things that--and I would have
mentioned this, too, in response to your earlier question. One
of the most successful programs that we have seen to provide
support to women really before pregnancy, to your point, but
also, we are looking at a model that would provide support
postpartum is around this idea of group prenatal care, but it
can be extended into the postpartum stage as well.
We have seen, for example on the prenatal side, where we
have seen improved outcomes with respect to birth because of
the group support nature of prenatal care that can be carried
in the postpartum phase. We would like to see more and more of
these kinds of programs be scaled because many, many women who
experience pregnancy is already tough enough. Having the baby,
once they arrive, is already hard, but that group support can
be an effective model, that peer support that you mentioned.
But the other thing that I just want to call out too is the
fact that we have done more, thanks to a lot of your
colleagues, to expand access to care with maternal mental
health. The maternal mental health hotline that was started in
fiscal year 2021, funded at $3 million, we are advocating for
more and increased funding for that. It can be another way to
sort of help women before pregnancy and after pregnancy, to
your point, be screened for mental health challenges, and then
be connected to the support they need.
And certainly to your point, lastly, COVID-19 has actually
exacerbated all these issues around maternal mental health, and
we have to shine a greater light on all of these challenges. So
thanks for the question.
Mr. Fleischmann. Thank you so much.
Madam Chair, I yield back, and I thank you.
The Chair. Thank you.
And let me recognize Congresswoman Barbara Lee.
Ms. Lee. Thank you very much, Madam Chair. Thank you so
much for this hearing. I want to thank all of our witnesses,
because you all have definitely laid out a roadmap in terms of
solutions, and I really appreciate that.
A couple of things I just want to ask, but let me just put
this in context for me personally. I was born a few years ago.
My mother almost died in childbirth, due to the fact that she
was not allowed into the hospital because she was Black. Once
they finally admitted her, long story, they did not provide
medical care or care at all, and they had to finally do an
emergency delivery, and they had to use forceps to pull me out,
and I had a scar above my eye for years up until very recently.
Fast forward to today. We are still dealing with the same
kind of circumstances in terms of the structural racism and
racism in the healthcare system as it relates to Black mother
mortality, and infant mortality rates. And, so, you all have
done a great job laying out the solutions, but I wanted to ask
you a couple of questions.
Why does the United States still lag in wealthy countries
as it relates to maternal health outcomes? And then secondly, I
guess, Ms. Asare laid out the issues with regard to social
determinants of healthcare, and how of all of these issues
intersect in terms of Black maternal mortality and what have
you. But beyond that, we still have barriers in the system, and
structures that need to be dismantled before we can move
forward to, you know, solve this problem, which is a deadly
problem for Black mothers and babies.
And, so, can you kind of describe what systems that we need
to look at to begin to dismantle, and, then, what we can do in
terms of the workforce in terms of unconscious bias training,
and is that included in the workforce training for midwifery
and for nurses and physicians who are part of the delivery
system for children?
Dr. Sakala. Representative Lee, I can take the question on
international comparisons. I was on the National Academy's
Study committee that developed last year's birth settings in
America report, and we commissioned a study by an esteemed team
of international researchers to understand differences that
might explain the superior performance of maternity care
systems in other high-income countries.
And their analysis highlighted several things that are much
more reliably available elsewhere. First of all, affordable and
accessible healthcare without the kinds of barriers that many
of our childbearing people experience here. Secondly, midwifery
as the first line of care for the majority of women. Third,
more standardized and centralized data collection to understand
trends, and rectify concerns.
Moreover, there is more integrated system based on
respectful, trusting, interprofessional relationships, both
within care teams and across settings and providers.
And, lastly, they note that several countries also have
national, evidence-based guidelines developed through multi-
stakeholder processes for all professionals versus our more
siloed and uneven approach.
Ms. Lee. Thank you.
Ms. Asare.
Ms. Asare. Yeah. I would--you know, you talked about bias
training, but I think one of the things we have done in New
Jersey is we have just listened to moms. Before we did
anything, we actually went out into the communities and really
talked to the same folks who are at risk to say what is going
on. And what we heard certainly was about, you know, sometimes
lack of access to healthcare and things of that nature, but it
was just stress, all the way across-the-board stress. I need a
job, I don't like the schools my kids are in, transportation,
childcare, all of those social determinants of health, and I
don't always feel respected, or treated well when I go to seek
care.
And so out of that, all we kept hearing was social support,
social support, social support. That took us to the selection
of things like group prenatal care, investing in doulas, really
investing in other areas that would augment and ameliorate the
quality of life for these women.
So, when we talk about this Community Health Worker
Training Institute, it creates jobs for folks, jobs that make
more than minimum wage, that we do in conjunction with
community college, so folks have an opportunity to get an
associate's degree and then get a bachelor's degree.
We are sort of working with doulas, women from communities.
They themselves have had poor birth outcomes, so they know what
it feels like. They, then, are now being employed to be doulas,
community doulas, and to serve their communities. We have a
Medicaid reimbursement dentist, so now we have a sustainable
funding source.
I say to folks, health equity is not just about health. It
is about money. It is about education. It is about housing. It
is about all of those things. We try to be comprehensive in our
responses to really meet women where they are, continue to
allow them to inform us in our decisions and the selections
that we make in terms of interventions.
Ms. Lee. Thank you, Madam Chair.
The Chair. Thank you very much.
Congressman Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair, and thanks for
holding this hearing today. I wanted to follow up on some of
the comments you had made about, you know, there are maternity
care deserts. You mentioned the urban areas and rural areas. I
represent a more rural district, and it is something that
access to more specialized care in rural areas, like the one I
represent, 31 percent of Michigan counties have no obstetric
services. And I wanted to ask the witnesses, and maybe start
with Dr. Sakala.
What can be done to increase the number of service
providers who want to practice in rural communities? And are
there any models that are out there that can bring these
services back to rural communities? And then I would open it up
to any of the other panelists as well.
Dr. Sakala. So thank you very much for this question. I
think there are some residency training programs that are
devoted to creating practitioners who feel confident and
committed to working in rural areas. There are also some
innovative ways that we can combine, for example, training
general surgeons to be able to do Caesarian birth and a couple
of other crucial procedures, and then certified nurse midwives
are able to have extra capacity in assisted vaginal birth,
ultrasound, things like that. So we can be very creative.
Also, there are a series of studies that show that birth
centers in rural areas have the same high-quality outcomes as
in areas that are more closely located to backup facilities and
higher-level care. So all of those are some of the creative
solutions that we might try.
Mr. Moolenaar. Wonderful. Thank you. Any--go ahead.
Ms. Stewart. I would just like to add to that. Thank you
for the question. The March of Dimes did a study on these
maternity care deserts back in 2018, and we updated it in 2020,
and what it shows is exactly what you said, that about over 50-
some percent of the counties in the entire country are
considered maternity care deserts. I mean, they lack obstetric
services, lack an OB-GYN, a birthing center, you know, no
certified nurse midwife, virtually no obstetric services.
It affects about--and then there are other counties that
have very limited access to care. You know, this affects about
7 million women of childbearing age, and it is a big issue. So
here are some things that we would sort of urge everyone to
think about with respect to how we address these gaps in care
for so many women, where four-fifths of these maternity care
deserts actually do occur in rural areas to your point.
First of all, we need to look at regionalizing care, where
there is a sharing of resources across a larger regional area.
I think one of these we have seen over the pandemic is this
reliance on telemedicine and telehealth. We have got to expand
access to digital--digital access to care, especially for women
in those rural areas.
This idea of expanding access to midwifery care is also
really important. Can we put more birth workers in areas where
there may not be a formal hospital or a birthing center to
still provide that kind of care to women; and also,
incentivizing providers to be in these underserved areas. Do we
provide enough incentives for people to work in areas where
there may be a lack of care?
So there are a lot of different strategies we can pursue in
these maternity care deserts, and reaching those women where
they are, so that they don't go without the kind of care that
they need, especially if they are in a high-risk situation.
Thank you.
Mr. Moolenaar. Great. And just to follow up with you, you
know, you mentioned telehealth. There is a digital divide in
some areas. For instance, in my district, there are many areas
where people aren't able to access the internet. How is that
impacting maternal health services where there is a digital
divide?
Ms. Stewart. Well, we know--one of the things that, you
know, we have seen is that so many women actually went without
prenatal care during the pandemic, because they either were too
concerned or too afraid to actually go out to visit their care
provider. And if they didn't have access to those services by
telehealth, they simply went without them. We did see a notable
increase in the number of women, especially during the
pandemic, who did not even receive prenatal care, which is, you
know, obviously a very dangerous situation, both for the mom as
well as the baby.
So one of the things that we have seen is that if women do
have access, we have seen a greater comfort level with many
women who would be willing to access these services if they had
the kind of digital access that is required. So we have got to
invest in those kinds of areas, so that we can make that care
more available to more women where they live.
Mr. Moolenaar. Wonderful. Thank you.
And thank you Madam Chair, and I yield back.
The Chair. Thank you. Thank you very much. Congressman
Pocan.
Mr. Pocan. Thank you very much, Madam Chair, and thanks for
having this hearing, and thanks to all the guests. I think this
is such a nonpartisan hearing. Almost every question area has
had Democrats and Republicans asking in the areas, and I really
appreciate that.
I want to go to a couple of them that have been asked to
ask a little deeper on, if I can. One is specifically on the
mental health aspects. I know that Dr. Asare and Stewart both
talked a little bit about the questions that came from DeLauro
and Fleischmann. We have--in Wisconsin, we had about 64,000
births last year, which 20 percent of the moms had--were
impacted by mental health conditions, but only 75--but only 25
percent of those were able to get treatment. So we had nearly
10,000 moms not getting treatment.
And there was the HRSA mental health--maternal mental
health training program. Wisconsin applied for a grant,
unfortunately, didn't get it. Only seven of the 30 states that
applied got it. Can you talk, perhaps Dr. Stewart--or Dr.
Asare, I think you referred to this earlier. Talk about that
particular program and its increase in funding and why that
would help out in the mental health area?
Ms. Stewart. I would be happy to take that first.
So HRSA screening and treatment for maternal depression-
related issues and disorders-treatment program provides grants
to States to address maternal depression, and it really helps
new mothers and their babies achieve the best possible start.
You know, with increased funding of about $5 million for this
program, HRSA would be able to fund an additional five
programs, and provide technical assistance to non-grantee
States. Right now, only seven States have received funding and
were able to create programs that really provide this kind of
real-time psychiatric consultation, care coordination, training
for frontline workers and providers. This is really a
critically needed resource.
Again, through this pandemic, the rate of maternal
depression and the rate of need with respect to treatment for
maternal mental health conditions has increased three to four
times that of what we saw before the pandemic.
So, these are really critical programs. We have to invest
more in this. We tend to not pay attention enough to the mental
health of moms, pregnant moms, pregnant women, and new moms. We
have to invest more in this, and especially during this
pandemic, we have seen the rate of this kind of need increase
dramatically. And that is why we are advocating for more
attention paid to this issue as well as increased funding as
well.
Mr. Pocan. Thank you. I also appreciated the fourth
trimester. I haven't heard that before. I feel like I have
learned a little terminology.
A question on rural, and Mr. Moolenaar asked you where I
was going, but I do want to take it a little farther. You know,
in Wisconsin, I have--26 of my 72 counties don't have an OB-
GYN, and we know nationally, the rate of hospital obstetric
services went down. Now we are at 55 percent in 2014 that
didn't have that access.
In Wisconsin, we at the University of Wisconsin Madison has
a great rural residency training track for OB-GYNs. It is the
first training program in the country for rural women's health.
Unfortunately, funding to train that program remains very
limited. In the last budget, I appreciate the chair of the
committee helping us get from 11- to $11.5 million for the HRSA
Rural Residency Training program. But could someone talk a
little more, maybe Dr. Sakala, about this type of funding, and
why this is so important, because again, my district is over
half rural.
Dr. Sakala. Thank you for that question. It is really
important to try to find out who wants to practice in rural
areas, and that includes people who have grown up in rural
areas and want to stay in their communities. So these programs
are really important for supporting them and dealing with the
unique circumstances of rural healthcare practice.
I would also identify an innovative program at the Frontier
Nursing University, where everything is remote, except students
come a couple times in the course of their training for nurse
midwifery, and that enables people to reduce their costs and to
stay in their communities, not even to leave for their
education. So I think for some professional groups, we could
consider expanding access to actual remote education.
Mr. Pocan. Thank you. I yield back, Madam Chair.
The Chair. Thank you.
Congressman Cline.
Mr. Cline. Thank you, Madam Chair. I want to follow up on
that very topic that Congressman Pocan had raised. In answer to
my colleague, Ranking Member Cole, several of you discussed the
importance of developing the workforce as one of the main ways
to help address this crisis. Not only do we have a shortage of
medical professionals, but we also have a shortage of
professors that train the next generation of medical
professionals.
Yesterday, I met with nursing deans, directors, and chairs
from colleges across Virginia, and in my district on this very
issue. My home State has great options for nursing schools, for
prospective students, and, often, the waiting lists are long,
but there is far more demand for spots than there is
availability. This is coupled with the demand for medical
professionals in the workforce, and the demand for professors
to leave the workforce to come and teach, and addressing that
demand is a challenge.
What are some of the best ways we can address this
workforce shortage from both the education side and the career
side? And Dr. Sakala, if you want to begin, and then anyone
else who wants to chime in on that.
Dr. Sakala. Thank you. So Dr. Gordon is actually a
professor in a program, so I think she would----
Mr. Cline. Great.
Dr. Sakala [continuing]. Have some excellent ideas about
the pipeline for professors and academic leaders, so I will
respectfully request that she provide an answer.
Mr. Cline. Perfect.
Dr. Gordon. I would be happy to. Thank you. Thank you for
the question.
It takes 3 years to educate a midwife. But right now, there
are fewer than 50 accredited midwifery education programs in
this country. By comparison, there are almost 200 accredited
medical schools. So we need to expand the programs that we
have, and we need to create new schools, and both of those
actions require funding. The Midwives for Moms Act would
provide support for those accredited programs to create new
schools, to expand existing ones, to support students directly,
and also to increase the number of clinical preceptors.
One of the things I mentioned earlier in my testimony is
that a lot of those teachers and preceptors are not actually
compensated for that work. So, being able to compensate people
so that it is a feasible thing for them to do, and some of
them, you know, are earning from their practice, but doing this
on a volunteer basis. And as I mentioned earlier, it does take
more time to do that. So compensating people appropriately for
the work that they do as clinical teachers and as academic
teachers is really important for that to be feasible.
Mr. Cline. All right. Thank you very much. I wasn't aware
of the length of time, 2 to 4 years by what I am looking at
here, depending on the plan and the--and which format you are
in, whether you are in a full-time or part-time. The training
to become a doula, how long does that usually take?
Dr. Gordon. Sure. Training to become a doula is usually
much more condensed, because it is not a clinical or medical
type of role. It is a supportive role, where people provide
physical and emotional support during labor. So the role of the
doula is largely putting tools in the toolbox to help support
people to work through the intensity of labor.
The time that it takes to train a doula may be a weekend
workshop or a couple of weekends. Some of them now are online,
and so, they have been able to stretch it out and cover much
more than just the hands-on work.
Mr. Cline. My sister is a doula. That is why I was just
curious. Thank you for answering that question for me.
So, when considering the challenge for us to find
incentives for nurses to leave the profession to become
professors in the field, do we have that same challenge with
regard to midwives? Or people not wanting to leave the field of
midwifery to become instructors because of the pay cut that
they would take in the same way that nurses would take a pay
cut when they go to become professors?
Dr. Gordon. I recognize the time has expired, so I will
just say yes.
Mr. Cline. Thank you, Madam Chair. I wasn't even looking at
the clock. I apologize. I was too interested in the subject. I
appreciate and yield back.
The Chair. Thank you. Thank you.
Ms. Clark. There you are. Yeah.
Ms. Clark. Yes. Thank you, Madam Chairwoman, for this
excellent hearing, and to all the witnesses for your work and
being with us today.
I want to go back to talking about what we know is our
desert of maternity care in many rural and urban hospitals that
have closed their obstetric units due to economic pressure, and
the high cost of providing maternity care. So, can you speak to
the role of birth centers, and how they can help underresourced
communities? And I would look to Drs. Sakala and Gordon.
Dr. Sakala. Okay. I can start off.
As has been mentioned, over 1,000 counties have been
designated as maternity care deserts. This lack of access to
maternity care poses tremendous risk to childbearing families,
including traveling long distances, and especially when weather
gets bad, or in dramatically--geographically dramatic
conditions. So several studies fortunately have found that
birth centers located in remote areas have outcomes similar to
those in more populated areas, even though the remote centers
have less ready access to higher levels of care. So, to me,
this means that midwifery-led birth centers are a crucial piece
of our rural access crisis.
Ms. Clark. Wonderful. Thank you.
Dr. Gordon.
Dr. Gordon. I echo everything that Dr. Sakala just
mentioned, and it takes--it is more cost effective to have
birth centers in rural areas than to build a whole hospital. So
the Babies Act is the legislation that would provide funding
for Medicaid demonstration projects for freestanding birth
centers in six States. And, so, given what we have learned from
the Strong Start Initiative and the studies that have come out
of that, the Babies Act would be the next logical step in
expansion of the freestanding birth center model. I mean, also,
it would be to make sure that there is licensing for birth
centers that is available in all States. That currently is not
the situation, and that would need to occur as well.
Ms. Clark. Can you give me an idea of the percentage of
States that do have licensing requirements?
Dr. Gordon. I do not have that number off the top of my
head.
Ms. Clark. That is okay. We can find out, and thank you for
the plug for the Babies Act. I appreciate that.
Also, Ms. Stewart, I want to go back to the mental health
impacts of this pandemic. And we know as in everything
affecting healthcare, there have been even more barriers for
moms from communities of color, and low-income communities in
accessing mental healthcare. What are some of the targeted
interventions that we need to effectively mitigate the
inequities that persist in maternal mental healthcare access?
Ms. Stewart. Well, thank you for the question. I think
there are a couple of things. One is that we simply have to
acknowledge that mental health issues among pregnant women and
new moms is significant. For too long, we have sort of
stigmatized the issue, and have underfunded access to care and
made it much more challenging. That is why I think the funding
and the establishment of the maternal mental health hotline
would create, really, services that are culturally appropriate;
texting services; ways to provide 24-hour day care to women
wherever they are, is really important. And expanding that
access to care, that hotline is super important as well.
But we also have to acknowledge that in the healthcare
system, too many women of color don't feel adequately served,
don't feel heard and listened to. We heard that earlier, and
so, this idea of expanding care, expanding access to care of
doulas and midwives, research shows that that kind of care can
actually produce better outcomes for mom and baby, reduces
anxiety and stress. We know based on research the kind of
impact anxiety and stress can have on women. We know that
anxiety can be a leading cause of the kinds of chronic health
conditions that actually exacerbate birthing outcomes that are
poor for women of color, especially Black women.
And, so, we have to do a better job of integrating our
systems of care to make sure that as women are receiving
adequate care for their physical needs, they are actually
receiving the kind of care throughout pregnancy, before
pregnancy, during pregnancy, and during childbirth and address
their mental health needs as well. The hotline is really
important.
The other programs that I have talked about earlier with
respect to the funding that is being done by the Maternal Child
Health Bureau, those kinds of screening activities are also
really important. And that is why we are advocating so strongly
for expanded access and attention and care around maternal
mental health.
Ms. Clark. Thank you so much. I see my time has expired,
and I yield back.
The Chair. Thank you.
Congresswoman Frankel. Congresswoman Frankel. Congresswoman
Watson Coleman.
Ms. Frankel. I am trying. I am trying.
The Chair. Okay. We see you and hear you, Lois.
Ms. Frankel. Okay. I just have one quick question, which is
from all the panelists is has the--I think the past 4 years,
there has been a reduction of the Title X money, because of a
certain policy regarding--it is the gag rule. I am just
wondering if that affected this issue at all. Hello?
Dr. Sakala. Thank you. I can jump in and say that pregnant
people deserve access to the full spectrum of reproductive
healthcare, and the ability to decide whether or not to
continue a pregnancy and control over the timing and spacing of
pregnancies is closely connected to maternal health. So, we
should be investing in healthcare that supports all of the
different pregnancy outcomes, and that gives people agency to
choose the best option for their health and well-being.
Ms. Frankel. I will take that a step further. I know a lot
of the Planned Parenthood facilities had to reduce their care.
I am just curious whether you saw any reduction in care over
the last few years because of the gag rule.
Ms. Asare. I would say in New Jersey--this is Lisa Asare--
we had the benefit of having restoration with State funding,
recognizing that we had that situation, and we had a governor
that gave us $7.5 million in State funding to mitigate some of
the things that you are describing.
Ms. Frankel. That is good. Thank you. Anybody else?
With that, Madam Chair, I am on another Zoom, so I am going
to yield back, but thank you for this. I don't know if you do
this, but I wanted to give a shoutout to Brenda Lawrence, who
really has been a leader on these issues, and really as the co-
chair of the women's caucus has really been pushing this as a
priority to deal with these issues.
The Chair. Keep Zooming.
Ms. Frankel. Thank you, Madam Chair.
The Chair. Keep Zooming.
Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you very much, Madam Chairwoman,
and to each of the witness, thank you so much for the
information you have shared. I agree with 1,000 percent, and it
has been very informative.
I am very proud of New Jersey. As you can see from Dr.--
from Ms. Asare, just all the wonderful things that we are doing
there, and I think that it serves as a model for other States
to embrace.
I want to talk a little bit about the disparities in
mortality and morbidity in both mothers and babies as it
relates to women who are of color, and who share the same sort
of socioeconomic educational background as White women, yet the
disparity in healthcare outcomes is very different.
And so I agree we need to have additional workforce,
greater access, but even for those who had the healthcare,
something that I am very concerned about, one of the first
bills I introduced was the Moms Act, which was to give women a
say at what insurance they needed as coverage when they found
themselves pregnant, and would also extend Medicaid for a year
for those. I understand the need for greater access to care.
What I don't know is how we deal with bias.
How do we deal with the bias that Black women and women
of--Latino women, et cetera, experience when they encounter the
whole spectrum of healthcare as it relates to a woman's
pregnancy? What is it that we are seeing that--strategies that
are used, educational tools that are used, accountabilities
that are being used to help us to overcome that which I know is
very, very tough to deal with and very, very tough to qualify
and quantify.
And I wanted to ask Ms. Asare: What in New Jersey are we
doing to get at implicit biases, and, then, I would like to
also ask Dr. Sakala as well.
Ms. Asare. Thank you, Congresswoman. I really appreciate
the question. I think the first thing we have done in New
Jersey, we have called it out. In our Nurture NJ Strategic
Plan, we have talked very specifically about structural racism,
but thanks to HRSA, and also State support, we have investments
in implicit bias training, and I would go even further and call
it anti-racism training. We are putting together curriculum for
implicit bias anti-racism training that will take place in all
49 maternity hospitals, and not targeting any one group within
the hospital, targeting everybody from the intake desk
coordinator person, security, nursing staff, clinical staff,
all of them, because we feel that it all contributes to that
patient experience.
I really appreciate your remarks about socioeconomic status
doesn't change things. We know Serena Williams, as famous and
as wealthy as she is, did not feel listened to, so we have
considerable work to do in this space.
Mrs. Watson Coleman. Let me ask you a question. Are there
any changes that are taking place in the medical training that
residents and doctors get and nurses get while being educated
in college? Are there any changes to the continuing education
requirements that doctors, in particular, have to have that
address this issue, and if not, how do we address it? What can
we do? What should we do as Members of Congress?
Ms. Asare. Yeah. We do have legislation on the books that
requires cultural competency training for medical students and
residents that was established back in the 1990s, but we are
currently working on legislation, again, around implicit bias
training. In talking to the medical schools, New Jersey Medical
School, Robert Wood Johnson Medical School, certainly medical
schools within the New Jersey system, about integrating that
into the training, you know. We need to go upstream, you know.
We have docs and folks who are practicing right now, but we are
training folks as well, and it is really important to give them
that requisite competency.
Ms. Stewart. If I could add to that, at the March of Dimes,
we offer implicit bias training for workers that are working
with pregnant women and new moms. We have trained over 10,000
healthcare providers. But you are right, it does need to be
further integrated into our training programs, our medical
programs, nursing programs. It is not just the implicit bias,
it is also the explicit bias and racism that really impacts the
health outcomes of moms and babies in this country.
Mrs. Watson Coleman. Thank you. It is an issue I would
really like to pursue, but my time is up, and I appreciate the
responses to my questions.
I yield back.
The Chair. Congresswoman Lawrence. Congresswoman Lawrence
may have had to drop off. Let me just do this, because we have
a little bit of time, and I would just ask--I will try to do
the same order. If you have one additional question, and I
would ask, you know, the question be brief and the response
brief. I would like to get in any other efforts. We have a
little bit of time here, so I will go last in that regard.
So I think in order, Congressman Harris.
Mr. Harris. Thank you very much, Madam Chair.
If some of the experts we have here would comment on the
contribution of drug use to our maternal mortality and
morbidity issues, and whether or not they think that the COVID
pandemic is actually going to make some of these issues worse
as well as postpartum maternal depression, and any of the
participants.
Ms. Stewart. I will start with that, because I do think
this is issue of substance use disorder has really been a
challenge. We know that opioid epidemic, for example, has
really put a strain on many Americans. It has also put a strain
on many women who are pregnant.
One of the things that we have been concerned about is some
of the punitive measures that we have seen taken against women
who are maybe suffering from substance use disorders. We
strongly encourage policymakers and others to not do anything
that would discourage women from seeking the care that they
need if they do have a substance use disorder, which is why we
have been so supportive of measures to increase investments in
making sure there is access to care, access to substance use
support, including the Substance Abuse and Mental Health
Services Administration Pregnant and Postpartum Women's
Program. That has been really important. Again, expanding
Medicaid access, giving women the coverage that they need in
order to seek that kind of care is also really important.
We have seen, again, a slight decrease in opioid overdose
deaths in 2018, but opioids are continuing to really ravage
communities. And we are not only concerned about opioid use but
also other--other substances as well. We have to make sure that
pregnant women feel the kind of support and receive the kind of
support they need to make sure that they protected and safe, to
make sure that babies are safe. And whatever we can do to
expand and make sure they are not further stigmatized, because
of substance abuse disorder, is really important in all of our
efforts to protect moms and babies.
Mr. Harris. If I could just ask one follow-up to that. My
local law enforcement tells me that methamphetamine use is
going up. If I recall right, that is associated with some pre-
term deliveries. Are we seeing that, an increasing problem
nationwide among pregnant women?
Ms. Stewart. I would just follow up to that to say that we
know that the kinds of risky behaviors around use of the
substances, smoking, for example, all of these kind of risky
behaviors can put greater risk for a mother to deliver early
and deliver prematurely. You know, we have seen that data. We
have seen that. That is why the March of Dimes has been such a
strong advocate for making sure that women receive the kind of
support to reduce that kind of risky behavior so that they
don't put themselves at risk. And I don't know that I have the
data right in front of me, but it certainly wouldn't surprise
me that with increased use of substances that we would see some
poor birth outcomes as well.
Mr. Harris. Thank you very much.
I yield back, Madam Chair.
The Chair. Thank you. Thank you. We will do 3-minute
rounds. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Okay. Actually, I don't have a question.
I just want to point out a couple of things that were
highlighted during the testimony. And one is from the American
Congress of Obstetricians and Gynecologists report. It says
that no significant increase in the number of medical school
graduates entering obstetrics and gynecology residency over the
last three decades, and projects a shortage of 6,000 to 8,000
obstetrician gynecologists by 2020, and up to 22,000 by 2050. I
think that also highlights the increased need for C and M's,
and CMs, which would significantly enhance the ability to
provide adequate women's healthcare in the United States.
And I do want to put a plug in for the Midwives for Moms
Act, which would increase the number of midwives educated in
the U.S., and it will support the education of a more
culturally diverse maternity care workforce.
Also, with regards to the point that was made by one of the
panelists was the need for better coordination and
accountability in the action plan. And, again, I just want to
point out that the Moms and Babes Act that I will be
introducing provides, or creates, an HHS coordinating committee
on optimal maternal outcomes that would help create that
coordination and accountability that is missing at this point.
So I yield back. Thank you for that opportunity.
The Chair. Thank you. I understand some members have
dropped off, so what we are looking at is Congresswoman Clark.
Ms. Clark. Thank you so much, Madam Chairwoman. I want to
go back to the answer to Dr. Harris' question. Can we talk a
little bit about as we are seeing a rise in substance use
disorders, and the real impact it has? Can you tell me a little
bit more about how punitive policies hurt maternal health
outcomes, particularly for women who don't have access to
quality healthcare treatment? And have you seen these policies
result in a reduction of neonatal abstinent syndrome births and
substance use treatment admissions? I believe Ms. Stewart.
Ms. Stewart. I am happy to start with that, and others can
chime in. So, one of the things that we have to all be
concerned about is the impact of opioids not only on the moms,
but the babies as well. And we certainly have seen a
significant increase in the rate of neonatal abstinence
syndrome.
The number of infants that were diagnosed with NAS grew
nearly sevenfold between the years 2000 and 2014. Doctors
consider NAS to be expected and treatable, but there are some
very long-term effects to infants who actually suffer from NAS.
When women are not able to access the care they need
because of a fear of some sort of punitive outcome, the rate of
babies who then suffer from NAS can increase. And we know that
that can provide, again, a long-term impact on those babies,
and the impact can be quite severe.
It is why the March of Dimes has been such a strong
advocate for making sure that these kind of punitive measures
do not get implemented. We know that there has been a tendency
to try to criminalize the kind of behavior that really needs to
be treated as a legitimate mental health issue, and women need
to receive the kind of care and support that they really must
have in order to make sure that their babies are protected.
We are concerned that through the pandemic, the rate of
increase and the rate of substance use has not declined, in
fact, has just been exacerbated because of the pandemic. So we
need to pay more attention to making sure that we don't further
criminalize and increase any kind of punitive measures around
women, again, expanding the support that women need to have
access to, especially if they are addressing a substance use
disorder.
Ms. Clark. Thank you very much. I yield back.
The Chair. Thank you. I want to recognize Congresswoman
Lawrence. I recognize Congresswoman Lawrence for 5 minutes,
since she hasn't had any opportunity to ask any questions in
the first round. Congresswoman Lawrence.
Mrs. Lawrence. Thank you so much. Sorry I had to jump off,
but thank you for allowing me.
I have a bicameral bill with Senator Cory Booker and it is
called the DOULA Act. And the panel has just been excellent,
talking about the power of doulas. And what it does, it makes
it an option for our women, veteran women, to be able to have
access to doulas.
But the thing I wanted to talk about is mental health for
mothers. We understand, and I am looking at mental health on so
many different levels. We have built into the health care of
postpartum women that they go back in 6 weeks to check on their
physical health. We should include mental health as that check-
in. When we say, come back, mother, to make sure that
everything is healing and you are physically recovering from
your pregnancy, why don't we include, at minimum, the
suggestion of a check-in on your mental health? Because a lot
of times women don't talk about it, because some are
embarrassed, as you know. Why am I depressed? I had the most
amazing experience in life, and everyone is so happy and I am
depressed. What is wrong with me? And they won't talk about it.
And, so, we know that we take physical health, we send you
to a doctor, you get an exam to make sure that you are okay. So
can anyone comment on how we can roll in not only funding of
mental health, but incorporating it into the routine of
postpregnancy and afterbirth for mothers?
Ms. Asare. This is Lisa Asare from New Jersey. I will take
a stab at that.
I mean, you talked initially about the doulas. And I think
that before you get back to the doctor after 6 weeks, you can
be seen by your doula. And, so, one of the things that we are
looking to do in New Jersey is really work on developing that
workforce, but give them some basic training in, sort of,
mental health screening, because we think that they can sort of
get in there before women get back to a doctor's appointment.
And, so, we are spending quite a bit of time, with gracious
funds from Title V, we are putting out a doula learning
collaborative, which is the first of its kind but a real
workforce development center that will help them with training
and things of this nature, because we see them as being part of
the solution and as really being able to sort of stand in the
gap.
Before you get to the 6- or 8-week postpartum checkup,
somebody else should be checking in on you, and that may be a
person that you feel more comfortable in sharing with in terms
of how you are really feeling, because it is somebody that
should have been with you through the course of your pregnancy
and birth and postpartum.
Ms. Stewart. Congresswoman, if I could just add to that as
well. One of the reasons, again, that we are advocating for
extending Medicaid 1 year postpartum is for that very reason,
that we have to provide more care after the baby comes, to make
sure that mothers are getting the kind of care that they need
to deal, with not only their physical challenges that they may
be facing, but also their mental health challenges.
Nearly one-third of all the maternal deaths that happen in
this country happen 1 week after the baby is born, out to 1
year, and one of the leading reasons for that is tied to mental
health challenges. So this is really a critical issue.
We would love to expand these access-to-care models like
postpartum group care, which we think can be as effective as
what we find in group prenatal care. We know that there are
doulas who provide postpartum care as well. So not just doulas
that are there, you know, at the time of pregnancy and
delivery, but can we have postpartum doulas who can stay with
the mom even 1 year out.
And, then, the last thing I will just say is that it is
really important that we make sure that this fourth trimester
is really embraced in this whole model and continuum of care.
We cannot just look at addressing the maternal and infant
health crisis as if it is an issue of pregnancy and childbirth.
It extends beyond.
And I think once we start to really embrace that notion, we
can sort of look at the continuum of care and make sure women
are provided the kind of access to care that they need that
covers them, especially 1 year after the baby is born and
beyond.
Mrs. Lawrence. Thank you, Madam Chair, and I will yield
back.
The Chair. Thank you. I think Congresswoman Watson Coleman.
No. Are there any members that I have missed for a second
question here?
Mrs. Lawrence. I would like to ask a second question.
The Chair. All right. You go ahead, and then we will wrap
up.
Mrs. Lawrence. Madam Chair, thank you so much.
My second question is, the certification of doulas, how
structured--I have always wanted to ask this question. How
structured is that training, and whether the certification
process is uniform or universal? Can someone talk to me about
the certification and the recognition of you being qualified to
serve as a doula?
Ms. Asare. I am happy to take that on. In New Jersey, we
have a doula Medicaid reimbursement benefit that went live
January 1. And, so, as you know, Medicaid doesn't just pay for
anything. And, so, they are really looking to do just what you
asked about. What is the certification? What are those core
competencies? What are those standards?
So we at Department of Health have worked very closely with
Medicaid to really establish what those core competencies are.
And, so, there is sort of standard competencies around the
birth and support. But we have also added health equity and
adverse childhood experiences to the training, because we think
it is a requirement for doing community-based work in New
Jersey.
Mrs. Lawrence. Well, this is where I get stuck. I
understand that we have doulas, but is there a national
standard? Like, to be a nurse, there is a national standard.
There are benchmarks that you prove competency in, and then you
are issued a certificate. Is there a national standard?
Ms. Asare. I think the national sort of custodian of that
is sort of DONA, which is a national doula organization. So
they do provide certifications, and different doula training
organizations provide certification. So I would say yes. They
are varied and they are diverse.
Mrs. Lawrence. Is that an issue, being varied and diverse,
or where are we with that?
Ms. Asare. I think it can be. And in New Jersey, what we
are doing is really working initially with Medicaid to
establish what that core competency is. And then, as I
mentioned, in terms of the challenges, we are actually
establishing a doula-learning collaborative, so an entity that
would be responsible for that workforce development. So if you
say you are a community doula in New Jersey, this is what that
means.
And, so, we have also received support from the State to
invest in a doula registry that will really allow us to sort of
maintain that database, and just in response to your questions,
really maintain some standardization and some certification.
Mrs. Lawrence. Thank you, Madam Chair.
Ms. Roybal-Allard. Madam Chair.
The Chair. Yes, go ahead, Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Yes. Congresswoman Herrera Beutler, this
is a very important issue for her, and she wanted to be here,
but, unfortunately, she has been detained. So she just texted
me a question that she would like for me to ask on her behalf.
The Chair. Go ahead.
Ms. Roybal-Allard. Breastfeeding is a high-value, low-cost
public health intervention that provides a substantial return
on investment. Since funding was first directed to support
breastfeeding programs in 2012, breastfeeding initiation has
increased, with exclusive breastfeeding at 6 months, increasing
from 16 percent to over 25 percent.
Funding for CDC breastfeeding programs support data
collection, track breastfeeding rates, and support partnerships
with States to help employers support breastfeeding mothers
with places to pump and store breast milk and much more. Data
from the CDC shows that most infants start out breastfeeding.
However, these numbers drop precipitously in the weeks and
months after birth.
Dr. Gordon, can you speak about how our Nation's
breastfeeding rates impact maternal and infant health outcomes?
Dr. Gordon. Thank you for that question. Breastfeeding is
one of the primary interventions for reducing infant mortality.
And what we know is that it is hard, for a lot of people it can
be hard. And, so, there, are--in the postpartum period, many
families don't have the intensive support that they might need
in order to successfully breast-feed for a long duration of
time, at least exclusively for the first 6 months.
The newborn--after birth, the newborn gets lots of visits
to pediatric providers, but the person who gave birth usually
only gets sort of the 6-week visit after hospital discharge,
and 40 percent of people don't even bother by that point.
So, there are a lot of issues that can occur in the
postpartum period, many of which involve challenges with
breastfeeding. And postpartum care is an area where, again,
many other high-income countries are doing it much better than
we are. In England, for example, people receive home visits
from multiple types of providers in the first several weeks
after birth.
Community midwives in the U.S. are doing this too. But
especially during this pandemic, most people have had little to
no support after they have given birth. And in a country that
spends more on healthcare than anywhere else in the world, our
families deserve better care than this.
I would encourage funding for demonstration models that
incorporate physicians and community health workers, midwives,
lactation consultants, doulas, and public health nurses, and
build in home visits in those first couple of weeks as well as
including a postpartum depression check-in around 12 weeks,
when many people have to return to work and breastfeeding
relationship changes, and then have regular telehealth check-
ins throughout that whole first year.
Ms. Roybal-Allard. Thank you.
The Chair. Thank you. Thank you very, very much.
I am going to ask just a couple questions, and then I will
just wrap up for a close. Did I miss any members?
Okay. I think we tried to--and this is a quick yes-or-no
answer. Should pregnant women and lactating women be part of
clinical trials?
Dr. Gordon. Yes.
The Chair. Dr. Gordon is saying yes.
Ms. Asare. Yes.
Dr. Sakala. Yes.
Ms. Stewart. Yes.
The Chair. Thank you. Thank you. Then are there any
restrictions in States on doulas and midwives? Are there States
that don't recognize, you know, these areas of study, and so
that we can't go further with, you know, branching out into
these areas of shortage of workforce? Do we have States who
say, No, you can't do that?
Dr. Gordon. Yes, we do. We do. Certified nurse midwives are
able to get licensed in all 50 States and jurisdictions;
certified professional midwives who attend home and birth
center births are able to be licensed in only 34 States and the
District of Columbia; and certified midwives are, I believe,
licensed in six States right now.
The Chair. So that is a State issue?
Dr. Gordon. Yes.
The Chair. So it becomes a State issue, so that is
something that we can look in.
Let me ask another quick question, which has to do with
research gaps. And, I guess, Dr. Sakala, what are some of the
key gaps in research on maternal health? What are the questions
that we should be trying to answer? And I guess you also spoke
about disaggregating the data.
What kind of improvements can we be making in that area,
just an overall question with regard to research, the gaps, and
what should we be trying to look for?
Dr. Sakala. Yes. So thank you for that question. As I
included in my testimony, I would reiterate the importance of
measuring the impact of the community-based perinatal health
worker groups that are arising organically across the country
to fill gaps in trusted, respectful, culturally congruent,
accessible care that, to me, seems like a very promising
practice where we really don't have the evidence to give them
the full support that they may deserve.
And I think--I appreciate all the mental health questions.
And of the same thing, we have a shortage of mental health
providers in this country, and we are still struggling to
integrate mental health services within healthcare.
And there was a PCORI--that is the Patient-Centered
Outcomes Research Institute--study that found that home
visitors can be trained to make a difference in people's
maternal health. I think we should be looking at what these
extended model doulas can do, what other types of providers
that are providing support in these community-based groups can
do to impact mental health.
I think that letting communities lead and letting them--
understanding that they have the power, the relationships, the
connections, the understanding that is often not there with
other kinds of health professionals. And, so, we should be
looking at how we can affirm those contributions.
The Chair. I think there are some areas that we need to
take a look at in terms of--where are the areas that we know
less about, in terms of research on maternal health? Do you
know about them?
Ms. Stewart. If I can answer that question. So, at the
March of Dimes, I think many of you all know, we invest a
significant amount of money into the research around maternal
and infant health. There are a lot of areas where we have
action information.
One of the biggest areas is around how social determinants
of health really impact maternal and infant health. We have
some evidence around that. We know that about 80 percent of our
overall health is really determined by what happens in our day-
to-day lives, the condition of our housing, the safety of our
community, access to good safe nutrition, and those kinds of
things. We don't still yet have enough information on exactly
how those social determinants really impact maternal and infant
health.
The other thing I would say is, to go back to this issue of
maternal mental health, we know that stress, anxiety,
addiction, trauma, all of those things have a significant
impact on our health. How those things impact the health of
women who are pregnant, postpartum women, moms, we need to
understand that better as well.
The last area is around comorbidities. We again have some
evidence to show how hypertension, how diabetes, how obesity,
how other nutrition-related conditions impact the health of
women, the health of moms. We need to have more and more
information about that, especially around cardiovascular
conditions, because we know that is a leading cause of health
outcomes as well.
We know that two-thirds of American adults have one of
these chronic conditions. So how those kinds of conditions
actually then impact the health of moms through pregnancy and
beyond, we need to do more research and invest more money in
those areas as well.
The last area I would just say is we spend a lot of time
talking about these health inequities. We have to go deeper in
understanding how health inequity, how maternal health equity
issues really impact communities of color in particular, and
investing more time and attention in that as well would be
important. Thank you.
The Chair. Just a quick follow-up to that, which is,
gathering the information that you have talked about, the
social determinants of health, housing, all of those, the
stress, anxiety, trauma, the comorbidities, do we need research
into these areas? Do we need to commission some sort of a study
to look at these specific areas?
Do we have data that is just not collected at the moment?
How are we able to get the--how does lack of housing? How do
evictions? How do, you know, these social determinants? How do
we gather that in one place to make the impact on where we need
to go?
Ms. Stewart. Well, I will start with that. I think there
are two issues. One is a research issue. Are we looking deeply
at these issues and really understanding not only the causes of
some of those outcomes that we are seeing, but also, what are
some of the solutions. But we also have a big data problem, and
that came up earlier. We have to invest more money in data
collection, data surveillance.
The Maternal Mortality Review Committees, for example, the
most important thing that came out of the Preventing Maternal
Deaths Act was the fact that we could now have in every State--
and we do have them now in every State but three States, or
they are underway--Maternal Mortality Review Committees that
allow us to finally collect the data of really the underlying
causes of maternal death, so that we can not only know exactly
what were the causes of these maternal deaths, but what is the
solution.
Hopefully, the collection of better data, the reporting of
better data will actually inform better research so that we can
look to better outcomes. That data surveillance that CDC does,
that the States do at the Maternal Mortality Review Committees,
all of that data is really important. And we have underinvested
in data collection efforts as well as the research that we need
to develop solutions as well.
The Chair. Thank you.
I am just going to say, as I get back to the organizations,
I think it would be useful for us--I saw the map in some of the
background material that we had. And to be very honest, it was
very, very confusing. What I would love to see--and I don't
know if your organizations can do this for all of us--is where
are the counties, or where are the States in which these
counties exist? Where are the deaths? The analysis of where in
the country we are finding these circumstances to see where we
need to target, if you will, where we are going and what we are
doing.
So, if you all have--any of you have the capability or the
capacity to do that or you would need assistance in doing that,
please let us know, because I think that could be enormously
helpful as we are trying to look to, in many regards, is have
our--and where there are no OB services as well, to take a look
at this as how this lays out across the country, and look at
the ways in which we might be able to attack it in that way,
and persuade potentially some of our colleagues, you know, that
these are investments that are essential, not just worthwhile,
they are essential if we are going to try to address this
problem. So we can talk, you know, we can be in touch with all
of you on that.
Let me just wrap up, and you have been really wonderful.
And I think we all are so indebted to you for the work that you
are doing and the clarity which you have brought to this issue.
And I will go back to saying what I said at the outset: You not
only are crystal clear of what the problems are, you are
crystal clear on what the solutions that we can address.
Oftentimes, you can't really get your hands around a
problem, because it is just so overwhelming. This needs a lot
of work, but we have some identified courses that we can move
through.
So I just--and one of the things that came out, and I will
just say this to you--and I see my colleagues, Congresswoman
Lawrence, Congresswoman Roybal-Allard, you know, we looked at
CDC, the Perinatal Quality Collaboratives, Maternal Mortality
Review Committees, Surveillance of Emerging Threats, the
Mothers and Babies Network, newborn screening, the workforce
training, midwifery training, doulas, data disaggregation,
NICHD and their research, CMS, what they are doing.
I don't know, we can talk at another point about this HHS
partnership that you have with the March of Dimes and so forth,
and what that is all about. Paid family and medical leave.
Maternal Health Hotline, the Momnibus legislation, and the list
goes on.
We have had substantial recommendations from all of you,
and this winds up being that we have got a ton of data. Yes,
there is more that we need that has been laid out, but for
God's sake, this crisis can be addressed, and we shouldn't be
crying out in the wind, because I believe it is a national
disgrace, you know.
To support women, to support mothers, to support their
children has to be a fundamental value of this country. And I
hope we can look to you again, because I know, and I am looking
only to the two members, but I can tell you about all of our
members. We are going to address this issue, because this is
the subcommittee that can do it. So we are going to be seeking
your guidance.
I am always mindful of what my colleague, Congressman Cole,
says, that it is about the allocation and the resources, but,
by God, where are our priorities and let's move ahead on this.
So thank you all very, very much for this morning's testimony
and for the work that you do every day. Thank you.
And I am banging on the table. This hearing has come to a
conclusion. Thank you. We are adjourned. Bye bye. Thanks.
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