About the eligibility requirements of the current child nutrition assistance cadre of programs as they exist today . I think the important thing when youre talking about reducing errors and improper payment which is i think we all agree is a very important endeavor is to create a culture where a culture of compliance with the rules. We want the rules to be followed. I dont think the rules themselves are the problem i think its helping people understand them and there are lots of different people involved in the system. Its families when theyre filling out applications, its schools when theyre running programs, its states when theyre administering them. So i think that kind of day in and day out work is whats most important to reduce errors and reduce improper payments in the program. I would second that and also add its important to as a former president once famously stated, its important to not only trust but verify. I would add to that and say its important to trust and verify in a meaningful manner. We found through our work that the verification process could be strengthened in several important ways. And its and i think that will serve the reduced improper payments rate and help drive that number down. Although i should add as miss neuberger responded on the counting side of the equation over 700 million the improper payments estimate is due to simple accounting errors at the School District level. So i think thats an area that could be addressed as well through Technology Better training. Theres some important ways they could drive that number down to enhance the operations of the program. So do you believe that more state and or local input on establishing eligibility requirements could be helpful in cutting down on some of the incorrect reimbursement rates . Well, personally i think theres two ways to go at it. You have to first explore the potential of Data Analytics and computer matching to help simplify the process, make it more efficient and you can do that in a more at the state agency level without getting down to the School District level. But at the School District level, again i think there needs to be greater awareness about how to fill out applications completely, the need to periodically do spot checks of what people are reporting. So i think you have to approach it in a multifaceted manner. Centrally at the state agency level as well as the School Districts as miss neuberger pointed out, though, theyre not as well equipped to do their own rigorous verification. One of the things that does make the School Meal Programs easier to understand and administer now is that they do have one set of rules that applies across the country. And that is an important simplification and source of fairness and i think its important to consult with districts and states about what will work to help the programs run more smoothly and more accurately in their areas. But thats not the same as considering changing the eligibility rules or other program rules. Do you think that categorical eligibility for school meals ought to be eliminated . No. Thats basically the source of tremendous simplification. I mean thats what allows families who are already getting snap benefits where theres a very rigorous eligibility determination, their income levels are going to be at or below the levels that are already set within the school meal program. So basically thats a tremendous simplification right now. So which ones if thats true then which ones should be utilized the most . Right now any place in the country is allowed to use data from the snap program or tanf cash assistance. There are other categories like children that are homeless or in costar care, they can be automatically eligible. Medicaid is only available for use in seven states right now and so thats a potential thats theres Untapped Potential there where additional states could benefit from utilizing that data. Okay. All right, my time has expired mr. Chairman, i thank this panel and look forward to the testimony from the next one. Thanks. Senator stabenow . Thank you mr. Chairman. I just want to do a quick followup, mr. Lord. You were talking about how as relates to simplification but also making sure we are rigorous in our in oversight standards and so on you indicated this snap program has a smaller error rate, which it does one of the smallest in the federal government in terms of overall errors and that theres a larger error rate in the food program. So if we were going more in the direction of tying it to snap Community Eligibility which has saved a lot of money in michigan and been very effective, is that what you were suggesting . Looking at snap which actually has more rigorous oversight lower error rate, and tying it to that might actually establish both goals of simplification and also tightening things up . That was yeah, thats what i was suggesting and i was citing the omb figures on their estimated improper payments. There is some degree of imprecision with it, but that alone suggests snap, even though there are some errors in the program, when you rely on that method to enroll people in school meals its its actually less. Because i think its below 3 if i remember right right now. So thats actually the low esther or are rate of anything we have in agriculture programs. Its around 3 and again the School National School Lunch Programs 15. 25 . So much higher. So i think thats an interesting thing for us to highlight thank you very much. One last point. In our report even though we know we did note that if you are deemed categorically eligible for a program through programs such as snap, though, under the current verification process, youre excluded completely from verification so our point was you may want to subject some of those eligible applications to scrutiny. Thanks very much. Senator klobuchar . We had a hearing on patent reform which was quite exciting or i would have been here earlier. Thank you chairman roberts and Ranking Member stabenow for holding this important hearing. Child Nutrition Programs in advance of our work to reauthorize the program. I worked hard in the last reauthorization to strengthen local wellness policies, to update the nutrition standards for Child Care Centers and afterschool programs and also to ensure that vending machines and a la carte choices wouldnt undercut Good Nutrition and the sale of junk foods. We all know how important schools are to our kids inu tradition. Im proud of the work that we have done in the bill and i think we know that weve seen some improvement but i think we also know that there are problems ahead if we dont continue this work to make sure the kids get the most nutritious meals possible when theyre at school. The 2010 reauthorization of child Nutrition Programs specified that usda conduct a review of food items provided by under the wic program at least every ten years based on the institute of medicine recommendations. Some have argued that the review process should be expedited in certain circumstances. Miss neuberger, does the current review timeline keep pace with scientific advances on the nutritional quality of fruits and vegetables and what can be done to improve the process . Theres a review under way right now, so i want to make sure everybodys aware of that. That is working as planned. And the rule is actually that the review has to happen at least every ten years, but it can happen more often than that if theres reason. So if there were important changes in dietary recommendations that might warrant a more frequent review. But i think the rule thats in place makes sense. Okay. Very good. And its been estimated by the journal of Health Economics that nearly 20 of annual medical spending in the u. S. Is obesity related. How does this factor into the decision about how we reauthorize this bill . Either of you can answer that. I think weve talked earlier both Programs School meals and wic have tremendous benefits in terms of helping children achieve the health and Development Outcomes youd like to see as well as better preparing them for learning. So they are critical investments, particularly for lowincome children who may not have access to adequate nutrition elsewhere to help them develop properly, stay healthy, and be ready to learn at school. Okay, thank you. Could you comment also on the potential cuts to the child Nutrition Programs under the fiscal 2016 budget resolution that weve just been talking about on the floor miss neuberger . Broadly speaking we would be very concerned about the consequences for lowincome families in that agreement. Thats not specific to these programs but across the programs that low income families rely on when theyre struggling to feed kids or make ends meet. And one last thing back to the wic program that we just talked about. You know it plays a critically Important Role in promoting the health of pregnant and postpartum mothers as well as Young Children. The continued success of the program is contingent on sound cost control and i understand that states that are given flexibility to develop their own food list based on usdas minimum standards and get some of the states leave lower cost products off the list of approved foods. Without dictating to states their wic food list, how can we incentivize states to consider cost controls when determining approved food items . Just to be clear, wic is a federal program. Most of the rules are federal. There are certain areas where theres state flexibility. States have a builtin incentive to contain costs in wic because they have limits . Because they get a limited amount of money so the more efficiently they can use the money the more people they can serve and thats been very motivating motivating. Wic is a very costeffective program. Wic costs have increased at about half the rate of inflation over time. Its a very sound investment and states have played an important part in that. So the way the program is structured really contributes to that incentive structure. Thank you very much. Mr. Chairman lord did you want to add anything for any of these questions . Not on wic, no, senator. Okay, very good. Thank you very much and im glad youre here. Its a very important topic and, as i said, the last bill with senator stabenow was involved in, i know senator roberts on the committee and now leading the committee i think was very important and weve made some Great Strides and we need to continue improvement in the nutrition standards. Thank you to both of you. Senator . Thank you mr. Chairman. Miss neuberger or mr. Lord, i want to look back at the program. Im from North Carolina. I was speaker of the house down there, worked a lot with the various school systems. We have 115 of them in North Carolina and they seem to be both for and against the Food Nutrition Program in terms that they like the outcome but they didnt like the overhead or they didnt necessarily like how the regulations required them to implement it. That the level of details involved. Has there been any work done on trying to figure out how we can if were measuring outcomes, and thats a question i had for you, mr. Lord. I know youre going through the gao is going through the verification process making sure that people who are entitled to it get it and those who dont, dont. But what about the more fundamental question of the baseline when this program started, the year over year improvement and outcomes which, at the end of the day, is Childrens Health and making sure that theyre fed. Are we measuring those in a scientific way and identifying best practices and intervening when theyre compliant with the program but not producing positive outcomes . Well i know miss knewberger is probably more well versed on that but in terms of the Outcome Measures for the verification process, that was one of our suggests to usda. Theyve recently started collecting a lot of good information on socalled forcause verification process. But they mix it together with other reporting so its unclear to us what the outcomes of all the efforts to conduct forcause verifications. And those are reviews of questionable applications so at least in that one area im very familiar with. Theres broad agreement they need to do a better job in looking at Outcome Measures in that area. Thats verification related and perhaps miss neuberger can come in on the broader nutritional outcomes. Miss neuberger . Sure. Theres generally quite a lot of research on the positive benefits of these programs in particular, for example, children who eat breakfast at school have been shown to have fewer academic issues less absence and tardiness and better performance at schools. So thats a clear area where theres a strong tie between participating in the meal programs and kind of educational outcomes youd like to see in school. One question i have, i dont know if its anecdotal or something that we need to look more at but you hear the stories of putting im not going to pick a vegetable because i always make a segment of agriculture mad when i do. But lets say a vegetable that for whatever reason kids dont like yet and theyre concerned that their ear satsyre satisfying the letter of the regulation but that goes into the trash. Do we have data to get that beyond anecdotal where they may be Something Else to put on the plate to make sure that the Young Persons belly is full and better using the things that were putting on their plate . I hope that youll ask that question in the second panel because you have some program operators. Im going to i just dont know if im going to be here. There is research on the extent to which children are eating the meals. This is not an area that i focus on so its not my expertise but it has shown that there is less way waste under the new rules than there was previously and theres certainly always room for improvement but its important to know things seem to be moving in the right direction in terms of figuring out how to get kids to eat. I think thats one of the concerns expressed by a lot of the people. I met with some members of the School Board Association and superintendents association. That seems to be a concern that they have expressed and i think its an area we need to look at. And the next program i hope im here so i can brag a little bit on our farmtoschool initiatives in North Carolina because weve been very aggressive and its beneficial, we need to do more of it. Convince those kids Brussel Sprouts are good, particularly when they know where they came from. But im going to hold and allow us to move us to the next panel and reserve my questions for that panel. Thank you. Senator tillis, ive been known to eat a brussel sprout or two but always with cheese on them. [ laughter ] mines with bacon. Well, with bacon and cheese it might work out but i have problems with the cheese but we dont want to go there. Senator heitkamp . Thank you, mr. Chairman. Thank you for this important hearing, making sure our children have every opportunity to succeed is something i think the entire committee believes in and this is a good place to start when were talking about child nutrition and basically giving them the opportunity to grow up healthy and learn throughout the day. Nutrition standards set in the health and hungry kids act is an important first step to help creating a healthier and more prepared next generation. But we should also make sure that the schools have the tools they need to provide healthy meals. In north dakota, 100 of our schools, im proud to say, are meeting the standards and a couple of months ago only one school still had asks for a waiver on the whole grain pasta requirement. So thats pretty incredible in a state that has a fairly high rate of problems as it relates to obesity. However, the pew study found that 74 of north dakota schools still need at least one piece of School Equipment kitchen equipment, in order to meet the standards. And senator collins and i have introduced a bill to help schools purchase new equipment and provide them with the Technical Assistance on food preparation and meeting the standards so i want to put a plug in for the School Food Modernization act which i think will give the tools that the many of our people who serve our children everyday, and by that i mean literally and figuratively that the equipment and the tools that they need. Especially this is especially important in rural schools where the School Districts are already strapped, where you have a Large Population but or a small population but a huge need for upgrading. Ive said it many times. My mom was a lunch lady so im especially partial to the school lunch program. I know what that meant. I know what she did everyday to try and put nutritious and good food on the table. And i also knew that there were kids that i went to school with where that may have been the only meal they got all day. So she took that responsibility seriously and so weve been talking a lot mr. Lord, about Program Integrity and making sure people who shouldnt be participating in the program arent. Obviously the surfer dude hit the news last year in a big way. But miss neuberger noted that one in four applications were denied despite actual household circumstance and were wondering, how as we close to loophole and make sure that we dont have fraud in this program, how can we make sure more kids get into this program who actually need these nutritious meals, who actually need that backpack going home on the weekend . Well i think you need to raise awareness and perhaps do additional outreach at the School District level. I think there is good awareness of the program but in some pockets, perhaps, there isnt. So thats part of your Outreach Campaign for the program. You always want to be sure those who are deserving are in the program. Weve done outreach. Im looking for a new solution. Well thats probably in my humble opinion, is something the next panel could probably better address. Theyre obviously working at the local level and they probably have really good perspective on that. I sort of have the global view. But i i think you take my point seriously which is we have fraud but we also have a lot of kids who go home hungry and thats got to be part of this discussion. Miss neuberger can you suggest any ideas on how we can expand awareness or how we can expand participation for children who go hungry . Sure. Awareness is certainly an important part of it making the programs accessible and making sure they stay that way. So we have focused a lot on the ways that you can improve accuracy and make sure the programs are working as they should. Its important at every step of the way there to make sure that youre not putting barriers in the way for families who qualify for the programs and need the benefits. And so that balance is an important way of making sure that the programs remain available to students. Some of the approaches we talked about earlier of relying on data from other programs, the Community Eligibility provision where very high poverty schools can serve meals at no charge to all students are ways to make it easier for lowincome families to get those benefits. Thank you. I yield the rest of my time. Thank you, senator. Senator brown senator bennett have questions for the next panel so i think unless i am mistaken this concludes the contributions from the first panel. Thank you so much for coming. And thank you for your very valuable testimony. We could now have the second panel please come forward. I think in the interest of time we are going to introduce all of the witnesses. Each one of course, deserves their timely moment of fleeting fame before the committee. But we would like to welcome mr. Brian riandeau from louisville, kentucky, where hes the executive director at dare to Care Food Bank. Earlier in his career mr. Riendeau led a government and Community Affairs for the kfc corporation. I think everybody understands who that is and served as the legislative assistant for Senate Majority leader that would be mitch mcconnell, wouldnt it . I cant remember. You cant remember . All right. Thank you for being here today. We look forward to your testimony. Mr. Richard goth of the office of child nutrition from West Virginia and their department of education is next. Mr. Goff joins us on behalf of the West Virginia department of education where he has served as executive director in the office of child nutrition back since pardon me, 2005. He has 26 years of experience with the West Virginia department of education, including work with the child and adult care food program. In his current role he oversees development of policies and Program Administration related to all child Nutrition Programs. I look forward to your testimony, sir, and your insight. Miss cindy jones of the unified School District 233. Im especially happy to introduce to the committee ms. Jones who serves as the Business Management coordinator for food service at the Public Schools in kansas. She has worked for oletha Public Schools food service for over 20 years. Started at 17 as i recall. She serves as the Public Policy and Legislation Committee that anywhere the School Nutrition association of kansas and has served as Vice President and president. I look forward to cindys testimony. Dr. Sandra hasink i hope i have that right. She currently serves as president and hails from wilmington, delaware. The dr. Has focused her career on preventing and treating obesity in children. She is a pediatrician at Dupont Hospital for children where she founded the Weight Management program in 1988, serve as the director of the pediatric obesity nushive the. The doctor began her medical career at the haventer built school of medicine as one of only 12 women in her graduateing class. I look forward to your testimony. We will start with you, sir, mr. R iendeau. Thank you chairman roberts, Ranking Member stabenow and the members of the committee. Thank you for inviting me here today. Im honored to represent feeding Americas Network of 200 food banks that serve 46 Million People in need, including 12 minute children. Dare to Care Food Bank works with 300 agencies across 13 counties in kentucky and indiana. Our service area spans nearly 4,000 square miles and includes urban, suburban and rural areas. Im here today to tell you that child hung surreal in the communities we serve and across this great country and its particularly its a particularly stark reality when children are not in school. But im also here to tell you today that we can solve child hunger through innovative Public Private partnerships and strong federal Nutrition Programs, we can ensure all children have access to enough food for an active and healthy life. Im here to ask you to help us make good programs even better. Food banks like mine cannot do our work without the federal Summer Food Service program and the child and adult care food program. And if certain changes were made to these program we could reach even more kids in need. My food Bank Provides more than a thousand hot meals a day to kids throughout the year. Children who visit our partner sites will not only receive a nutritious meal, but they eel have a safe alternative to being on the streets. They get tutoring, mentoring, and sports. But far too many children cant reach summer and after School Meal Programs, particularly in the summer. In fact, Summer Food Service program in my state reaches less than 10 of the lowincome kids and only 18 nationally. Why is that . Well, at dare to care, our programs are concentrated in Jefferson County an urban programming where Summer Services are available and where many of our children can get to sites. The current summer feeding model which requires children to consume meals at a designated site works great in these instances where children have already congregated for tutoring and mentoring. However, we face two challenges in reaching kids in our more Rural Communities. Lack of sites and transportation. Those communities simply lack facilities where kids can congregate and consume a meal which makes the on sight feeding requirement difficult or impossible to comply with. Even schools in those counties that try to provide summer feeding report low participation rates because kids are not able to travel to the site each day. There are several policy changes that you can make that would help dare to Care Food Bank reach more kids during the summer and after school and we believe it will require a twopart strategy. First, we need to strengthen the sitebased model by streamlining federal programs and making it easier for Community Providers to expand the number of sites available to children. Currently, we have to operate two different federal programs, one during the school year and another in the summer. Even if were serving the same kids, the same meals at the same sites year round. Moving to one program will allow us to focus on feeding kids and not pushing paperwork. Additionally, lowering the area eligibility threshold from 50 to 40 will expand the number of sites available and align sfsp with other federally funded youth programs. Second, no two communities are the same. We need to continue to maintain Strong National standards and accountability while providing new Program Models that local communities can tailor to best meet their circumstances to really make progress and closing the summer gap. Dare to care currently runs privately funded programs to fill this gap. Our Backpack Program and Rural Communities provides children with nutritious foods on the weekends and in the summer. But limited resources mean that we can not provide a backpack to every kid who needs one. Weve also looked into mobile summer feeding programs but our Rural Communities are so small and far apart that the time requirement of having kids eat a full meal before we can go to the next location as required would limit the number of children we serve and therefore be cost prohibitive. Waiving the congregate requirement to allow innovative Program Models in hardtoreach areas will address these barriers and significantly expand the number of children we reach. Finally, the summer ebt demonstration projects provide another model that has been effective at both reducing Food Insecurity and increasing nutrition. In this model, families of children receiving free or reducedpriced school meals are given an ebt card to purchase food at Retail Stores during the summer. Wed like to see this program significantly expanded if communities that have high need and are particularly difficult to reach. Id like to close by saying that im convinced that child hunger is a solvable problem. Its going to require collaboration between government, business, and nonprofit stakeholders and were counting on you to make closing the summer hunger gap a top priority in the child nutrition reauthorization and to give food banks like mine the tools we need to serve every hungry child. I thank you for this opportunity to testify and im happy to take questions. Thank you for the opportunity to be here today. Im the state director in West Virginia and id like you to to give you my perspective of the last two reauthorizations and how we implemented them at the state agency level. As you know, in april of 2007 the iom released the report nutrition standards for foods in schools. Nine months later, West Virginia adopted those standards in our standards for School Nutrition policy. The progressive standards were implemented in the cafeteria and outside the cafeteria. We required schools to have more fresh fruits and vegetables. We also implemented the skim and 1 milk provision. Our sodium standard was 1,100 milligrams of sodium, which is a little more stringent than the tier 1 requirement and we adopted the whole grain rich standard. This was all back in 2008. We do not permit al la carte meals in West Virginia. We just felt it was the right thing nutritionally for the student and financially for the School District. Also outside the cafeteria we implemented the competitive sales rules that the iom recommended for all good sold, served, and distributed to students during the school day. We removed soft drink machines and sugary sweetened beverages, junk food machines vending machines and School Stores had to meet the nutrition standards set forth by the iom. We also addressed healthy fundraising and required that if inschool fundraising was to occur during the school day on School Property that it had to meet the nutrition standards as well. We also instituted the professional standards at the time and had a staffing requirement whereby we required continuing education hours and a certain level of a degree for the Food Service Director at the district level. Additionally we did Something Different as well we addressed the food coming in from outside sources. Wed done everything that we could to ensure the School Environment was a safe and Healthy Learning environment in the cafeteria and throughout the School Environment. Yet we were turning a blind eye to what was coming in the back door in the form of parties and things of that nature. So we instituted a provision to address that as well. In 2010, in anticipation of the healthy hunger free kids act we redirected our focus on the technology and we developed a statewide automated Electronic System whereby everybody Public School in West Virginia utilizes the same pointofsale software. Students that come through the Public School system in West Virginia, a lot of times, would just put their finger their index finger on a biometric scanning pad and it logs and categorizes the meal. That has increased efficiency and accountability in the program and has dispensed with a lot of the overclaiming problems that other School Districts were seeing. The direct certification match when you have a statewide system like this it is done at the state agency level. And we do the direct certification match as well as the determination for Community Eligibility at the state agency and we push the data down to the schools. Once schools figure their claim for reimbursement, that data is loaded up to the district level and then pushed to the state agency level. So the interface goes both ways, from the state agency to the school, from the school to the state agency. By doing that, we were able to have statewide eligibility. So as needy families typically move around throughout the state, what we were able to do is focus on ensuring that their meal eligibility benefits were not interrupted. No longer were they required to submit an application at the new School District, eligibility followed them just like their name or their student i. D. Did. This also made it easier for us to monitor the system and improve efficiency and the integrity of this system. The threeyear monitoring cycle when we went from a fiveyear to a threeyear was not a burden for us. 50 of our monitoring is completed in our office at the Central Office at the state agency level in charleston before we even enter the field. We have a great relationship with the snap and tanf and foster child folks to get that data electronically direct certification is then uploaded on a weekly basis. We also were the first piloted the second year Community Eligibility. The first year West Virginia was not select bud we did it anyway. We piloted it a state agency level on something called the West Virginia universal free meals pilot project. Cep is very alive and thriving in West Virginia. 54 of all of our Public Schools are Community Eligible in West Virginia. Im very proud of that. That was a feed to achieve act, an act that our lej which you are passed that realigns School Breakfast with the instructal day and im about to run out of time. The act passed without a fiscal note and built upon the program wes already had in place and ensured all children would receive at least two reimburse reimbursable meals per day. Thank you and ill take questions. Ms. Jones . First i want to thank you for inviting me here today to testify. School nutrition professionals across kansas are working hard to ensure children receive the nutrition required for their health and academic success. Hungry children simply cannot learn and thrive oletha Public Schools is the second largest School District in kansas. I am responsible for all financial aspects of our Nutrition Programs. Our department has 275 employees serving 24,000 meals per day on a 12. 5 million budget. 27 of our students receive free or reducedprice meals. At oletha we are committed to delivering nutritious meals thanks to our universal free breakfast in the Classroom Program in five Elementary Schools we are serving 850 more healthy breakfasts east day resulting in fewer tardies and absentees and better behavior as students are no wronger complaining about being hungry. We also participate in summer feeding, serving 1900 meals per day, expanding access to these Critical Services has helped our program remain financially sound while providing the nutrition that is vital to our students even before the healthy hunger free kids act professionals have been working hard to improve school menus. We have offered unlimited fruits and vegetables, serve whole grains and meet limits oncale reis and unhealthy fats while reducing sodium however we face many challenges, under the new rules many students are now bringing meals from home. Our Elementary School participation has dropped more than 9 and at the secondary School Revenue has dropped as students have stopped purchasing a la carte choices. Almost all the students leaving the program are paid students. If this trend continues, the School Cafeteria will no longer be a place where all students go to east but rather a place where poor student goose to get their free meals. We have worked for years to fight this stigma so its heartbreaking to see our progress decline. Kansas students are leaving the program for a variety of reasons. Paid lunch equity mandates forced many schools to raise lunch prices. Many families do not qualify for assistance but are struggling financially. As we continue to raise prices some will no locker be able to afford to eat with us and the financial losses may force our program to cut staff further impacting the community. Smart snack rules have led to huge declines in a la carte sales, too with an estimated loss of 700,000 in revenue. Items such as our freshtogo salads had to be taken off the menu because the small amounts of meat, cheese, and salad dressings dont meet the sodium and fat requirements. Our sub sandwich was a popular a la carte item but we had to shrink their size, remove the cheese and switch to whole grain bread. Now we sell very few. We also have opportunities to serve diet soda, sugarfree gum and coffee. We have chosen not to serve these items but it just shows you how these regulations do not always make sense. Despite our best efforts to make meal mrs. Appealing were struggling with student acceptance. Were challenged to find whole grain rich tortillas, pizza crusts and other specialty items that appeal to our students. Every student must now take a fruit or vegetable with their meals, whether they intend to eat it or not. As a result, we have seen an increase in good food going to waste in our schools. We promote fruit and vegetable choices with free samples and i tried it stickers to encourage consumption but forcing students to take fruits and vegetables turns a hole think choice into a negative experience. Encourage and educate instead of require is always the best option. Olathes budget is tight. After labor and supply costs insurance, utilities, equipments and other expenses we are left with just over a dollar to spend on food for each lunch tray. Imagine going to a store with just 5 to spend for a family of four including milk fruit, vegetable and a healthy entree. Could you do that every day of the week . My involvement in the School Nutrition association of kansas has allowed me to witness the accomplishments and challenges of colleagues across kansas and missouri. Some districts have overcome challenges under the new rules, particularly those with high free and reduced price eligibility which provides higher reimbursements and participation and access to federal grants and programs. However many districts like olathe are struggling with reduced revenue declining participation and the higher cost of preparing meals. We dont have access to many federal grants thats why its vital to allow flexibility to all programs to be successful for the students and families we serve. Theres a lot of negative press about school Nutrition Programs about flexibility. To me this is hurtful. We are only asking for flex tonight ensure all school Nutrition Programs are successful. Have faith in the knowledge of all School Nutrition professionals that we know whats best for the children. After all, they are our children and grandchildren, too. Thank you for the opportunity. I will take any questions. Yes dr. Hassick. Thank you and good morning. Id like to thank chairman roberts and Ranking Member stabenow for inviting me here today. As i was introduced im Sandra Hassink and im president of the American Academy of pediatrics a nonprofit professional organization of pediatricians and pediatric medical subspecialist Whose Mission it is to obtain the optimal physical social health and wellbeing for infants childrens, adolescents and young adults. Its an honor speaking about my lifes work hield hood obesity and the connection between nutrition and health. The foundations of child health are built upon ensuring the three basic needs of every child sound and appropriate nutrition, stable responsive and nurturing relationships, and safe and healthy environments and communities. Meeting these needs for each child is fundamental to achieving and sustaining Optimal Health and wellbeing into adulthood for every child. Early investments in child health and nutrition are crucial. The time period from pregnancy through Early Childhood is one of rapid physical, cognitive emotional and social development and because of this this time period in a childs life can set the stage for a lifetime of good health and success in learning and relationships or it can be a time of toxic stress when physical, mental, and social health and learning are compromised. Micronutrients such as iron and folate have demonstrated effects on Brain Development but are commonly deficient in pregnant women and Young Children in the united states. These deficiency cans lead to delays in attention motor development, poor shortterm memory and lower i. Q. Scores. One of the most Effective Investments congress can make during the prenatal to school age period is to support the special supplemental Nutrition Program for women, infants and children, or wic and i thank the committee for its strong bipartisan support for wic over the past four decades. Wic helps give children a healthy start at life by providing nutritious foods, Nutrition Education and breastfeeding support. Children who receive wic have improved birth outcomes, increased rates of immunization, better access to health care through a medical home, and participation may help reduce childhood obesity. Wic has also played an Important Role in promoting breastfeeding and improving breastfeeding initiation. We recommend that the committee seek to find ways to promote breastfeeding initiation and continuation even further in the wic Program Including by an increase in the authorization for the breastfeeding Peer Counseling Program for 180 million. Wic is a targeted intervention for mothers and Young Children with impacts that can be longterm in nature, including improved health outcome, educational prospects and the prosperity of our communities. As a pediatrician ive seen firsthand the importance of nutrition in child health. When i started my practice in childhood Weight Management 27 years ago, i was seeing adolescents. When i retired last october i had a special clinic for children under five with obesity and we were seeing infants. These children were already showing the effects of their increased body mass index on Blood Pressure and measures of blood sugar control. We saw obesityrelated Liver Disease in fouryearolds and in children with prediabetes at age six. Today our children are experiencing an unprecedented nutritional crisis resulting in the double burden of Food Insecurity and obesity. The connecting factor for both is poverty. The highest rates of obesity are found in people with the lowest incomes and increasingly the picture of Food Insecurity in children is that of a child with overweight or obesity consume ago poor quality diet. Good nutrition is not only an essential component of chronic disease prevention and treatment, it also helps treat the effects of chronic hunger. Wic is just one intervention to address the double burden. Families or school, child care, communities and certainly pediatricians play an Important Role in shaping Healthy Habits. When youre in the middle of an epidemic, you cannot keep doing what youve always been doing. As pediatrician, Parents Community leaders and policymakers, we have an obligation to ensure the food we provide our children is healthy and nutritious and that we model Healthy Eating as adults. Good nutrition in childhood sets the stage for Life Long Health and just like we vaccinate to protect against illness, we can also vaccinate against chronic disease by providing pregnant women and children with nutritional assistance and breastfeeding support. And as we celebrate our mothers this weekend i urge the committee to put mothers and childrens nutritional needs first. Our Childrens Health simply cannot wait. Thank you. Ill be happy to take any questions. Thank you very much. We will proceed with questions. I know the chairman will be returning in just a moment so thank you to each of you for your comments. We very much appreciate. Dr. Hassink thank you very much for reminding us all what this is really about in terms of children and the health and the stake we have in children being healthy and having a chance to succeed. Mr. Goff i wanted to start with you because when i think of West Virginia, you have all kinds of school, you have rural, you have urban, and yet your state is 100 compliant with the new meal standards, including smart snacks. Looks like you were ahead of the game anticipating things. I want to congratulate you and the state for that. And im wondering how you were able to get to help your schools in this state to be able to achieve the goals and then secondly when many schools rely on the a la carte sales to supplement their budgets, and we understand tight budgets for schools, but the change to healthier items doesnt seem to have impacted your schools. So how did you help schools be able to achieve and how is it you were able to do that including a la carte sales in a way that didnt hurt your schools . Thank you for the kind comments. When we adopted the standards in 2008 right after they were released and we put together a very comprehensive Implementation Plan. As far as bringing the schools on board, you know, we went through the black eyes like everyone else is going through with the healthy hunger free kids act but we used quarterly workshops. We created a list serve where we could communicate with each Food Service Director through the internet with the push of the send button. We issued guidance memos. We met with principals groups, we met with superintendent groups, we did presentations before boards to get the word out and let them know just why the standards were changing and why we were doing what we were doing and the Science Behind it. We created a web site called smart foods for parents to educate parents of all the changes. So weve had a very comprehensive Implementation Plan and we staffed at the state agency level in preparation for all the changes as well as far as grant writers and registered dietitians and things of that nature. And our Automated System where we have an Electronic Technology system pointofsale system thats integrated throughout the entire state, they just need to know one system. Our reviewers go into the schools, they just have to monitor one system. Many of the concerns that mr. Lord spoke of we dont experience in West Virginia. Because the direct eligibility determination is done at the state agency level. And we notify the schools of that information. Our free and reduced application is online. So weve had a lot of the problems with that we experienced with the paper application which is basically become obsolete in West Virginia. As far as allah la carte children in the cafeterias gets a meal pattern thats fully reimbursed whether its free reduced price or paid. We just felt that thats in the childs best interest. We also worked to have salad bars put in place. Now, with by not offering an la carte sales that makes the point of sale activity. That lends itself to increased accountability as far as logging and claiming the meals. The we have never had an issue with as far as the revenue goes on an la carte sales. You get the full price of the paid meal and then you get the full federal reimbursement so you get both Revenue Streams in West Virginia. A la carte. That was never an issue for us. Well, its very impressive what you have done and when you look at the automated point of sale and the statewide eligibility so that the schools dont have to be focused on that and it moves with the child. I just think thats really something that we need to look at and how we can save the costs and the paper work for schools and families and still achieve things so congratulations. Mr. Riendeau, we have had a lot of bipartisan support over the years for our summer Meals Programs and we want to continue that. We know we need to strengthen both the con frequent gait and noncongregate models. Im concerned we create more exflblt in michigan. We have sup o submitted a request for the requirements and in fact, unfortunately, it was denied because of the current restrictions when a waiver can be issued so i wonder if you might speak a little bit more about the need for flexibility in terms of the summer and whats happening in terms of communities, whether its where children meet or whats been called grab and go or other kinds of models. Why this is important. Sure. And sure. Thank you for that question. In our case, dare to care, we serve urban and Rural Counties and i think thats where the difference between the two models is most stark. The vast majority of the meals that we serve through sfsp are in Jefferson County. Its a place where kids there are plenty of sites for kids to gather in the summer sites with programming and activities that the kids want to be a part of, the kids are there. And its easy for us to get those meals to those kids, have the kids consume them on site and allow us to you know, comply with the requirement of that program. In fact, we have our model is based on a 6,000 square foot kitchen we invested in to build two years ago that provides over 1,000 hot meals a day now and takes the meals to the sites and the Program Works very well there. Where the need for flexibility comes in is is in our Rural Counties. 11 are rural some are very rural. Frankly, they just dont have the community centers, the facilities for kids to gather. Even if they did have those theres a transportation issue. These kids are spread out. Many of them are living in hollows and small communities. Theyre dispersed across those communities. In the summer they dont congregate and so what wed like to see is the ability to work on the ground in those communities with government and Business Leaders in those communities to come up with unique partnerships and innovative programs that are tailored to meet the specific needs of those individual counties and i think you know, if we could have the flexibility that were talking about here, im very confident that we could reach many, many more of the kids in need. As i mentioned in my testimony you know, 90 of the kids in the state of kentucky who are eligible for sfsp dont get it because theres either no site for them to go or they cant get there. Thank you very much. Thanks. Ms. Jones, cindy, thank you for your help in our traversing kansas and enjoying School Breakfast and School Lunches. If you are provided with some that word again flexibility what changes would you make . I would allow us to go back to the 50 whole grains so were able to add some of those items back that the kids enjoy. Such as whole grain biscuits do not have much flavor. I dont know if any of you have tried them. Crackers. They taste like sawdust. Just some of those simple items, just like our children they love chicken null gets. All kids love chicken null gets. Now with the coating on the Chicken Nuggets they no longer like the flavor. Simple Little Things we could do with that. I would go back to encouraging kids to take fruits and vegetables. We keep hearing about, you know it is just a half a cup. But we have 29000 students in our district. Thats a lot of half a cups. And if two thirds of those kids eat the fruits and vegetables thats still 10,000 half a cups that we throw over and over a year thats one 1. 7 million half a cups. In our district we want the kids to eat their froouts and vegetables. We have unlimited fruits and vegetables. We go into those schools all the time encouraging them, giving the stickers because we want them to try their fruits and vegetables but because of the tight budgets we are having right now, this may be something we have to do away with and i would hate for those students that want to eat the fruits and vegetables to lose that opportunity because other students are forced to take them and just throw them in the trash. Also, i would like to be able to make the decision whether to raise the prices for our meals. I think a lot of our students are leaving the program because they can no longer afford to pay the meals price. I was visiting with a little girl the other day and she said that her mother now makes her choose two days a week to eat with us. Because they can no longer afford to pay those costs. So i would like to be able to do that too. We have just been joined by the whole grains champion of the senate who has a bill to exempt that standard. And i will give every opportunity to discuss that john but at any ratde, let me ask you, throughout my travels throughout kansas there were some schools doing well implementing the standards and they seem to be the schools obviously, with a lot of resources. And your testimony you mentioned that some high, free and reduced price districts in kansas have also overcome challenges. Is there a way to characterize the district that is are having a hard time or does it vary based on the individual community . The reason im bringing this up is that i think the distinguished senator from michigan and i tend to you put it to rural and small towns schools. Smaller schools. Right. And goodness knows they have problems with a lot of things. But im not sure im getting this exactly right. Is there a way to characterize the district that is are having a hard time or does it vary based on the individual community and what theyre doing, how they accept the program, et cetera, et cetera . I know theres been a lot of talk about training. Im trying to get at something here. I dont call it the attitude of the community or the attitude of the district or whatever. Not much choice in this regard. But help me out here. Well, what im seeing districts like my own, we have a lower amount of free and reduced. So a lot of those kids are making that choice to bring their own lunch. Where if youre at a district that they have a high free and reduce, those kids pretty much still will eat what we what they are being served. I was actually speaking to a director from a larger district and he said that because of the revenue that hes losing with his students he will end up in the red for the first time and this was around his tenth year of being there. So i think that is a lot of the problem is those schools that do not have the high free and reduce, we dont have the ability to get a lot of grant that is are available to those high amount of free and reduce schools. In my district we have a centralized building. We have two registered dieticians on staff. We have to pay for all of our costs, benefits. We even pay indirect costs to our districts to help pay for the utilities and the custodial staff at the schools. Little School Districts usually have someone within that school so they dont have all of the extra costs that large districts have, plus many of them have high free and reduced so they not only do not have the expense that we have they are able to bring in more revenue. Well, you have given me the exact reverse of what perhaps some of us may have as a bias. And i truly appreciate that. Thats exactly what i was asking about. I have so many different questions here. I would say to my colleagues. But i do want to get to senator don nelly who i think is next and then we have senator hoeven. Thank you mr. Chairman. I want to thank all of you for being here. Mr. Riendeau, i know youre based in louisville but i want to let everybody know that you also dare to care, serves washington, crawford harrison, floyd and clark counties in my home state of indiana. We are grateful to you for that. And i wanted to talk to you for a second about something that i know you have heard about, as well. And that is, the area you serve just outside of it is scott county which is just to the north of where you serve and we have had a devastating hiv outbreak there and drug epidemic there. And the county also has one of the highest Food Insecurity rates for children in our state. And i was wondering in your mind what is the best way to reach those kids . To make sure they have had enough to eat to make sure they stay in school and hopefully stay away from drugs, as well. Thank you, senator. And, yes, i live just down the road from scott county an i want you to know personally i share your pain with whats happening there. Its horrific. You know i guess i think in my mind whats happening there sort of points to the larger issue thats before the committee with this whole reauthorization. That is, you know investing in our kids today can prevent so many issues down the road. We heard that you know kids who grow up in a food insecure environment are going to have all kinds of issues and as they age out, they find themselves with less options for becoming productive self sufficient members of our community. Im certainly not an expert of drug addiction or hiv but i would have to guess that there is a very close correlation between the levels of Food Insecurity that you see in that county and some of the problems that folks are facing with no alternatives to turn to. And, you know, think the best way that one of the great ways that we could better serve counties like scott would be going back to the Ranking Members question about flexibility. Giving us the ability to tailor programs to be able to provide summer food to kids in those Rural Counties where the current model and the current regulations may not fit so well. Which ties in a little bit to my next question which is in that some of our rural areas you serve and the rest of the state and in the country there are pack a Backpack Program for kids on the weekend and such. And i know you help to work with that also. Do you think that as you look at that wed be able to reach more food insecure children if those meals in that program were eligible, free reimbursement as i know the funds come from private sector for that. Absolutely. That program is in our case with dare to care and serving the Rural Counties that is one of the programs we do use to reach kids in the rural councilties because when kids are at schools, we can get food to them to take home for the weekends. Currently, we fund that program entirely with private donations so its an entirely privately funded program. But in my mind, its a great Public Private partnership because were leveraging those private dollars to help address an issue that we currently cant address with federal dollars. And so the answer is yes. I think if we could find a way to vfl find a new Revenue Source that would allow us to provide more backpacks that would certainly have a positive impact on our ability to reach those kids. Thank you. Dr. Hassink, one of the areas of concern for me with Food Insecurity is also the general obesity that has occurred in children and the increase in diabetes type ii. And as you look at that, and as we look at that Going Forward what more can be done to teach about Healthy Eating lifestyles and how to prevent things like diabetes type ii because they can be so debilitating. Thank you. And certainly we as pediatricians are seeing the rise of type 2 diabetes in children. I think starting very early with early healthy infant nutrition and transition to solid foods and good feeding practices, Healthy Habits for families at home, to start out right is essential. Many of the children who have severe problems in adolescence with their health have already by age 5 been have had obesity. So early intervention, that means a family education. Stronger links with the Health Care System and food and providing information about food programs. Providing education. Understanding whats available for those families in the community. I think would help get them off to a good start. In 2007 when we wrote the expert guidelines for obesity, we considered all children at risk for obesity in this country and weve trained physicians to do preventive counseling for everyone because of this problem. Thank you very much. To the panel thank you for all of your work to try to help our children and our families. Thank you, mr. Chairman. Thank you senator donlly. Senator hoen . Thank you mr. Chairman. Thanks to all of the witnesses. Ms. Jones, you mentioned in your testimony some of the difficulties of complying with the sodium standards and the whole grains requirement. What can we do to help in that regard . What do you think the solution is . Sorry. We just want to make sure that we dont go forward with target 2 for the sodium because right now we are we are able to get by. Were struggling but were able to meet those requirements. But if we go on to target 2, that would mean we are serving therapeutic sodium level. There will be no flavor to the kids food. I just received an email from my director letting me know that the students surveys are back from parents and many of them say that their children are no longer eating with us because theres no taste to their food. Thats a big concern and if we continue on i think that will be even a larger concern. So last year ien colluded a provision that actually kept the whole grains at 50 rather than having 100 of the whole grain or the Grain Products having to be whole grain enriched and now ive introduced legislation with senator king, this was Bipartisan Legislation senator king from maine, that would both keep us at the lower sodium level but not go to the next target level and would continue the provision that 50 of the Grain Products have to be whole grain enriched. Is that something that you thinks workable and that your state would find workable and you feel other states would find workable . Absolutely. Okay. And then touch on for just a minute issues as far as the competitive requirements for the a la carte menu. We want to make sure that the School Lunches are healthy and the kids are eating them. Right. And then we also want, you know, you to be able to continue with the a la carte and i understand theres some issues in terms of what you can provide a la carte. Right. Right now we would like to be able to serve items on a la carte also on the reimbursable meal because you have to look at each a la carte item. If its on a meal you can compare it throughout the week and its much more difficult to be able to get an item to serve on a la carte. So we would like to be able to do that. If we can serve it on a reimbursable meal, it should be healthy enough to serve a la carte. Again. Just some flexibility . Flexibility absolutely. Thank you. Mr. Goff you know im glad to hear of your successes in terms of implementing the program in West Virginia. And certainly flexibility does not mean a role back of Good Nutrition standards. But it again, making sure that we have healthy meals and meals that kids will eat and that our schools are able to make their budgets. Could you tell me how many of your schools have applied for an exemption from the 100 whole grain requirement . Well, we did 100 , the whole grain rich requirement back in 2008. The only thing thats affected our schools and that was implemented across the board in all schools and schools arent having a problem with it. The only thing thats really touched in West Virginia is the as it relates to pasta and thats only because we have some schools that are having trouble getting the product. Right. And thats the point. Some cases whether its speet or tortillas or pasta, i mean, when we talk about whole grain enriched, it is not just the food and so forth but all the other products hence some flexibility is helpful and thats why you know ive advanced the 50 whole grain enriched. Youve had a number i have a number but you have quite a few schools that have applied for exemptions. Wouldnt some flexibility be helpful to them here . Well i cant speak for the schools. I think that when youre looking at granting waivers, my fear of that would be that it would give industry a pause to come on board and make the products more available at a sooner time. We had lots of waiver requests when we were implementing some of our standards as it relates to professional standards or even competitive sales. And i think if you have a good standard thats in the childs best interest then you hold that standard. I certainly cant speak for a state like kentucky. But our participation in West Virginia and our school meals is the highest its ever been. Our breakfast participation is starting to exceed that of lunch so i think in West Virginia and we have cooperative purchasing groups that pool their efforts to get the product, i think were on the right track there. But you so you dont feel there needs to be any tlexability, even though you have schools that have applied for exceptions . I dont know the numbers of those schools. 22. 22 schools out of we have about 700. So certainly thats cause for a waiver until the product can become available but its my understanding it was more related to pasta. I understand in some case it relates to pasta or tortillas or some of these other products. And i that makes sense if theyre healthy and the kids will eat them. Ill wrap up here mr. Chairman. But the current dietary requirements allow for some refined grains, as well. If we allow it in the guidelines for all americans why wouldnt some flexibility in that regard make sense for school kids, too . I understand. Okay. Thank you. Thank you, mr. Chairman. Senator stabenow you had additional question . I do. Thank you. I do. Thank you again to all of you. I guess im trying to put in perspective, you know, i realize we are making changes in the last five years and behaviors always hard to change, serving a process of moving in the direction of all of us of wanting to be more focused on health and wellness and we all know the benefits of that and we know change sometimes is hard and i have to say i have seen visited a lot of School Districts, some very creative where you take the vegetable and you put green peppers and onion in the tacos and the kids dont know theyre getting it and someone else says the government says you have to eat broccoli and a very different reaction depending on how things are, you know, are presented and we want to be in the Creative Process of that where were sneaking it in and kids dont even know beans are a vegetable, right . But mr. Goff i wanted to ask you about specifically the exemptions for whole grains and my dear friend and i really mean that from north dakota has been very passionate about this but yet out of thousands of schools across the country we have had only 350 requests for waivers on whole grains and to put that in perspective, 350 requests across the country, there are 900 School Districts in michigan alone. One request in north dakota. Four requests in kansas. And so im wondering have you received very many requests at this point and, again, why would you believe your schools wouldnt be asking for the flexibility of the waiver that we put in place at this point . Well i couldnt give you the number. We have received some requests. But its my understanding in talking with the cooperative purchasing group that is comprise our state that the requests is for pastas. And its because the products not readily available for them to purchase and it has something to do with that that particular product has trouble maintaining its consistency. So until more of that type product hits the markets, some of our schools were struggling with it. But as far as the whole grain rich requirement we have had that in place since 2008. Students are very accepting now of what they call the brown bread. So i think its a good standard. And i think we just need to wait for industry to come up to speed. Im wondering also, there are differences between larger and smaller districts and some that have the Community Eligibility and as ms. Jones was saying just larger districts where there are smaller number of student that is are qualified for free and reduced lunches and so on. Again, in West Virginia, how have you handled that with a larger district where theres a smaller number of children sort of the economics of that for schools because im sure that is different. So have you how have you handled that in terms of districts where virtually all of the children are qualifying for free and reduced lunch versus a district where maybe less than 50 . As far as as far as the sort of the economics of the of funding and so on because that seems to be the one of the concerns is that Community Eligibility . Large districts are losing money because there are fewer children being reimbursed on free and reduced lunch and other children arent buying lunch. Thats a great question and we anticipated those type of things before we implemented Community Eligibility. Like i said the first year that they piloted that we werent selected so we did our inversion called West Virginia universal free meals and we knew that if we just if we just selected nine districts or however many we did select and said like, said that you now can have breakfast and lunch at no charge. If we didnt change something, it was going to create a problem with their budgets so we worked in conjunction with our state legislature and we passed senate bill 663 called the West Virginia feed to achieve act and what that did one of the provisions of that act, is it realigned breakfast with the instructional day. We were offering breakfast at the worst possible time as most schools do at the startup of school when the bells arriving, the buses arriving late kids want to talk to their kids. We have a state law that it could not compete with the startup of school. Breakfast in the classroom, breakfast at first period or breakfast after the bell or some combination of that. And every school at every grade level and what its done, that in conjunction with Community Eligibility, our breakfast participation is starting to exceed that of lunch. Financially speaking thats very good for the programs because the margin of profit if you look at the federal reimbursement versus the cost to produce a breakfast, the margin of profit on breakfast is higher than that on a lunch and its the most important meal of the day and now we have the naysayers in the beginning that for example, the teachers that didnt want the food in the classrooms, will now go to bat for the program and are actually promoting the program because they can see such a huge difference in test scores, student attentiveness, reduced tardies, fewer trips to the school nurse. Fewer behavioral problems. Its really changed the way our were educating kids in West Virginia. We have one School District that district wide mason county, their breakfast participation last year averaged almost 90 . 90 of the children in that school ate had a breakfast on a daily basis and thats how we have tunnel it through the economies of scale the cost to produce one more breakfast or one additional breakfast is the cost is not that significant but the federal revenue coming in on that one more breakfast is substantial. Thank you very much. I know my time is up mr. Chairman, so thank you. Excuse me. Senator boozman. Thank you, mr. Chairman. I apologize for running back and forth today. Theres this is such an important hearing and such an important topic for arkansas and the rest of the country. Im on another subcommittee though, that also is very important and has to do with violent crime. Gangs and things like that which, again, all of these things go together. And so like i say, i apologize for running back and forth. Mr. Riendeau again, i know that these things have been discussed already and things but its such an important thing for our arkansas. Our summer meal participation increased in recent years and is very, very important. However, we struggle to reach children in rural areas. Can you talk a little bit about the challenge that you have experienced with the Meals Program and then also based on your experience can you give us some concrete recommendations as to what we can do to overcome some of those challenges . Sure. You know, as i said before we have dare to care serves both urban and Rural Counties and probably much like your Rural Counties, particularly in indiana, you know, the distance between the communities is so great and the communities are so small that its just very, very difficult to find locations where kids can go and congregate. Unlike our urban counties there arent robust boys girls ss clubs and the challenge is how do we find a way to get these kids access to summer food based on the realities of the county in which they live . And, you know, so we have looked at several different options. One of the thoughts we have is weve looked at we actually have a bus. We have a school bus now and were actually looking at the possibility of prepareing meals in our community kitchen, loading those in and putting them on the bus and taking them out to the Rural Counties and driving to the hollows where you will have a community of 20 families and dropping the meals off. And letting the kids consume them as the bus goes away and goes to the next community. The challenge with that model under the current rules is unless the kids unless we stop and the kids eat the meal on the bus an we count the number of children we cant be reimbursed so the sustainability of that model is doubtful and thats kind of the challenge that were facing which is why, you know, one of the things wed like the committee to consider is allowing us to look at more flexible models in those counties like im sure in arkansas would probably benefit deeply from that. Let us look at those and make those eligible for reimbursement, as well. Mr. Goff you mentioned that youd started your program in 2009. And i think thats right. Okay . And i think that you know, our states need the flexibility to do as they feel like is best. Can you tell us, you know, based on 2009 to now what are your obesity levels or have they gone down or flattened out or continued to go up . Do you have any challenge about that . In West Virginia . Yes, sir. We adopted those standards in 2008 and our whats happened as a result . I think our obesity rate has leveled off. I dont have the data. But i do know that our School Environments are healthier. In West Virginia, hunger and obesity live side by side. In trying to put the finger on the culprit we have done everything in our power to provide safe and Healthy Learning environments for our kids. I agree with that totally. The only reason i mention is that this does go together with a whole host of other things and we need to address this, you know and like i say i dont disagree you all are doing a great job in the sense of doing what you feel like is best for your kids. But it is i think one of the probables we run into is that, you know we feel like if we do this or that in this particular area well solve our problem and the reality is it with p. E. And you know, lots of other things after school activities, all of that goes together and if we dont do it all then were going to be in trouble. Ms. Jones, you mentioned in your testimony the importance of flexibility. Can you talk to us a little bit about specifically the kind of flexibility that youd like or maybe in some areas or two . Sure. Just like when we talk about our a la carte the fact that we had to take a healthy choice off like a sub sandwich with turkey and cheese. That doesnt make sense to me. That is a healthy item. We would like to have that flexibility to put those items back on the a la carte items. Having the decision to be able to raise the price of a meal or not, i mean that should be determined by each district, by what they feel their enrollment would be able to pay for. We want to be able to keep those kids into those cafeterias because we cant serve them nutritious meals if we dont have them eating with us. So those are the type of things were wanting to look at. Like i say with the fruit and vegetable, we really want to encourage our kids. Thats something that weve always thought is important but we do not want to lose our unlimited froouts and vegetables because we cant afford to do that anymore. Good. Thank you. Thank you, mr. Chairman. Dr. Hassink i apologize that we have not paid more attention to you. Especially with all of the work that you i would have if i had more time. Thank you. But you made as a typical situation where a chairman of committee is answering the question that i would have asked you. You made some excellent points with regards to a lack of specific nutrients at a specific time. And the detrimental affect that thats had on attention and development. Short term memory. Iq scores. Everything that everybody strives for. But if they miss the boat, they miss the boat. Im not asking you to expound upon that research. I think it is self evident but i want to let you know how much we appreciate your coming and your statement. I am now moving to the conclusion of our hearing this afternoon. Yes, it is this afternoon. Thank you to each of our witnesses and to the first panel, as well. For taking your time, your very valuable time to share your views that are related to the child Nutrition Programs. These testimonies that have been provided today are very valuable for the committee to hear firsthand and to keep on record. Your thoughts and insights will be especially helpful as we undergo the reauthorization process and to my fellow members i would ask that any additional questions that they may have for the record be submitted to the committee cleric five business dales from today or may 13th. The committee now stands adjourned. Heres a look at some of our featured programs for this week. Saturday morning beginning at 10 00 eastern on cspan, live from greenville, South Carolina for the gop freedom summit. Speakers include Scott Walker Ted Cruz ben carson and florida senator marco rubio. Sunday starting at noon eastern members of first families remember first ladies. Featuring the daughters of jackie kennedy, lady bird johnson, betty ford and laura bush. On cspan2, saturday night at 10 00 eastern, on book tvs after words, jon krakauer on sexual assaults and sunday evening at 10 00 ann dunwoody. And on American History tv on cspan3, saturday afternoon at 4 45 eastern, an oral history remembering the liberation of nazi concentration camps with an interview of kurt klein, lost his parents in auschwitz and as an interrogator for the u. S. Army questioned hitlers personal driver and the end of world war ii in europe with commemoration of the event at the memorial in washington, d. C. Get our complete schedule at cspan. Org. At a Senate Hearing on Rural Health Care, officials from the centers for medicare and Medicaid Services and local Health Providers discussed the challenges of rural hospitals. This Senate Appropriations subcommittee hearing is just under two hours. So the appropriations Cub Committee on labor, health and Human Services education related agencies will come to order. Glad to have all of you this morning. I want to thank the witnesses for appearing before the subcommittee today to discuss the unique Health Care Needs that face Rural Communities. We have two panels this morning. Members should know i expect to call up the second panel around 11 00 a. M. So we have adequate time to hear from both. And of course if for some reason we get done with this panel earlier than that, well go to the second panel quicker but no later than 11 00. Were glad that everybody has come today to help us talk about this issue. Certainly one of the priorities of the commit tee and one of my priorities in congress has been to ensure that all americans have access to quality and Affordable Health care in their local communities regardless of where they live. The obstacles faced by Rural Health Care patients and providers in Rural Communities are unique and often significantly different from those in urban areas. Albeit Truman Medical Center in kansas city tomorrow and they have a different set of problems but they have some unique problems, too. And both our inner City Hospitals and our rural hospitals have challenge that is are unique to them. In Rural Health Care the issues can range from a lack of access to simple primary care physicians to difficulty finding specialists. As a result, many patients have to drive long distances to receive care or simply may not seek care until its too late. This creates unnecessary disparities in health care not found in other can parts of the country and ultimately cost taxpayers more than if we had provided access in a better way. I think its critically important that washington recognize that Health Care Access is essential to the survival and success of rural countries across the country. Im concerned some of the proposals within the departments budget and recent regulations that have been issued that would affect Rural Health Care and jeopardize Health Care Access and in fact when you do that you really threaten the survival of small towns. The medicare Payment System often fails to recognize the unique circumstances of rural or small hospitals and this administration has appeared in my view to target rural hospitals in particular. For example, the department once again has proposed to decrease the reimbursement rate for critical access hospitals and eliminate critical access hospitals within ten miles of any other hospital. The department has proposed that change for years. Yet, just recently, been able to provide details to the congress about which hospitals would be eliminated if we look at that new mileage standard. The department has continuously issued regulations that would affect small and rural hospitals more than their larger urban counter parts. Cms is abrupt enforcement of the 96hour condition of payment for critical access hospitals and the direct physician supervision rules and recovery audit contractor audits not only hinder the care of patients but medical staff time enresources to comply with those rules. Finally, given the fact that the department requested 4. 1 billion increase for the coming fiscal year its even more surprising or maybe not so surprising that the office of rural health received a 20 million cut in the proposal that the administration issues the administration, in fact, has never once asked for an increase in rural health programs. More than 46 million americans live in rural areas and rely on rural hospitals and other providers as their lifeline to care. They face ongoing challenges in assessing proper medical treatment while Rural Health Care providers are overwhelmed with federal rules. Certainly senator murray and i both have an interest in this. I look forward to working with her and the rest of the committee to ensure that all americans regardless of where they live have access to Affordable Health care. And senator murray. Well thank you mr. Chairman, for calling this hearing on such an important topic and i am very pleased to welcome all of our witnesses who are here today but im particularly excited to welcome julie peterson. Hi. Julie is the chief executive officer of pmh Medical Center in washington and through her work at pmh and the leadership and helping make sure that Rural Communities get the health care they need. So thank you for coming all the way out here testifying today. Over the last few years we have taken historic steps forward when it comes to making our Health Care System work better for our families but i believe strongly there is much more we can do to continue to improve affordability, access and quality and to keep building a hel care system that works for women, families and seniors and puts their needs first. In my home state of washington where about 1 out of every 5 residents lives in a rural area, a critical part of this work is making sure that families can find the doctors they need right in their own communities regardless of whether they prif in prasser of seattle and this is true in many other parts of the country, as well. This is a serious challenge. Ive been focused on for a long time an im proud that Washington State is doing so much to tackle it head on. Washington state recently received a federal grant to explore the role of Community Paramedics in providing home followup care. This approach could reduce emergency visits and help patients avoid the inconvenience of leaving home to get care. I also hear repeatedly of number of new patients getting coverage through the Affordable Care act across my state. For example, a network of four Rural Health Clinics reported a 43 increase in patients last year. Thats great news but it also means we need to think carefully about how to make sure there are enough doctors and other Health Care Providers to treat all of the patients. So im glad to have the opportunity today to talk about the investments we need to make if we need to so we can build on that progress. The agreement the president recently signed into law to fix the broken sgr system took important steps to access to rural areas. Including funding for Health Centers and each of which play a Critical Role of expanding access to primary care for struggling families, especially in our rural areas. Sgr legislation also extended funding for Teaching Health center residencies. My home state of washington was a leader in sething up these Training Programs and now primary care providers are being trained in communities with a shortage of Health Care Providers from spokane to yak ma. We know that training in rural areas is critical to keeping providers with an interest in rural practice in our high need communities. Im pleased were able to agree to sustain those investments and hope well be able to be able to do more moving forward and pleased that the president s budget maintains investments in other key programs that do support rural health. The 3040b drug program is drugs to providers at lower costs. 26 out of my states 39 critical access hospitals which provide crucial support to to Rural Communities participate in that program. Similarly, the budget continues to support enhanced payment for Rural Health Clinics and community Health Centers. In my home state and many others, these facilities help make sure that when, for example, a parent needs to take a sick child to the doctor or a senior needs followup care its easier to get the treatment they need in their own community so we need to make sure they have the resources that they need. I do also want to express concern that the budget proposes to cut the Rural Hospital Flexibility Program. That programs helped sustain and improve hospitals in the most difficult to reach communities including ten hospitals in my home state. I believe we absolutely need to see continued strong support for this investment in the health and safety of families in Rural Communities. Finally i know Rural Health Access is a priority. All of us here care about so i want to note that the president s sbugt able to sustain those investments along with supporting other key priorities from education to infrastructure to defense because it responsibly replaces the harmful cuts of sequestration that are now set to kick back in. Im proud last Congress Republicans and democrats were able to come together to Reach Agreement that rolled back sequestration for fiscals years 2014 and 15. With the deal set to expire, i hope we can build on that foundation and prevent these harmful cuts to investments in families and jobs in our economy including critical support for our Rural Health Care. I look forward to working with all of our colleagues on this in the coming weeks and months and again i want to thank all of our witnesses for being here. Mr. Chairman, again thank you for holding this really important hearing. That is topic that means a lot to the people in my state. Thank you, senator murray. We have two witnesses on the first panel. Shawn cavanaugh, centers for medicare and Medicaid Services and tom morris, associate administrator for the federal office of Rural Health Policy Health Resources and Services Administration. Were pleased youre both here and well listen to your opening statements. Okay. Mr. Chairman members of the committee, i want to thank you for the opportunity to testify today on behalf of the Health Resources and federal office of topic of rural health. Im pleased to discuss not only the challenges you have already outlined but the accomplishments of our programs. Across the department of health and human vftss very a range of programs and resources that support Rural Communities. In 2014 this included 11 billion in Grant Funding to Rural Communities. My office is the focal point with a continual focus on improving access to care. Today there are nearly 15 Million People living in rural areas, thats about 15 of the population. Spread across 80 of the land mass in the united states. Individuals in Rural Communities, often have to travel further for their care, and this can have an impact on their outcomes. New Research Shows that over the past 20 years Life Expectancy in rural areas is lower than urban and that gap is widening. Hersa improves access through a variety of initiatives includes supporting rural Health Centers building a Strong Health care work force and expanding the use of tele health. The office has several niche tifrs to focus on capacity building. We fund the state offices and that ensures theres a focal point for rural health within each of the 50 states. The flexibility Grant Program and the small hospital improvement Grant Program work with small rural hospitals on Quality Improvement and stabilizing finances. Her hersa supports startup funding for Rural Communities. Community Health Centers are a component of the Delivery System with affordable and efficient care in underserved communities. Hersa has nearly 1,300 Health Centers supported national with 90,000 Service Sides and about 50 of the Service Sites serve Rural Communities. Hersa announced 164 new access point grants for new community Health Centers. Totallying 45 million in investments to go to improve access to care. Hersa held Training Programs and worked to increase Health Care Access by ensuring providers. The National Service corps supports loan repayment and scholarships for primary care providers with almost half of those providers we support located in Rural Communities. And in an fy2014 students supported by hersa went to 11,000 training sites and invest in training and work with 34 rural training tracks around the country. T ele health is an Important Role of enhancing the work force and expanding the reach. Hersa is funding projects in 230 rural and underserved communities and 48 different clinical areas and Mental Health. We have seen them pilot new initiatives. We also have 14 Resource Centers around the country that provide free Technical Assistance to communities to get started in tele health or advance what theyre doing. Rural communities benefited from the white house rural council. The councils focused on getting federal agencies and departments to Work Together to coordinate and serve Rural Communities better. I know in our case this has will led to ongoing partnerships of my office the u. S. Department of agriculture and the department of veteran affairs on a number of Health Projects and we have expanded the National Service corps to critical access hospitals. I want to thank you for the opportunity to be here and thank you for your support of hearsesa programs and i look forward to answering any questions you might have. Chairman blunt Ranking Member murray and members of the subcommittee, thank you for the invitation to discuss the center for medicare and medicaid efforts to preserve access to Quality Health care in rural areas. Providing high quality care presents unique challenges. Rural areas often have fewer hospitals and physicians and beneficiaryies reside a significant distance from the nearest provider. Beneficiaryies represent a higher percentage making the organizations particularly sensitive to changes in medicare payment policy. At cms we have taken steps to improve service. We have numerous opportunities for stakeholders to engage to make sure we understand their concerns and challenges. Cms has Rural Health Coordinators who meet monthly with Central Office staff and representatives from the hersa office of Rural Health Policy to discuss emerging issues and regular Rural Health Open Door forums for programs and learn about issues. Were also trying to remove regulatory barriers for rural Health Providers. Last year cms reformed regulations we identified as unnecessary, obsolete or excessively burdensome. Which will save providers nearly 3. 2 billion over 5 years. This rule included specific provisions to reduce burdens. For example, a key provision reduces the burden on critical access hospitals, Rural Health Clinics and fqhcs. This provision recognizes improves for lower cost maintaining high quality care. Were also expanding access to rural care through technologies. Medicares benefit allow services normally requiring a patient and practitioner in the same location delivered by interactive system. A variety of practitioners are authorized. The statute requires that medicare pay for professional consultations, Office Visits and psychiatristsighpsychiatry services. Cms solicits Public Comments on Additional Services that should be billable under the tele health benefit. For 2015 we have added the annual wellness visit, family psychotherapy and prolonged e and m services. Were also exploring how to improve the current benefit. The centers for medicaid and medicare innovation is testing Pilot Services to communities. For example, the Health Care Innovation awards initiative awarded a grant to health link now and pairing aspects of medicine with navigators and specialists to serve patients with chronical conditions in frontier communities in wyoming, montana and Washington State. Also, this year we announced the next Generation Model that will be is currently accepting applications to begin next year and that model will be testing expanded use of t ele health services, as well. Critical access hospitals are small facilities that serve communities that might otherwise lack care. Medicare reimburses cause at 101 of the reasonable cost. There are currently more than 1,300 in the united states. Here i would pause and just thank Congress Also for expanding the medicare dependent hospital legislation. The Rural Health Clinic Program Helps us expand serving medicare patients in rural areas, approximately 4,000 rhcs nationwide with access to primary Care Services in rural areas. And finally, the Innovation Center is uniquely positioned to test and evaluate new models for quality care for Rural Communities. For example, testing two models designed to support acos in rural areas. The advance payment model is meant to help entities such as smaller practices and providers with less access to capital and help them get into the medicare shared program and the aco investment mod sell a new model of prepaid shared service to advance payment model to encourage them to form in rural and underserved areas. Cms recognizes the challenges faced by providers in rural areas. I look forward to continuing to work with hersa and the congress on further improvements for quality care regardless of their location. Thank you again and im happy to answer your questions. Thank you both. Let me ask you a couple of questions and then well do fiveminute rounds here. On, mr. Morris, the department, the budget, the administration submitted would have cut your budget by 20 million. Did you ask for that cut . Mr. Chairman, we support the president s budget and the request that came forward. We think it supports the key programs for our office. It includes flexibility programming, for our policy and research activities. And we think that those are the programs that can be most effective in meeting the needs. So where are you going to spend 20 million less than you are spending this year . The president s budget does have there is that decrease, yes, sir. What programs are you going to decrease . Theres no question for the funding of the Small Hospital Improvement Program and theres no request for the funding of the rural access to emergency Devices Program. In the case of these programs and the administrations request, these are challenging budget times. And they require some tough choices sometimes so i think the president s budget reflects a request that for the programs that we think are think are really effective in meeting the need. In the case of the Small Hospital Improvement Program, we have the Rural Hospital Flexibility Program and there is a 25 million request for that program. That program focuses on what we see is the most vulnerable of the rural hospitals sector, which are the critical access hospitals. So there will be 25 million requested to support Quality Improvement and partnering with the states and those states. In the case of the rural access to emergency Devices Program this is a program that places automatic external defibrillators in Rural Communities. We think that the need has largely been met in that program. Not only through federal funding, but also through state and private sector funding. But we do allow people to come in through our Outreach Funding to get at that same issue. So an applicant could come in for Outreach Fund organize Network Funding under the program that is requested in the budget and do the same thing as the aad program and since that they could develop a program that seeks to purchase those defibrillators and put them in Rural Communities. So for the remaining need that is out there we feel it can be met through outreach program. And the hospital Improvement Program that you would continue is a 25 Million Program . Yes, sir the flex in the current year youre spending 25 and proposing to spend another 25 next year . Correct. And then the 20 that you would have this year for similar purposes would go away in the president s budget . Yes, sir. The ship program, Small Hospital Improvement Program, there is no request for that. It had been funded historically at 15 million. And the other 5 million is from the access to rural emergencies Devices Program. What obstacles do you see in telehealth . We have people telling us that there is still issues that theyre trying to work through with your department on telehealth. What would you say would be the top obstacles to move forward and telehealth . Well, one of the issues were trying to get at for telehealth is the whole issue of crossstate licensure. Providing services in another state. So the congress has provided funding through our telehealth programs for the licensure and teleportability program. We with the state and provincial psychology boards. Were trying to work with licensing boards so that say a psychologist was practicing in missouri but was providing services in another state, rather than having to complete two completely different licensure applications, they could adopt a common licensure. So it makes it easier for somebody to practice across those state lines but it still protects Patient Safety this terms of the licensing and credentialing for that provider. Thats one way were trying to get at it. Weve been investing in telehealth for a number of years. I think we now have improved access to care. I think one of the challenges is finding out which applications have the best clinical outcomes. So the Evidence Base for telehealth could be expanded. So one of the things we did this past year is put money into a teleemergency evidencebased program. And what were trying to understand is how does the outcomes from using teleemergency care compare to when you got those services facetoface. I think thats a question any insurer would want to know about. And i think the more we can learn about the Evidence Base and what works best in telehealth i think can then help us target investments moving forward. We may move forward with that a little bit even in our Telehealth Panel there. Senator murray . Im a strong supporter of hirshs workforce Training Programs. In particular the National Health service core provides critical support to physicians and other providers that agree to work in our rural and underserved areas. And i also just want to recognize your agencys Important Role in documenting workforce shortages through the National Center for Health Workforce analysis. And i wanted to ask you what are the current projections what do the current projections say about our National Health Care Workforce shortage . Sure. Demand is expected to increase for primary Care Services through 2020. And that is due to the fact that the population is aging, and the population is growing. And then there are also impacts that you referenced earlier in terms of more folks having coverage may result so the National Center has done some projection work. And what theyre projecting is there will be a shortage. This is mitigated by if we were able to take advantage of the supply of Nurse Practitioners in and pas and use them to the full extent of their training. If that really happened and the mp training and deployment and same thing for physician assistants, if that happen, i think the shortage drops down to about 6,000. So what are kind of Health Care Providers are most needed in our Rural Communities . I think the full spectrum of providers, primary care. We see shortages in Mental Health and thats for everything from licensed clinical social workers to psychologists. Psychiatry is not a service you often find in Rural Communities. But even some Rural Communities even have challenges in terms of the allied Health Workforce and regular nursing. So those are all challenges i think that Rural Communities face. Talk to me about how the Additional Resources that you requested for the National Health service core and the budget help address shortages like we have in rural washington. Well, the administrations request would dramatically increase the funding for the National Service core. And the advantage of that is right now we fund National Service core loner payment scholarship down to the level of funding that is available based on how how underserved they are. Basically what their score is in the Health Professional shortage. So the more funding that is available and the funding that is in the president s budget would allow us to fund more clinicians to be supported in those communities. And that would mean a lower hip is a score which means more Rural Communities would have access to it. Its been a lifeline for Rural Communities. As i noted before 50 of the placements, just under 50 of the placements for the National Service core go to Rural Communities, even while rural only represents about 17 of the population. Okay. How can we continue to leverage the teaching Health Centers program to make sure that residents say in rural areas . Is there anything we can learn from this program to attract other specialists . Talk to me about that. Well i think one of the big lessons from the Teaching Health Center Program is that you can do Residency Training in a communitybased setting. So much of our Residency Training takes place in large academic Health Centers. Yes. And if we can get more folks exposed to communitybased training, the hope is that theyll be interested in that communitybased training. So well see them working in our Rural Health Clinics and our community Health Centers and our small hospitals. I think the Teaching Health center shows the path forward. And i think that informed the president s request around really reshaping how we train physicians and creating a new Grant Program to do communitybased training. And that would include Rural Communities. We know also from some of the work we do with the rural training tracks, which started in your stale in colville, washington, this is a unique model where they do one year in an academic Health Center and two years in a rural setting. 70 of the graduates end up practicing in Rural Communities. I think the evidence is strong that if we do more communitybased training, well meet the needs better. The teaching Health Centers are a First Step Towards it and i think the president s request is another step toward that. Yeah, i completely agree. Ive seen this working in my state. Where you practice and do your residency really makes a difference on where you stay. And when we have such a need in our rural community, having those residents in those Rural Communities, doing their residency, it works really well. So i hope we can continue to build on that. And i thank you. Senator cochran . Mr. Chairman thank you for convening this hearing on the challenges that were facing in our Rural Communities throughout america in making Available Health Care Services, some of which are partially paid for by federal government agencies. And we hope to learn from this hearing ways to provide the needed resources up to the point where we are authorized to do so. Its been brought to my attention that the Health Resources and Services Administration has released a grant notice regarding the intent to provide funding for a telehealth focused Research Center cooperative agreement. Could you tell us more what that is and what are you looking for in an applicant and what are the goals that would be funded by this cooperative agreement . Yeah, i think this builds on the comment i made earlier that again, i think we know telehealth improves access. And i think the real challenge is finding out what the impact of that increased access is. What were hoping to do with this Research Center is to help build the Evidence Base for finding out which applications work best and deliver the best outcomes. And so what were looking for are experienced researchers who can do comparative outcome research. So we can look at you provide a Telehealth Service and here is the outcome. How does that compare to whether you had it facetoface. I think that will really inform the Evidence Base. Are you encouraged by the results of your applications and those who are petitioning the government to choose them . Weve gotten a lot of calls on this funding opportunity, just in the week its been out there. Mr. Cavanaugh, i understand the centers for medicaid and mediCare Services restrict reimbursement for telehealth based on geographic locations. How do you administer that . How do you choose which urban areas, for example, are more eligible than others for telehealth reimbursement . Thank you for the question senator. In this statute, it gives us instruction to allow telehealth to be provided in certain geographic areas. Pleased that with help from our colleagues at the office of Rural Health Policy a few years ago, we changed our regs to expand the definition of rural areas that qualify. But the geographic restrictions really originate in the statute. The good news is through the Innovation Center which congress created were
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