Audio & Notes (4 of 4) from 4/8/09 House Health Care Committee Mtg

Rough notes from the
Audio recording of the 4/8/09 Public Hearing of HB 3000, House Health Care Committee.

Continuation of third blog post on testimony before the Committee.
Notes pick up after testimony by Dr. Gina Green, Ph.D., Board Certified Behavior Analyst-Doctoral (BCBA-D), Executive Director of the Association of Professional Behavior Analysts (APBA)
.
This post is on the testimony of two Oregon parents, a teen who has achieved normative functioning through ABA as a young child, submission of written testimony by Blue Cross/Blue Shield of Oregon, spoken testimony of Jake Oken-Berg, Government Relations Consultant, Kaiser Foundation Health Plan, Portland, OR , closing statement by Dr. Gina Green, and adjournment of the meeting by Rep. Greenlick.

[Blog author note:
Because this is a summary of some points of an audio presentation, this is not an exact transcript nor should it be quoted as direct statements of the participants--readers should listen to, and consult the full audio of the Committee Meeting for the proceedings of the full meeting and testimony given.]

Running time of the audio 2:22:09

h:mm:ss
1:57:25 - Next speaker: [Parent #1] - Introduction as small-business owner family that believes in covering health care for all employees. In 2004, they contracted with Pacificsource at a cost of about $2500/month, including $1200/month for the family. In 2006 son diagnosed with autism. They received prescription for treatment, including ABA therapy, and have received denial after denial from insurance plan for any treatments still being paid for while paying $60,000 out of pocket for son's therapy, and have exhausted appeals process at Pacificsource. Unquestionably their son needs ABA therapy and he is only receiving half of the therapy he needs due inability to be able to financially expend more than they already are or to access health care that they pay for every month. Their pediatrician and other medical professionals continue to prescribe ABA therapy for their son. He's made great strides but needs much more to treat symptoms and behaviors. Financial and emotional resources are exhausted--beyond the financial burden they have lost time from other children just to deal with the health care crisis, and the other children are being robbed from opportunities that they could have, if there was not the strain on the family.

In sum, Pacificsource acknowledges that the policy covers the diagnosis of autism. The parent stands here today asking why they cannot have access to the therapy needed to treat this diagnosis?
2:00:13 - Rep. Greenlick - thanks the parent.

2:00:19 -[Parent #2] - Greets the committee, and introduces self as insurance agency owner and city council president and father of an 8 year old almost fully recovered from autism spectrum disorder. He sells a variety of insurance policies, and the question most often heard is whether a policy will "take care of me" if something unfortunate should occur. He always thought that this contractual process could be true until he himself had to deal with small group health insurance carrier for treatment of his son. At 3, his son was diagnosed by a medical professional and given a treatment plan of therapies and contacted insurance carrier to discuss how to proceed and told bluntly that the condition of autism not covered by the plan, as "not medically necessary". How could this be--this is a medical condition, diagnosed by a medical doctor, and somehow a single diagnosis is singled out and not covered by a policy. Cancer, leukemia, multiple sclerosis, muscular dystrophy, countless other conditions covered--why not autism?
After fighting with the insurance companies for awhile, the family moved forward with the aggressive treatments as every expert has said, the earlier the intervention begins, the better the results. They spent years going to a variety of providers and spending thousands out of pocket for treatments that greatly improved their son's quality of life. He went from non-verbal and being unable to be left alone outside the home, to now achieving an appropriate grade-level vocabulary, attending a mainstream classroom with an aide for only 30 minutes a day, vs. the previous year where he had a full-time aide, and loves going to school.
Lastly, as a city counselor for the past 10 years, this parent has learned is that constituents expect elected officials to demonstrate leadership and take action on a variety of issues; the citizens appreciated the city council for taking on a topic, held public hearings and open houses to get the information to make a decision--yes or no. That's what politicians and elected officials are sent to office to do.
This issue was already raised in the 2007 session, with an autism work group created, gathered information during 2008, and here now again, discussing a bill that will not even take effect for over 2 years. Delaying or ignoring an issue such as this, when it has already thoroughly vetted. He is here for the families who have yet to begin this journey, and to ask the elected officials to remove one of the roadblocks that will keep families from financial ruin and provide the insurance coverage to improve children's quality of life. All of those here today ask that you move HB 3000 out of Committee and for a vote to the full House. Thousands of Oregon children are depending on the Committee for action on this important issue. Thanks the Committee.
2:03:24 - Rep. Greenlick - You did notify the insurance company that the disease was covered, this was in 2007, uh, we did that in 2007.
2:03:35 Parent #2 - The diagnosis was back in 2004.
2:03:44 - Rep. Greenlick - We took care of coverage in 2007, but only for those things usually covered--diagnosis and specific therapies.
2:03:52 - Parent #2 - There are people falling through the cracks and I think we need to strengthen the bill.
2:03:57 - Rep. Greenlick - I also want to point out to the Committee that if we mandate this, we aren't mandating it for everyone; we are mandating it for about 40% of the population that's covered.

[Blog author note: This is true for most, if not all mandates. Those plans that are ERISA, self-insured, and sometimes under a minimum employee number are not covered by state-mandates for all conditions, not just autism. Experience is that in some states insurance plans which are are not dictated by the mandate statute have volunteered to extend the benefit after passage of such bills into law]

2:04:09 - Parent #2 - It's a small step in the right direction.
2:04:13 - Rep. Greenlick - It's just that when we went to mental health parity, we disappointed a lot of people in self-insured plans and others who found out that mental health parity didn't relate to them, it only related to a segment of the, it's a segment you deal with everyday.

2:04:33 - Speaker #3 - Testimony of Chris xxx
Chris xxx : Diagnosed at 2 1/2 with autism. Received ABA therapy.Lots of 1:1 intervention. Did two preschools a day for social aspect, same for Kindergarten. Then graduated from ABA. Parents paid out of pocket. He thinks he is doing very good, and doesn't feel he'd be where he is now get good grades, plays basketball and track (missing a practice to attend the hearing), played the tuba in the Metropolitan Youth Orchestra, and planning to attend a college that provides his interests. He considers himself a lucky case because his parents were able to pay and he did well.
2:06:30 - Rep. Greenlick thanks Chris for his testimony.

2:07:10-Written testimony of Regence BlueCross/Blue Shield, dated April 8, 2009, related to HB 3000. put into the record.

2:07:41 - Jake Oken-Berg, (Government Relations Consultant, Kaiser Foundation Health Plan, Portland, OR.)
[Blog author note: this may be somewhat more narrative and detailed than the previous testimony accounts]

Greets the members of the Committee. Special interest because father a psychiatrist at Kaiser for 30 years and mother pediatric social worker at Kaiser, and manages the developmental assessment clinic for ages 0-5, for 25 years.
At Kaiser, we followed the Autism Spectrum Disorder Workgroup during the interim (2008), and gave preliminary findings and attended outreach meetings. We also read the Oregon Health Resources Commission ASD Treatment Report requested by the 2007 legislature and released in October 2008. In light of the evidence presented by both groups, HB 3000 seems to be putting the cart before the horse. In the words of the HRC, the majority of the research studies looking at ASD treatments have significant limitations and most show insufficient evidence. Oregon's legislature has recognized the importance of making evidence-based medical decisions, but HB 3000 creates a specific exception for one condition.

[Blog author note: at the current time Oregon has 36 mandates, somehat below the national average as stated in the CAHI report of 2008, so the argument of "one condition" is somewhat misrepresentative. Other mandated conditions are alcoholism, general mental health, mental health parity and drug abuse. Until 2007 autism was generally excluded completely from health insurance coverage, and under HB2918, the rehabilitative therapies of speech, occupational and physical therapies were included.]

and exception for one specific treatment, applied behavior analysis.

[Blog author note: Again, HB 3000 also mandates, or more correctly reiterates the rehabilitative treatments of Speech-language, occupational therapy and physical therapy which were previously mandated via HB 2918 of 2007, as well as drugs. Applied Behavior Analysis is a specific treatment modality, but it is not the sole aspect of the bill]

It is noted by your own Commission's study that it lacks sufficient evidence under efficacy,

[Blog author note: Not exactly true. The exact statement, on p. 20, is

Finding: Limited evidence suggests that this intervention is effective in some
children but there is no method to determine which children are most likely to
benefit.

Given that efficacy and effectiveness have specific meaning in research and reporting conditions of outcome, it would be useful to know if these were used intentionally or genericly. To put it in perspective, the vast majority of the interventions in the HRC report were of "no evidence" or "insufficient evidence" to determine effectiveness, or evidence of "no effectiveness". To have limited evidence is a step up within this particular report.]

The Commission Report also noted that the lack of evidence of effectiveness does not equate to known evidence of ineffectiveness of an intervention,

[Blog author note: Again, in the case of EIBI, it is not "lack" of effectivenss, as the report itself states that there is evidence of effect with limitation, similar for PRT]

with that in mind, we here at Kaiser are doing universal screening of young children using the Ages & Stages questionnaire, four times before 36 months, and we are glad to see your work with the Governor to establish the Oregon Commission on ASD. We are committed to helping this new Commission and we are eager to continue providing our medical expertise on this bill, as well as any other legislation that you may consider on Autism Spectrum Disorder. Thank you.

2:09:54 - Rep. Greenlick - Jake, what does Kaiser do, once they diagnose someone as being likely being on the spectrum?
2:10:04 - Mr. Oken-Berg - One of the good pieces about the Ages & Stages Questionnaire, is that it now allows an immediate referral to Early Intervention, not only (?), but we've worked out a similar deal with Multnomah County, across the river in Vancouver, in Clark County without having to do a reassessment with the limited programs that do exist, to get young children immediately plugged into those. In addition, immediately following the work done by you in 2007, there is a sensory integration benefit that Kaiser has, that is significant, that did not exist before.

[Blog author note: From the Oregon Health Resources Commission report, p.25,

C. Sensory Integration Therapy (SIT)
In a 2003 review Tochel et. al. evaluated children with ASDs receiving Sensory
Integration Therapy vs. multiple comparators. Insufficient evidence was found about the clinical effects of SIT in children with ASD.
Finding: There is insufficient evidence to determine effectiveness.]

2:10:51 - Oken-Berg -So Kaiser does some things that, uh, yeah...but in regard to ABA, we do not provide ABA therapy.
2:10:56 - Rep. Greenlick - Any questions?
2:11:01 - Rep. Greenlick - Does running a spirited campaign for mayor at 18 indicate any sign on the spectrum at all?
2:11:06 - Oken-Berg- I don't know.
2:11:12 - Rep. Greenlick - For those of you who don't know, Mr. Oken-Berg was a very serious candidate for mayor of Portland as a sophomore in college.
2:11:20 - Oken-Berg- 27% of the vote
2:11:23 - Rep. Greenlick - 27% of the vote. Not bad.
2:11:28 - Rep. Greenlick - Yes (to another Rep)
2:11:28 - Rep (?) - I'm unsettled, I'm grappling here. How do you deal with the data presented by Ms. Unumb, the Mayo Clinic data, etc.? Claiming, touting the efficacy of the treatment? You're suggesting that it's not nearly as...effective.
2:11:50 - Oken-Berg - Absolutely. Let me say two things. One, I've spent time in the last year talking wiht my family members but also the best experts in the field and actually hearing things that I never thought that I would, like the journal Pediatrics, which just last month took a subset of ABA therapy, ABI, and once again came to the conclusion that there's insufficient evidence that it does work--I have a copy of that abstract online for anyone that wants to.

[Blog author note: Despite Mr. Oken-Berg's apparent shock and awe, the journal referred to by Ms. Unumb is The Journal of the American Academy of Pediatrics, usually referred to as Pediatrics. The journal that he calls Pediatrics, is in fact, The Journal of Pediatrics, published by Elsevier, and is an entirely separate publication. The article referred to by Ms. Unumb is a policy statement of the American Academy of Pediatrics. The article referred to by Mr. Oken-Berg is a research meta-analysis, which may have significant weakness because the number of studies analyzed are too small to have accurate validity in the analysis.
See, Letter to the Editor of The Journal of Pediatrics, dated 12/4/08 from Tristam Smith, Ph.D., Svein Eikeseth, Ph.D., Glen Sallows, Ph.D. & Tamlynn Graupner, M.S., commenting on factual errors and errors of meta-analysis in the research article by authors Spreckley & Boyd, and being used by Mr. Oken-Berg to state lack of evidence.
What Mr. Oken-Berg also fails to mention is that two other meta-analyses have also come out recently with contrary results to the one he states. See the presentation by Dr. Gina Green citing the meta-analyses by Drs. Reichow & Wolery, and that of Drs. Eldevik, Hastings, Hughes, Jahr, Eikeseth,S., & Cross. Both of which come to the conclusion that EIBI/ABA does have positive effect]

Oken-Berg -Kaiser in addition last November, did its own analysis of its own studies around the country and came to the same exact conclusion that the Health Resources Commission did as well, and I've just tried to read that and understand it.
In regards to what was up earlier, in terms of research methodology and that you can discover things when you just look at one child, without a doubt that is true, anyone who studies autism spectrum disorders knows that no one child is the same on the spectrum, therefore no one type of therapy will work for every single child .

[Blog author notes:
This is a misrepresentation of what a controlled case study or N=1 research paradigm is. Real "one child" studies represent one particular research design used for particular purposes and experimental conditions; much more often, within-subject research with multiple clients is used and incorporating methodologies of multiple baseline, reversals, changing criteria. Small-n studies can be aggregated for meta-analysis and obtain both within-subject and between-subject information on and intervention.
The point seems to continue to be missed, either by intention or misunderstanding that as one of its core dimensions, ABA, in order to meet the dimension of effectiveness a priori and de facto, that choice of procedures from the science must be, individualized. "ABA therapy" is a composite of a variety of component techniques and technologies available to be applied, after direct observation, assessment and with ongoing data analysis towards meeting the target goal, with an eye to progressing towards the best outcome that may be achieved].

2:13:05 - Rep. Greenlick - No one therapy will work for any two children. Well, sometimes part of the problem is that no one child will be the same either.

[Blog author note: To use this line of thought, no manualized or standard application of speech, occupational or physical therapy should work for any two children, when clearly that is not the case, even for children with special needs. To reiterate again, from the

HRC Report, The exact statement, on p. 20, is

Finding: Limited evidence suggests that this intervention is effective in some children but there is no method to determine which children are most likely to benefit.

So, even with stated limits, it seems to be the case that this therapy indeed does work on any two children, since "some" is probably more than two.]

2:13:12 - Oken-Berg - We at Kaiser do not want to fall back on, there are so many studies stating a lack of evidence that we want to dismiss ourselves from the responsibility of finding what the right role is for the medical profession, community health, the schools and so forth...but we will point out that in places like VA, where one of our leading developmental pediatricians comes from, the schools do much more on this, and they feel that they have not even begun to reach the level of what their side of the bargain should do in this, and at the same time, the Commission just created by Executive Order, we want to play an active role in that.

[Blog author note: Without the particular significance or special insight involved, the description of what was said by the colleague, "leading", or not is what is known as "anecdotal" or "testimonial". It may well be that VA schools are better, or not. If such was sufficient as evidence, the matter at hand, then we could dispense with experimental design altogether. The point is moot and irrelevant of the merits of this legislation. And if retaining it to the question of schools, if the anecdote that VA schools are doing much more but only scratching the surface, what does that say about the level of therapy in any venue available in Oregon?
FWIW--VA has been one of the leading states in attempting to gain coverage of ABA via legislative insurance mandate, and did so this legislative year as well. So apparently the schools "doing much more" are insufficient for the citizens of VA to feel that they are obtaining adequate treatment of ASDs.
Perhaps it is also because IDEA is an educational Act intended by law to provide a Free and Appropriate Public Education, not to ameliorate or remediate treatable medical conditions. IDEA is not intended to apply maximum medical benefit, but to demonstrate adequate educational progress, with "adequate" being somewhat unspecified, applied by those whose training is primarily in education, and not medicine nor psychology. The point is that to claim that autism treatment is the provenance of schools is to ignore the function of public education, that autism is a medically diagnosed condition, and and attempt to foist the medical role onto that public entity and that public budget. ]

2:13:50 - There are alot of people applying to that, and we want to be on that, and one of the specific charges is the treatment piece, and if we can design better treatment studies, we want to be part of that. I just finished a discussion with the head of our center for health research, and that's an area that they're very interested in. One fortunate note, President Obama announced a four fold increase in his health budget for autism treatment studies, through the NIH. It would be very wonderful if as a state we could not just leave it as inconclusive--if we could tap into some of that money, perchance in concert with OHSU, CHR and in two years just get some better evidence

[Blog author comment: These statements are speculative, at best. If applied behavior analysis at the experimental intensities and variants already studied, is not part of the research plan, new research in Oregon would not make any impact on addressing relevant questions currently discussed. You can only obtain research data on that which is studied. As previously stated that Kaiser does not provide ABA, that possibility seems unlikely at best.
The blog author also seriously questions whether a large scale research protocol could be approved by IRB, submitted to the NIH, referreed, awarded, then recruited, assorted for matched-cohorts, experimentally studied, data taken and analyzed, article authored, paper submitted to a journal for possible acceptance, referreed, returned for edit, galleyed and published, all within the space of 2 years.
Addition and correction 4/20/09- Having looked into the granting opportunities offered under the Stimulus Plan, it seems even less likely that these are grants for applied research of immediate applicability--if this description is accurate, none of the $ 57Million will be spent on treatment modalities, but on genomics, genetics, environmental risk factors, biomarkers and biological signatures, and immune and central nervous systems interactions. Although it must be spent within 2 years, it is NOT anticipated that these studies will be completed, but only jump-started. As for the $10Million allocated for autism from the NIH Challenge Grants in Science, that money is targeted for biomarkers, novel interventions, and new tools for screening, among other topics, developing systems for pooling data, not pooling the data nor pooled studies,

While all of these are interesting, and possibly useful, basic research and preparation for new treatments and tests--none of these provide immediately the information claimed to be needed now. Since the window of maximum opportunity is only 2-3 years, it's hard to see how this research is going to be much help to today's 2 and 3 year olds.]

2:14:30 - But just going off of the work that has been done, it does not lead to the conclusion that we need a $36,000 benefit paid by insurers up to age 21. There is far more nuance to this than this bill captures.
2:14:45 - Rep. Greenlick - I think there's the methodological argument of the N of 1, compared to it, and I think that until we do the studies that need to be done that are acceptable to methodologists, without getting into an argument on the N of 1 question, the answer is going to be up in the air. And it's very, clear, and Mr. Oken-Berg made the point very clearly that the results generally do not say that there is no effect to the data, although there are some subsets where the data are clear, it seems to be no effect. There isn't enough data to say with scientific certainty that they're effective, and those of us who've spent a lifetime of work doing behavioral research, I understand the complexities of the issue of behavioral research, but ultimately, we need to be sure we make that investment so we do know what serves, and the problem in other types of complex diseases, it's not easy to make general prescriptions for things. 'Cause different things work for different kids...

[Blog author: which brings us back to the original point. Is the Representative's point that we should study this until we absolutely know what works for all kids which does not reconcile with the statement that different things for different kids? This still skirts the point that the HRC report itself states that ABA IS effective with limitation on knowing preemptively which populations might optimally benefit, and the progress and prescription question is addressed within the bill by an annual review of clinical progress. ]

2:16:01 - Oken-Berg - and I purposefully, in regards to this not try to deal with the monetary aspect, because when you're dealing with wanting to help one child, obviously you do whatever it takes, within your capabilities, but in a public policy framework, that is also an important consideration--it's the same reason that the schools do not provide robust ABA benefit because there's a significant cost to it, for some benefit but it's across the board, and it's not medically proven.

[Blog author note: The gentleman states that some benefit with a less than robust implementation, which is inconsistent with his previous statements that there is unknown efficacy (and effectiveness, for that matter); neither statement strictly corroborating with the statement of the HRC report,. and that there is benefit is more consistent with the multistudent research studies of intensive ABA implementations compared to control.]

2:16:31 - Rep. Greenlick - Go ahead.
2:16: 32 - Oken-Berg - I was not going to go with the financial aspects, you went right where I was hoping you would, and I was wondering how much it it has to do with statistical analyses, and it's been a while since my statistical analysis class, but N of 1 was not something we had a lot of faith in, or to place alot of focus on.

[Blog author note: Again- the gentleman somewhat glibly dismisses and misrepresents the issue. "One person" case study is seldom done, but has value for particular reasons of novel or variables particularly of interest using in-subject research. Most, if not all, ABA research uses far more than "1" students, and with different kinds of control methods to distinguish real treatment effects, such as multiple baseline, reversal (if possible), comparison groups. This concentration on this point is attractive because it's an easy target, but hardly represents the real situation of significant discussion and refinement of "evidence" within the medical community, and the question of whether Randomly Controlled Studies (RCT) alone really are the claimed "gold standard", and are suitable for measuring effects in individuals, given that some large-scale RCTs have resulted in medications released which had to be later pulled, and that strict dependence on RCTs as defining strong evidence and effectiveness, may in fact be used to exclude and gate-keep treatments that are, in fact, effective.]

2:16:57 - Rep. Greenlick - If you have some spare time.
2:16:59 - Oken-Berg -Yeah.
2:17:00 - Rep. Greenlick - If you had some time, I think we would value your judgement--I've read about 10 cases of material on this, about 10 cardboard boxes, and I think it would be very useful from your background to get a look, at least starting from the Oregon Health Resources Commission and the reason that I asked for our other witnesses to to get us other studies is that it would be useful although we quickly get mired in the N of 1 argument, which is legitimate, I guess.

[Blog author's note: With due respect to Mr. Oken-Berg, who had an excellent HS and college record, graduating with a degree in political science, and has a part time avocation in a band besides his profession as a Government Relations Consultant, and was a political staffer with Sen. Ron Wyden, this particular skill set seems neither appropriate nor sufficient background to serve as evaluator of research design, evidence base, quality of meta-analysis, across different scientific fields using different experimental designs.]

2:17:33 - Oken-Berg - And in addition, we are happy to provide any of the folks at Kaiser, which is not only in this region, but has networks nationwide, to get you evidence, and we have pediatricians who are lifelong advocates for autism, both parents and children. So we'd be happy to provide that to you and and directly.
End of Mr. Oken-Berg's testimony

2:17:52 - Rep. Greenlick - Dr. Green, are you still there?
2:17:55 - Gina Green - Yes, I am.
2:17:57 - Rep. Greenlick - How about a last word from you?
2:18:00 - Gina Green - I would suggest in evaluating the reviews that have been done of research on applied behavior analysis, that you use the same standard and look for the same conditions as when you review your medical treatments, that applied behavior analysis, that is behavior analysis is a discipline. It is not the same as clinical psychology, it is certainly not the same as pediatrics, and as I mentioned, this discipline has it's basic research methods. Many of the reviews that I have seen have been conducted by people who have not had training in behavior analysis and also have not had training in its research methods and that's like asking a bunch of us behavior analysts to evaluate a medical treatment.

2:18:48 - I don't think that you would treat that as very credible. You need some expert behavior analysts to take a look at the treatment. They're the ones who know the treatment and know the research methodology, and I would really recommend looking at the documents and studies and a book that has recently been published by the Journal of the American Medical Association on evidence-based medicine regarding N of 1 studies- they are only talking about ONE KIND of single case experiment, evaluating medical treatments. There are also several kinds of other treatments that are tried and true for evaluating changes in behavior. At this time, autism is behaviorally defined, behaviorally diagnosed, and I would dare say that there are a number of medical treatments covered, for example, I heard the gentleman from Kaiser mention Sensory Integration Therapy- there has not been a scintilla that that is beneficial for children with autism.

Again I am recommending that you hold ABA to the same standard that you hold other interventions. Other treatments and medical treatments that are far from perfect.

2:20:17 - Rep. Greenlick - If we're going to hold it to the same therapy, I can assure you that there is not a single other therapy mandated by statute. It's up to the insurers and the providers to determine how to treat a disease that they recognize. This would not be holding it to the same standard, this would be creating an entirely different social policy standard. That's why we're having some trouble with it.

[Blog author note: It could be interpreted by allowing continued exclusion and denial of ABA therapy of suffient intensity, quality and duration applied by those trained in the discipline, that the state is applying a mandate of sorts by restricting access to the availability of ABA to those willing and able (the latter the key point of HB 3000) to pay out of pocket, would choose that therapy, (since even when available, others will choose other treatment modalities, including eclectic models or alternative treatments).
Social policy also includes availability and access to service and treatment (see, mental health parity)]

2:20:52 - Gina Green - There a framework of scientific standards and other kind of standards, and again if you had people who knew about that treatment and studying that treatment helping to evaluate it, to evaluate that evidence--I would suggest doing the same for applied behavior analysis. It's not like clinical psychology, it's not like medicine, it's definitely not like a drug treatment or a shorter term medical treatment, it's vastly different from that.

2:21:25 - Rep. Greenlick - Well, I'm going to end this call, and I'm going to gavel out of this hearing and adjourn the Committee. Thank you all very much for coming,

END OF AUDIO TRANSCRIPT