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Wednesday, March 4, 1998.






    Mr. PORTER. The subcommittee will come to order.

    Continuing our hearings on the Department of Health and Human Services, we are pleased to welcome Dr. John Eisenberg, the Administrator of the Agency for Health Care Policy and Research. Dr. Eisenberg, this is your first appearance, is it not, before our subcommittee?

    Dr. EISENBERG. It is, in this room.

    Mr. PORTER. So, we definitely welcome you and hope you are challenged by your new job, which I imagine you are. Could you introduce Ms. Koch and then proceed with your testimony.
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    Dr. EISENBERG. I would be happy to. I think you know Dennis Williams.


    In some ways, this is not my first testimony. I testified before this committee for the Physician Payment Review Commission when I was chairing it. Ironically I was asked in the questions and answers what I thought about this agency, the Agency for Health Care Policy and Research, and how important it was for physician payment. And my response was that it was very important to guide the evidence that helps us to understand the way in which physicians practice. I still, obviously, feel that way or would not have left Georgetown to come and join the agency.


    I would like to talk today about AHCPR briefly and then talk about our budget. As you know, AHCPR focuses on research that moves biomedical discoveries like the ones generated at the National Institutes of Health into medical practice.

    Our research bridges that gap between what our scientists know and what health care Americans receive. The decisions about health care in this country are very personal ones. Every one of us makes a personal decision but those decisions about health care are often made with help, maybe from a doctor or a nurse or a loved one, but they still remain very personal and individual decisions.
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    What I want to emphasize today is that those decisions, those individual decisions, are made in the context of a very complex area, one of the most complex in modern life, the health care system. It is here that patients and clinicians usually do not have all the information that they need, sometimes do not have any of the information that they really need, to make the best choices among the alternatives that are available to them.


    Our mission, as I see it, is to provide science-based information so that we can help with those decisions, so that we can improve decisionmaking by all the decision makers in health care. Those are AHCPR's customers, the people who are making those decisions.

    They are patients, they are clinicians, they are health care system leaders, they are public policy makers in both the public and private sectors. They use this kind of information every single day to make decisions that have an impact on all levels in the health care industry, from an individual patient deciding on whether to have surgery, to the health plan deciding on what kind of new benefits it might offer. Our budget for Fiscal Year 1999 addresses these challenges that are faced by the agency's customers.


    Our research, as you know, is both conducted and sponsored by the agency and the vast majority of our funds go outside the agency to the best researchers in the country, people who compete for funds with grant applications and undergo peer review in the same way that NIH does.
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    For example, one agency AHCPR-sponsored project found that we could cut the cost for antibiotics for people with pneumonia by two-thirds with no adverse effect on patient's health by a simple change in the way in which antibiotics are used. It is that kind of research that I think is so useful.

    And ironically, before I joined the agency, I was chairman of the Department of Medicine at Georgetown. And, so, my name is still listed on a number of managed care plans in Washington, in which I participated. I still get their mail. A few weeks ago, I got a brochure from four health plans in the Washington area who had put together an educational program for physicians. This brochure was about this very AHCPR research that showed how better care can cost less. And that, I thought, was very satisfying for an agency which generates research that we want to see translated into practice in the private sector.


    A very important component of the research that we do on outcomes and on effectiveness is not only sponsoring that research, but also being sure that the research gets translated to clinicians and to patients for their decisions about treatment, and also gets translated to plans so that they can make decisions about what they are going to cover.

    One of our new programs deals with the evidence for what works and what does not work for a variety of different treatments and interventions.

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    Last Fall we named 12 evidence-based practice centers located around the country and we assigned the first round of topics to those organizations. We are expecting reports from the EPCS within a few months.

    We expect the reports to be used by our partners. Each of those topics was nominated by either a public or a private sector organization who said, we need a public sector review of this material, an assessment of this material.

    These are organizations in health care and medical societies. They nominated the topics because of their need to develop quality improvement tools, practice recommendations and educational programs to improve health care.


    One example of that is a sponsored project that we did on colorectal cancer. This project developed an evidence report that contributed to the Congress' decision to cover colorectal cancer screening as part of the Balanced Budget Act, and also contributed to HCFA's decision about how it would pay for colorectal cancer screening, another way in which this research gets translated into action.


    We recognize that need to get this information, this research information, out to our customers. One of the ways we do this is through formal partnerships.
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    For example, we have a partnership with the American Medical Association and the American Association of Health Plans to establish a National Guideline Clearinghouse. The NGC will provide one-stop shopping to Americans about the best practices in clinical care.

    This is a clearinghouse that will be available on the Internet in the Fall. It will make existing practice guidelines developed by public and private sector organizations available to every doctor, every nurse, every patient, and every health plan who can use a computer.

    In addition to the research that we do on this level, the clinical level, to help doctors and nurses and patients make decisions, I think it is very important for us to remember that there are health plans, system leaders in health plans and health care organizations, who are making similar decisions and need similar kinds of information.


    For example, last month, Secretary Shalala released the AHCPR Consumer Assessment of Health Plans Survey. This survey will help not only consumers, but also employer benefits managers, and those who are making decisions for group purchasers about health plans, choose the plans that are most satisfactory to the people who are in them.

    I was very pleased when HCFA announced last week that it would use this survey, CAHPS, to survey Medicare beneficiaries. You, your staff, and all of us will soon have a chance to use CAHPS as well; the Office of Personnel Management announced that it will be using the survey, and we are looking forward to it spreading even further.
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    Already several States and several private corporations are using CAHPS as a way of getting information to their people about the differences among the plans.


    We have developed a budget request for this year, for Fiscal Year 1999, under the framework of the Government Performance and Results Act, GPRA.

    And let me say, that we have developed an internal evaluation strategy as well that will allow us to assess our progress in meeting the annual objectives so that we will know the impact of our research initiatives on the health care system. That is very important for our translation efforts.

    We are pleased that we met our Fiscal Year 1997 GPRA goal in improving the timeliness of data that we collect in our Medical Expenditure Panel Survey.

    The first release of this data for 1996 came out in April of 1997, a remarkably quick turn around for this kind of data and we have kept up that pace.


    In Fiscal Year 1999, AHCPR requests a total of $171,435,000. That is an increase of $25,000,000 over the Fiscal Year 1998 Appropriation.

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    The additional $25,000,000 will allow AHCPR to expand our emphasis on research to measure and improve quality, and to collaborate, as I have already mentioned, with other public sector agencies and the private sector to improve health care in this country.

    Our research is going to emphasize improving the quality of care for all Americans especially for those who are at the greatest need.

    For example, we will devote $5,000,000 to concentrate on the cost, quality and outcomes of care for people who have chronic diseases and disabilities. We will devote funds for research and demonstrations to improve the quality of care for children, as well as evaluations of the effectiveness of State and local approaches to implementing the CHIP legislation.

    We will support major new assessments of preventive services to provide information that will help all of the agencies customers that I enumerated earlier to make decisions about preventive services.

    In addition, the Food and Drug Administration Moderization and Accountability Act gave our agency a new responsibility to support two Centers for Education and Research in Therapeutics.

    These so-called CERTS will increase our knowledge about the new uses and risks of medical products through research, and will also help to prevent adverse effects of medical products and the consequences of those effects.

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    Mr. Chairman, approval of AHCPR's budget request for Fiscal Year 1999 will ensure that we continue to have unbiased, reliable information. It will allow us to provide more and better unbiased and reliable information on cost-effectiveness and effectiveness of treatments for specific conditions, as well as strategies that will help us to translate the best science into routine practice, into every day medical practice in this country.

    That will give us high quality care at an affordable cost. My colleagues and I will, obviously, be happy to answer any questions that you have.

    Thank you very much.

    [The prepared statement follows:]
    "The Official Committee record contains additional material here."

    Mr. PORTER. Thank you, Dr. Eisenberg, we appreciate your fine statement. Ms. Koch, I thought that Dr. Eisenberg was going to introduce you. I just want to welcome you as well. We appreciate both of you being here to testify.


    Dr. Eisenberg, $15 million of the $25 million you are requesting as an increase in Fiscal Year 1999 is to support a Secretarial initiative to improve health care quality. We thought that was already what you were doing. Isn't this just the status quo in a different wrapping? Tell me how this is different from what you do now and what are the outcome measurements for this initiative?
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    Dr. EISENBERG. The theme is similar, of course, to what we are currently doing because we are already devoted to trying to develop better ways of understanding and improving quality. What we want to do is to devote this agency to generating better quality measures, which are in great demand by this country, as well as to understand better what works and what does not work in trying to improve the quality of care that Americans get.

    Unfortunately, because of our budgetary constraints last year, Fiscal Year 1997, we were only able to award ten new grants. This year it looks as if we will be fortunate to be able to get to the 15th percentile on applications.

    There are a number of talented American investigators in this area who, I think, have a tremendous amount to contribute to what we know about quality and what we know about ways of measuring it and improving it. Our request is formulated to take advantage of the talent among the investigators in this country to apply the science to better quality of care.

    That is why we have asked for additional funding. Because of the passion that the Congress feels and the commitment that the Administration feels to improving quality of care research, we have asked for an additional $15 million in this area.

    Mr. PORTER. So, you are just giving the request for an increase in funding a name because you are already doing the quality research in any case.

    Dr. EISENBERG. Well, we are doing some of it. What we have done by giving it a name is to transmit the message as clearly as we can that this is a high priority for the agency, and that this is the area in which additional funding would be dedicated.
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    Mr. PORTER. All right. Your agency sponsored a national conference to chart the course for the next 10 years for investment in outcomes research. It was anticipated that the results of this conference would be published in the spring of this year. What is the status of the report and how will the information be used?


    Dr. EISENBERG. Well, the report is being finished now. We had the conference in the fall. The report, what we call the ''outcomes squared initiative'' or the outcomes of outcomes research, will be used in two ways. One way will be to help us target the areas in which we commit our resources to further research about outcomes and to understand where the research pays off the best. What kinds of outcomes research needs to be done?

    That could be the measurement of outcomes. For example, how individual patients value various outcomes. Or the content areas, those diseases in which they need to measure outcomes.

    But, in addition to that, one of the concerns that we all have is that this research be translated into improved health care. And, so, one of the other outputs of the outcomes initiative is to look at how we can take this research and get it translated into improved practices through education, through changes in health care organizations, through better information to patients, and through better information to physicians. I anticipate that the report will be ready within a couple of months.
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    Mr. PORTER. This will, I think, help to pin down what you are talking about by perhaps your giving us some examples.

    Your agency has invested in 14 original Patient Outcomes Research Team (PORT) projects and 11 PORT II Projects. These projects have generated numerous findings. For example, the diabetes PORT has demonstrated that for Type II diabetes, insulin treatment is significantly more costly and not always more effective than oral agents.

    Like other PORT findings, the teams are working closely with professional organizations to get these results widely disseminated. Once these findings are made available, how do you know if, in fact, they are being used? And, in your response could you tell us first, if they are being used how do you measure the impact they are having, and second, if they are not being used, why they not being used?

    Dr. EISENBERG. Well, first, are the outcomes of these patient outcome research teams useful and what are the outcomes? Let me give you a few examples of some of the reports that have come out recently. The Patient Outcome Research Team at Johns Hopkins, which focused on cataract disease, developed a measure for understanding the impact of cataract disease on individuals who have cataracts. It has been described as the best method of understanding both who will likely benefit from cataract extraction, as well as understanding the outcome and what the contribution of those outcomes has been. That measure is already beginning to be used.

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    The second example is an outcomes assessment that was done at the Massachusetts General Hospital on prostate disease, in which the outcomes of benign prostatic hypertrophy were evaluated. A videodisc was developed to help patients to understand their decisions. We have already seen the impact of this study for example, with the urology community picking up on that measure of outcomes such that that article has now become the most quoted article, I am told, in the urologic literature. This is a new measure of the outcomes of prostate disease.

    And we also understand that this videodisc, which is a way of translating the outcomes to patients so that it can help with their decision making, is being adopted by individuals who want to help their patients understand what the options are for them with prostate disease.


    Mr. PORTER. But you are not actually measuring who is using it. You are saying it is out there, we put it out and we hear people are using it or talking about it, at least. How do you know if it is actually being used?

    Dr. EISENBERG. Well, we have asked the investigators in each of those Patient Outcome Research Teams to monitor the degree to which their work is getting disseminated and is being used by people in the community. And so far, that is the best way that we have of tracking that, other than watching some findings become commercial products, which some of them have, of course, as they appear to have value to those who would like to translate them and make a commercial product out of some of those findings.
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    But the process is really using the investigators because they are the ones who are most likely to understand the way in which this is being disseminated.

    Mr. PORTER. See, this is the point at which we really want to provide some focus because in the past, and not necessarily applying to this agency, the measurement might be how many ports did you do how many reports were generated? Well, it does not matter how many reports are out there if nobody ever reads them or does anything with them. Right?

    Dr. EISENBERG. Right.


    Mr. PORTER. What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?

    Dr. EISENBERG. Well, let me respond to that in two ways, because I could not agree with you more. In the several months that I have been at the agency that has been one of my own personal campaigns. We need to tell the story, to understand the story about what this agency's products have meant, not only getting the research published, but also doing something with it.

    I keep reminding our researchers that when they have their articles accepted that is not the end of their obligation to the public sector. It is in some ways the beginning of their obligation to the public sector that they need to get that research translated into action.
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    Mr. PORTER. And you need to determine whether it has been.


    Dr. EISENBERG. Yes. We need to determine whether it has been translated. I would go a step beyond that actually, and say that we are looking now to develop partners who promise us that the research, once we have funded it, will be used. So, that for example, with the Evidence-based Practice Centers, we have partners who have assured us that when the report comes out they will adopt and they will use the results. For example, the American Psychiatric Association and the Academy of Pediatrics, have said that when our report on attention deficit disorder comes out, they will use it.

    We are also going to have the report from the schizophrenia PORT come out within a few weeks, and we have a commitment from the psychiatric community that it will be used. My sense is that we cannot just let it get out into the published literature——

    Mr. PORTER. I would go a step beyond that and if it is used, is it efficacious in directing at the disease or syndrome that we are attempting to do something about.

    Dr. EISENBERG. Right, right.

    Mr. PORTER. In other words, what effect is it having on people? Not how many reports are out or how many people have read it or how many people are actually using it, but is it working?
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    Dr. EISENBERG. Right.

    Mr. PORTER. You need an evaluation all the way to the end.


    Dr. EISENBERG. I agree with you.

    Mr. PORTER. Okay. At last year's hearing, your predecessor, Dr. Gaus, testified that the agency would soon be signing a partnership agreement with the American Medical Association and the American Association of Health Plans to jointly sponsor a National Clearinghouse of Clinical Practice Guidelines.

    This clearinghouse is intended to provide an electronically-based catalog of every guideline in the country as well as a comparison of the guidelines. What is the status on this initiative?

    Dr. EISENBERG. It is going right on schedule, in fact, a little bit ahead of schedule. The National Guideline Clearinghouse has contracted with an organization that is expert in putting these Web Sites together and in gathering the information.

    We have had several meetings of a planning group, which includes the AAHP and the AMA, to design the site, to decide on what the criteria ought to be for entry into the site, and to be sure that we are following the schedule as it has been laid out and we are right on schedule. We expect that it will be available on the Internet in the Fall.
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    Mr. PORTER. Again, how do we determine whether professional societies and other groups will actually use the site and are they willing to finance any portion of its cost?

    Dr. EISENBERG. Well, I am pleased to say that the AMA the AAHP have already begun to finance part of its cost. They are partners with us in this project. As for use, we have the usual way of measuring whether or not a Web Site is being used, of looking at hits. But that really does not tell us whether or not it has been translated into action.

    We have met with a variety of specialty societies as recently, in fact, as last week in Chicago, to talk with specialty societies about the National Guideline Clearinghouse. We are letting them know it is coming and have begun to talk with them about ways in which they can enable their members to use it most effectively.

    We started to anticipate the concern that you have, that we have as well, because we do not want this to just sit on the Web, we want it to get used. We will follow that up with measures of how satisfied people are with the Web, and what their impression is of how much they have been able to use it. We are looking now for ways in which we can look at its impact on actual practice patterns, as well.


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    Mr. PORTER. How does this differ from what, say, the National Library of Medicine does?

    Dr. EISENBERG. It differs substantially in that our role as a research agency is to generate the evidence reports and then to put them on the Web. We bring the guidelines together in a way that evaluates the degree to which they meet certain standards of evidence, of being evidence-based, and then collaborate with other organizations to make them available.

    We have collaborated with the NLM because of their expertise in using Web Sites and getting informaiton to users. They have been enthusiastic about working with us in this area. But the content of the National Guideline Clearinghouse is an area in which we have, I think it is probably fair to say, unique expertise within the Federal Government. The Library of Medicine's expertise in using the Internet and using the Web dovetails nicely with ours. And, so, we are seeing it very much as a partnership where we bring the expertise, the content, and the medical practice area, and they contribute expertise in how the Web can be used.

    Let me just say in addition, that one can get into this Web Site through NLM's site. We wanted to be sure that no matter how people come into the Web that they had ease in getting into the National Guideline Clearinghouse's Web Site.


    Mr. PORTER. If I go down, as I did, to a Community Health Center in inner-city Chicago, they have sitting there a television set or a monitor that's hooked into the National Library of Medicine. Do they not have these practice guidelines already available?
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    Dr. EISENBERG. They do not have the guidelines available. They only have access to a small sample of guidelines. You have to know how to go to the various sites for each of these guidelines.

    What the NGC will do that is different from what you just described is two things in particular. One is that the individual who wants to gain information about a particular problem that they, he or she faces, has to go to only one place on the Web, instead of having to be an expert and finding all of the different sites that they might have to find anywhere on the Web. That is one contribution.

    But I think the most important contribution is that—and this really gets to your previous question about what value-added we bring to this—is that because of our expertise in evaluation of medical services and using the evidence-based approach, we are putting together a side-by-side analysis of the guidelines that are available. This analysis will show not only who put the guideline together and what the audience was, and who the patients were and how the study was done that generated the guideline; but also a side-by-side analysis that compares the content of the guidelines, so that if you wanted to know about a particular area, like colon cancer, you could do a side-by-side analysis of each of those and compare what every organization said about that particular question. You cannot get that by yourself.


    Mr. PORTER. Well, we are going to have Dr. Lindberg here and I am going to ask him the same question because it seems to me there is a potential at least for some duplication there and if there is then we have got to make certain that one of you is doing what needs to be done and not both of you doing exactly the same thing.
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    Dr. EISENBERG. Well, you are absolutely right. That is why Dr. Lindberg and I meet every month to talk about what our two agencies are doing.

    Mr. PORTER. You know what his answer will be.

    Dr. EISENBERG. Well, we believe that we ought to cooperate and collaborate because we have a lot to learn from each other, I think.

    Mr. PORTER. Mrs. Northup, let me apologize. The last time I looked over in that direction, you were not there. So, please, proceed.


    Mrs. NORTHUP. I understand that you are doing the work we talked about last year of assessing different plans and the efficacy of them and the efficiency of them and patient satisfaction. I assume you are doing that for managed care firms?

    Dr. EISENBERG. Well, we are not doing it for managed care firms so much as about them.

    Mrs. NORTHUP. Assess them.

    Dr. EISENBERG. Yes, yes.

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    Mrs. NORTHUP. Well, I wonder if you know there are several consumer protection bills regarding HMOs that have been proposed in the Congress and in fact, the President has endorsed certain proposals, but I wonder if it does not make more sense to see what your research shows both in consumer satisfaction and price control before we begin enacting new legislation that affects these plans?

    Dr. EISENBERG. Well, I agree with you fully about the importance of being able to do those side-by-side comparisons. In fact, the Health Care Financing Administration has begun to use the CAHPS, the Consumer Assessment of Health Plans Survey. They announced this a couple of weeks ago. The Office of Personnel Management is also using CAHPS and a number of programs around the country, States and private organizations are using it, as well.

    What it offers us is a way of providing one of the things that many of the people who are concerned about consumer protection believe is the first step—that is more information, better information so that we can compare what people think about the different health plans.

    I am pleased to say that between the time we answered this question last year and now, that the CAHPS survey is available. The State of Maryland, the State of Washington and others already have booklets developed using CAHPS that allow people to make choices about their health plans.

    To the degree that CAHPS addresses one part of the consumer protection agenda, which is getting good information to people so that they can make choices, I think that it is a very important part of that agenda and your bringing them together, I think, is an important and correct way to link them.
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    Mrs. NORTHUP. Of course, when we talk about in enacting anything like consumer protection information it is as though it is going to affect the private sector insurance market only. However, many of the Medicare and Medicaid plans, Medicaid in particular, in Kentucky, have gone to HMOs processes and any sort of legislation that we pass that would profoundly affect the price of those is also going to affect the Federal budget and our ability to access more health care for people who are in those programs. Would you agree?

    Dr. EISENBERG. Well, on the price, let me just say that the Consumer Assessment of Health Plans Survey deals more with satisfaction about the care that people receive than——

    Mrs. NORTHUP. And outcomes?

    Dr. EISENBERG [continuing]. And the outcomes that they receive, their perception of the outcomes that they receive, of course, which is an important part of outcomes. It does not focus as much on the price issues. What it does is to say we can measure the price. What we have had trouble measuring in the past is satisfaction and outcomes. This is a step towards balancing the measure of price so that we do not choose on price alone, but so we can choose on price and quality.


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    Mrs. NORTHUP. Actually I think if we looked at the HMOs plans that are under state jurisdiction and we sort of proposed consumer health or consumer protection mandates, it is very easy to see what it does to the price.

    Because the state plans have experienced what happens to the price. I think what is important for us to know before we do anything in Federal policy affecting any other policies is to find out whether, in fact, there is an outcome problem or a consumer satisfaction problem.

    And that is why I am eager to know what your study showed.

    Dr. EISENBERG. Well, that is obviously what this agency is all about—measuring those outcomes and trying to get that information to individuals. I would be happy to show you what the CAHPS survey shows. It is different, of course, State-by-State because the plans do differ State-by-State.

    But what it looks like is sort of like what you are used to seeing when you buy a car. They have the various characteristics of the plan so that you can see how they do on the various aspects of delivery of care that are important to you.

    Some users report it in stars, some report it as those circles that have different quadrants built in. But I agree with you that it is a very important part of being sure that people can make choices among their plans.

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    Mrs. NORTHUP. The Office of the Inspector General I know is also doing this type of work. Are you all coordinating your results?

    Dr. EISENBERG. Not with the Office of the Inspector General. No, not with the Inspector General.

    Mrs. NORTHUP. Well, I might suggest that, you know, if we have two agencies doing the same type of research it might be interesting to have some coordination, some idea.


    Let me ask you another question. Last year, this subcommittee included report language regarding congestive heart failure. I had specifically brought that up with my colleagues concerned about what we know as the ''stroke belt.''

    This particularly effects Kentucky. We have a lot of rural health service and the availability of, for example, cardiology specialists in rural health is limited. And the suggestion by this subcommittee was that we link a teaching hospital on practice, a hospital that has a practice dedicated to that service and rural health care providers with cardiologists in these centers, so that the most advanced practice would be available to rural communities without the increasing cost of somehow attracting those practices.

    I just wondered if you had been able to do any work related to this? I mean I know that you all have grants that support this type of work and I just wondered if you had concentrated any of that in the ''stroke belt''?
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    Dr. EISENBERG. A number of the projects that we are doing relate to the topic that you have raised. One of them is a project that is designed to evaluate the recurrence of stroke, ways in which we can prevent the recurrence of stroke through the appropriate use of anticoagulant drugs, and getting physicians to do what we know they should be doing in terms of reducing recurrence of stroke in that way.

    One of the major factors that leads to stroke is atrial fibrillation, irregular beat of one of the chambers of the heart. We have some projects that we funded in that area as well, which should reduce the incidence of stroke.

    We also have a guideline that the agency has produced in the past that looks at what should be done in the area of congestive heart failure.

    And I have had personal conversations with the American Heart Association and the American College of Cardiology about the need for us to collaborate with them to develop additional information that would be available to practitioners so that they can help to reduce the stroke.


    Mrs. NORTHUP. I am hurrying because I have to chair the meeting across the hall. But I think I am specifically asking about something else.
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    And that is the demonstration study or a grant that would be targeted to where we already have a high incidence and a under-served area.

    And about trying to put together expertise in a very efficient, effective way to communicate either by telephone or computer or whatever the most advanced medicine. I think what you are talking about is practice parameters, practice practices that are good medicine.

    What I think I am thinking of is that there are those patients that do not respond as you expect and so forth, and they are not in Louisville, Kentucky, they are in rural areas and general practitioners do not have the expertise to, even if they had followed what was in the guidebook, and trying to bring advanced medicine specific to the patient. I just wanted to bring that to your attention.


    If I could just ask you one more question. It is about your research and I know you are an outcome-based agency. And I just wondered if you use peer review on the studies that you have conducted and the importance of peer review?

    Dr. EISENBERG. Yes, we do. Peer review is a critical part of what we do. All of our grants are reviewed by experts from around the country in exactly the same way this is done at the NIH.

    Unfortunately, in Fiscal Year 1997 we were only able to fund down to about the 8th percentile.
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    This year we are hoping we can do a little bit better than that. That is one of the reasons why we have asked for additional funding for this year—so that the peer review process can approve and fund some grants in the future.

    Mrs. NORTHUP [presiding]. Thank you. I am sorry. We are adjourned until 10 o'clock tomorrow morning.

    Thank you very much for your testimony.

    [The following questions were submited to be answered for the record:]
    "The Official Committee record contains additional material here."

Thursday, March 5, 1998.






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Introduction of Witnesses

    Mr. PORTER. The committee will come to order.

    We continue our hearings on the budget of the Department of Health and Human Services, and are pleased to welcome this morning Dr. Claire V. Broome, the Acting Director of the Centers for Disease Control and Prevention.

    Dr. Broome, we're very pleased to have you with us here today. We're sorry to have lost Dr. Satcher to higher pursuits, perhaps, within the Department, but I know he'll continue his interest in CDC from his new position.

    We appreciate your standing in today, pending the nomination of the new Director for CDC. And obviously, we on this committee appreciate very much the work that CDC does, and consider it a very high priority for our country.

    I'd also like to welcome Jay Dickey to our subcommittee today. Nice to have you here, Mr. Dickey. [Laughter.]

    Mr. DICKEY. Thank you, sir.

    Mr. PORTER. Dr. Broome, why don't you proceed with your statement, and then we'll have questions.

Opening Statement
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    Dr. BROOME. Thank you, Mr. Chairman and members of the committee.

    It's a real pleasure to be here with you today to speak with you in support of the President's budget request for the Centers for Disease Control and Prevention for fiscal year 1999 in the amount of $2.45 billion. This represents an increase of $78.6 million, 3 percent over the fiscal year 1998 appropriation.

    I also really want to thank you, Chairman Porter, and the subcommittee, for your ongoing support of the Nation's prevention agency.

    I'm confident that each of you here today would agree that prevention is vitally important to the health of this Nation. Although it's crucial to be able to treat and cure sick people who become injured or disabled, we would all prefer to remain healthy in the first place. Public health activities are essential to the health, well-being and productivity of this Nation.

    The fact is that as we approach the turn of the century, we could be doing more for the quality of the Nation's health. Millions of people are still dying prematurely or suffering unnecessarily from preventable disease, injury and disability.

    What I want to emphasize today is what I call the prevention gap. In many instances, we already know what works to prevent diseases and injuries. And yet, there's a disconnect between knowing and doing. We're not always putting our knowledge into practice.
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    Let me give you some examples of CDC's prevention strategies that work, and to point out what we still need to discover to close the prevention gap. We know how to protect our older citizens from the suffering and untimely deaths associated with influenza. Influenza vaccine works. It works not only to prevent deaths, but to help seniors maintain healthy function and quality of life.

    Yet more than 18,000 died unnecessarily of flu-related causes last year. Over 40 percent of persons 65 and older, the fastest growing age group in this country, did not receive influenza vaccine in the past year. Even worse, more than 60 percent of African-Americans went unprotected. That's a prevention gap.

    We also know how to protect our children and grandchildren from certain birth defects. Folic acid works. Each year, 4,000 babies are born with the life-threatening birth defects spina bifida and anencephaly. We've known since 1991 that at least half of these cases can be prevented if women of child-bearing age consume adequate amounts of the vitamin folic acid. But 75 percent of women of child-bearing age still do not get enough folic acid in their diet.

    We know how to help prevent today's healthy young people from becoming tomorrow's victims of heart disease and stroke. Cardiovascular disease is the leading killer for men and women and across all racial and ethnic groups. Cardiovascular disease is responsible for over 960,000 deaths each year.

    Physical activity and proper nutrition work. Research has shown that moderate physical activity and a healthy diet can help protect Americans of all ages, not only from heart attack and stroke, but also diabetes and even some cancers.
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    Yet poor diet, coupled with lack of physical activity, remains the second leading preventable cause of death in this Nation.

    Having the basic scientific knowledge about effective preventive measures is only half the battle. Scientific findings are worth little if they sit on a shelf. We must put our scientific knowledge to work for people if the public's health is to improve.

    We believe that CDC is in a unique position to close the prevention gap. We have the ability to conduct prevention research to close the gap between knowing what works and knowing how to turn that scientific knowledge into effective programs.

    We also have the scientific ability to answer new questions about how to prevent disease, injury and disability. Then, very importantly, we have strong long-term collaborations with State and local health departments, health care institutions, other community organizations and private practitioners, the people on the front lines who can deliver prevention programs and practices directly to your communities.

    The President's budget request includes funding increases to CDC in five critical areas. These increases will help us move from knowing what works to putting that knowledge to work.

    Food safety. The President's budget includes a $5 million increase to support activities under the Food Safety Initiative. Each year, an estimated 6 to 33 million Americans develop a food-borne illness, and 9,000 persons die as a result. The annual cost attributed to food-borne illness is $5 billion to $6 billion.
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    This increase will enable CDC to expand the National Early Warning System for detecting food-borne illnesses, and enhance links between Federal and State laboratories with sophisticated computer technology so that we can identify organisms which may be causing food-borne disease in multiple different locations.

    We know how to increase the safety of America's food supply. With your help, we can act.

    Adolescent smoking and health. The President's budget includes a $46 million increase for our continuing struggle to keep the next generation of young people from starting to smoke. Smoking is the number one preventable cause of death in this country, resulting in 420,000 deaths each year.

    In addition to this preventable loss of life, medical costs were estimated to total $50 billion in 1993. Studies show that over 80 percent of adult smokers became regular smokers before the age of 18. Each day, to our national shame, over 3,000 young people begin smoking.

    The budget increase will allow CDC to significantly increase grants to States for their smoking control programs. This will include all States, both the States that participated in the National Iinstitutes of Health (NIH) American Stop and the States Smoking Interventin Study (ASSIST) supported through CDC's Initiative to Mobilize for Prevention program. Results from these and control of tobacco use (IMPACT) programs have defined the type of anti-tobacco public health program that will help us reduce youth tobacco use, exposure to second hand smoke, and help adults stop smoking.
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    We know ways to help protect young people from addiction to nicotine. With your help, we can act.

    Eliminating disparities. The President's budget includes a total of $80 million for the Department to support a major goal in his initiative on race. Of this amount, CDC would receive $55 million to address the President's ambitious goal to eliminate disparities in health status suffered by racial and ethnic minority populations by the year 2010.

    One target of the initiative is HIV/AIDS. It is appalling that the rate of AIDS is more than seven times higher for African-Americans than for white Americans. We need serious attention to improving our prevention programs to eliminate this disparity.

    Because of its experience in conducting prevention research and programs, CDC will play a major role in the President's race initiative. CDC will help conduct a series of research demonstration projects in communities to address six areas of identified health disparities. HIV infections, infant mortality, cancer, cardiovascular disease, diabetes and child and adult immunizations.

    We know we can accomplish this challenge, as shown by the significant gains in childhood immunization rates of minority children, where we have essentially eliminated health disparities. We know that we can reduce the extra burden of disease borne by minority populations. With your help, we can act.

    Emerging infectious diseases. The President's budget contains $79 million, an increase of $20 million, to help combat emerging infectious disease. You've only to listen to the nightly news to know that the Nation remains vulnerable to deadly infectious diseases. Terms such as hepatitis C, Ebola virus, avian flu, and antimicrobial resistance have become household words.
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    Hepatitis C, only recently identified, accounts for 8,000 to 10,000 deaths per year. And yet most of the 3.9 million Americans chronically infected with hepatitis C virus are unaware of their infections.

    The requested budget increase will be used to expand the Nation's emerging infectious disease early warning system in as many as three additional States, for a total of 33 States. These efforts will strengthen the surveillance network and capacity of State and local health departments to respond to infectious diseases by increasing the speed at which outbreaks can be detected, investigated and controlled.

    With your help, we can do it.

    Prevention research. While we have many proven prevention strategies, such as the ones that I've mentioned, and are implementing successful programs based on these, there's still much that we don't know. We need prevention research to bridge the prevention gap. We need research that can help transform findings from bench level research into prevention programs that reach people, and research that can tell us about the effectiveness and the cost effectiveness of those programs.

    The President's budget contains $25 million for a new prevention research program at CDC as part of the Research Fund for America. With this funding, CDC will support extramural research in academic health centers, such as schools of public health and medical schools, local and State health departments, and other community organizations.

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    As illustrated by chart one, which is the only chart I'll be using in my presentation, we thought it would be helpful to look at the kinds of questions we feel prevention research is needed to answer. There are very pragmatic questions.

    How do we keep organisms such as cryptosporidia and E. coli from invading our water and food supply? What factors motivate workers and employers to adopt protective work practices? How is hepatitis C virus transmitted among adults with no history of injection drug use or blood transfusions?

    How can we use what we know about the health consequences of smoking, obesity and unsafe sex to help people choose healthy lifestyles? Can we prevent the chronic disease complications of infectious diseases, such as cervical cancer or ulcer disease, a fantastic new opportunity for prevention?

    We know that prevention research is needed both to discover new ways to prevent health problems and to help us move knowledge into practice. With your help, we will do it.

    Mr. Chairman, with your support for the President's budget request of $2,457,000,000 for CDC, you can help us close the prevention gap. CDC has the unique capacity to move from discovery to action. We can move research findings quickly to prevention programs located in communities throughout this country—programs that help people remain healthy.

    With your help, we will be able to move more prevention know-how into practice.
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    Thank you for this opportunity to appear before the committee. I'll be happy to answer any questions you may have.

    Mr. PORTER. Dr. Broome, that was an excellent statement, and you organized it very well, and covered a lot of ground in a very short time.

    ''With your help, we can do it'' may be fairly close to lobbying. [Laughter.]


    But we got the message. [Laughter.]

    I want to begin by asking a question, because much of, all of what you really said, how do we put our knowledge into practice, how do we gain additional knowledge, which was the last part, but how do we put the knowledge that we have into practice, and what you're saying, of course, is that many of our problems, certainly not all, but many of our problems in our country are problems of lifestyle that, if we can get our people to exercise more, use proper diet, have safe sex, not use tobacco and drugs, that people are going to be a lot healthier and a lot of lives are going to be saved.

    In a free society, we can't make them do those things. We can narrow the use of tobacco in certain ways, we maybe can even outlaw that. But like drugs, even outlawing something doesn't necessarily change people's lifestyles, if they want to do it, they'll probably find a way to do it.
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    Many people believe, and Dr. Ernst Wynder is certainly a leader in this area, that what we have to do is get to our kids at an early age in their lives with these kinds of messages, and attempt to change the kind of lifestyle that they may otherwise be led to engage in.

    I wonder if you can lay out for the committee, what efforts do we have that reach children specifically, and are they being effective at all?

    Dr. BROOME. We agree with you and Dr. Wynder that this is a very important approach. That is why we have been very active in supporting comprehensive school health education programs, which attempt to educate young people, but also make them able to understand the risks and benefits, to understand the messages that they get from society that smoking is cool, and evaluate whether it's really cool to choose something that will have such far-reaching health consequences.

    We do have support for comprehensive school health education currently in 14 States, and we are working with all States in providing technical assistance on school health education programs.

    [CLERK'S NOTE.—The witness clarified that the correct number is 13 States.]

    We have also done very rigorous evaluations of the effectiveness of school health education programs, and have shown that these are effective in decreasing use of tobacco among seventh graders.
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    I'd also like to make one more general comment. I think there is understandable skepticism about the difficulty of changing human behavior. Because we all know how hard that can be. That's why I think it's really important to look at our successes, and specifically in the area of tobacco use. Since Surgeon General Luther Terry's report came out, the United States has experienced a substantial decline in adult smoking, which is not seen in Europe or other countries where there has not been the same emphasis on the health impact of smoking.

    Similarly, we have seen a dramatic decline in motor vehicle fatalities. Some of that is highway engineering, some of that is State laws regarding seat belt use, some of that is changes in cars. But some of it is changes in personal behavior, in terms of seat belt utilization.

    So I think we do have some successful models.

    Mr. PORTER. Excuse me, but a lot of that is related to drunk driving and the crackdown by States on drunk drivers across the country, I believe.

    Dr. BROOME. I think that's correct, as well. It's again an example of how sustained, organized attention to educating people around these problems and thinking about creative solutions can be effective.


    Mr. PORTER. Okay, but let me ask a question. It seems to me that education programs in schools are fine. But the medium that really reaches young people in our country and reaches all people in our country is the medium of television. And let me ask you a question about how CDC uses television and radio to get messages out on public health. Do you have to pay for those?
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    Dr. BROOME. We really have not had the budget capacity to support paid media advertising. However, we do think——

    Mr. PORTER. So who does it? Because there are public service statements made on radio and occasionally on TV, coming from CDC. Is that the stations absorbing the cost? Is it the Ad Council? Who does these things?

    Dr. BROOME. Let me make two points. One is that for example, in the tobacco area, we see advertising as part of a comprehensive campaign to educate the public, and particularly teenagers, about the risks of tobacco.

    We have a clearinghouse where we obtain media announcements developed in California, Arizona and Massachusetts with funding from their excise tax. And we make those very professionally produced and tested messages available to anybody who would like to use them. So we do provide a distribution service, if you will.

    We also do rely on donated public service announcement time.

    Mr. PORTER. But we don't buy any time anywhere?

    Dr. BROOME. My understanding is that to date, CDC has not purchased media counter-advertising. This would be part of our initiative for controlling youth tobacco smoking.

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    Mr. PORTER. See, I believe, and I know a lot of my colleagues don't believe this, but I believe that the people who use our public airways and are licensed to do so have a responsibility to the public, and the least they can do for us is carry these announcements, if necessary, on a mandatory basis, so that we can reach people with a message on a medium that they are attuned to.

    It seems to me that we do not do a very good job of combining your responsibility with the responsibility of our television and radio stations to help you get your message out to people, particularly to our young people. I think we have to have an initiative in that area, and I know some people say, ''well, you know, maybe we'll have to pay for all that time''. But it seems to me there ought to be a way of working it out with the networks and the media representatives to help you get this message out.

    Influenza, you talked about, 40 percent I think you said of our seniors who would be at risk are not vaccinated. Is that right?

    Dr. BROOME. Yes.

    Mr. PORTER. That's incredible in a country like this. If you can prevent illness and death, people I think would, and reach people with the message that these things are available, I think we're doing a very bad job of getting from where we are in our knowledge base to getting people even information that they need to make a wise choice in respect to health issues, and particularly getting a message to our children.

    Dr. BROOME. I can only agree with you. Although if you would permit me to make two other points. One is, in addition to advertising, there's a very innovative strategy for use of the media which we would like to explore further.
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    Jay Winston at Harvard has worked with Hollywood producers to introduce messages about the importance of a designated driver into the actual content of TV shows. And therefore, it doesn't look as much like, here's an ad preaching to you. It looks like part of the standard norms. And we think this can be a very powerful approach to getting public health messages across. We are looking at that with other areas.

    Mr. PORTER. Somehow we need a whole initiative, and I don't know whether it's Dr. Wynder's initiative, or one that would be brought forward by this Administration, but I think we need an initiative to reach young people in this country, and get at least their generation on the right track. I think we would save billions of dollars in health care costs over the long term and have a lot happier and healthier population if we did it.

    Mr. Bonilla.

    Mr. BONILLA. Thank you, Chairman.

    Welcome, Dr. Broome. It's a little unusual to not see Dr. Satcher sitting there. I've worked with him for so many years now on so many projects on the good work you're doing at CDC. Bill's almost extended family in our office, I think we've done so much work with him over the years.


    I want to say first of all that not just as a Congressman, but as a citizen of this country, I'm proud of what the CDC has done historically, and hope that the work can continue. On this subcommittee, we've had strong bipartisan support for what you do.
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    I want to start out, however, on cautioning CDC on delving into areas that might stretch the dollars even thinner than what you're already facing. We want to make sure the dollars that go to CDC go for legitimate medical research and disease prevention and continue the success stories. We read stories about flu hunters that have combed the globe and are oftentimes, with support with everyone at CDC.

    But when I hear initiatives like you outlined in your opening testimony about a race initiative, I'm concerned about that. Because CDC already does a lot of good work in economically depressed areas. I'm concerned that the Administration and others are split on this opinion, but I believe this is a great degree of bogus effort.

    I can cite for hours if necessary good prevention programs that already exist in Hispanic and African-American communities. Mr. Stokes and I have worked on this aggressively on this committee. But I want to just be careful that it's not part of a political effort just to pander to minorities in this country that has little substance.

    So let's be proud of what CDC is already doing and continue that, but be careful of political agendas that are occurring at a higher level. And I don't know if you want to respond to that or just accept that as a statement.

    Dr. BROOME. Well, Mr. Bonilla, thank you for your comments and support of CDC. We really appreciate that.

    I would like to say that the eliminating disparities initiative that Health and Human Services is proposing has very specific target goals, to have impact on health in minority communities. And yes, it very much builds on what we already are doing.
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    But I see it as an accountability, a way of saying, it is unacceptable to have higher rates of disease in minority communities than in the community as a whole. And we need to challenge ourselves to eliminate those disparities.

    Mr. BONILLA. Well, my contention, again, is that CDC is already doing this. So this new race initiative is just again a bogus effort to try to pander politically to minority groups in this country.

    And let me tell you, I can speak from those neighborhoods. My Congressional district is almost 70 percent minority, when you combine my Hispanic and African-American populations. There are a lot of good programs going on down there, either directly related or indirectly related to CDC, because we have some outstanding medical research facilities in that area as well.


    Related to that, last year we discussed the implementation of CDC's diabetes control program. And as you know, Texas has applied for a diabetes control grant to serve the more than 850,000 Texans suffering from diabetes.

    On page 86 of your budget justification, you state that about 14 to 15 States will be supported this year at the comprehensive level in their development of diabetes control programs. How many grants have been awarded so far?

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    Dr. BROOME. The expertise of the chronic disease center informs me that we have some funding for all States to have at least core capacity in diabetes. Five States will be funded for comprehensive diabetes control and prevention programs.

    Mr. BONILLA. Doctor, when do you expect the grant awarding process to be completed?

    Dr. BROOME. For this year, the grants will be completed near the end of the fiscal year, so that would be September.

    Mr. BONILLA. I understand that CDC and NIH, the Joint Diabetes Education Program, is now underway. Would you elaborate on the current status of this project?

    Dr. BROOME. We are very enthusiastic about this joint effort with NIH to have a national diabetes education project, which mirrors the kind of success that has been had with education projects in other chronic disease areas. We have been jointly funding this, and it is well underway.


    Mr. BONILLA. I want to get into another area that you talked about. We all agree that prevention is so critical in this day and age. In fact, it's mind-boggling to me that with all the warnings about smoking, with all the warnings about diabetes prevention, with all the warnings about obesity, that people still choose to ignore this. If you teach a person something 10 times, 20 times, 30 times, over and over, do we reach a point where we're wasting our effort, where we're wasting money?
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    In this day and age, with the media exposure we have to public service advertisements and the things that doctors, everyone who sees a doctor gets the advice from the authority face to face. And I'm just flabbergasted that more people in this country are not listening to what we're telling them. Every cigarette pack has a warning sign on it. In Texas, we have a law now that minors face if they buy cigarettes illegally. And I support that.

    But I'm concerned now, again, that some of these initiatives like the additional anti-smoking initiatives are just throwing money away, again, for a politically correct agenda that really isn't going to make a difference.

    Dr. BROOME. I think that there's a lot of difference between putting information out and having an effective prevention program. I'd like to point out several ways in which we think we can make a difference.

    Let's take the example of physical activity. And I think we all are very aware of the couch potato image that unfortunately is all too prevalent in this country. The Surgeon General's first report on physical activity put together a lot of scientific information about the risks.

    But the most important step forward was informing people that they didn't have to go out and run marathons in order to get the benefits of physical activity. Moderate physical activity also provides substantial health benefits. And that moderate activity can be very much part of your daily lives, taking the stairs instead of the elevator, walking the dog a little more actively.
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    And we're trying to follow up on that report with messages that are appropriate for different groups. For example, arthritis sufferers can very much benefit from moderate activity. We have a randomized controlled trial of the arthritis self-help course in which we've shown a decrease in doctor visits and a decrease in pain with a comprehensive self-help education course which teaches arthritis sufferers what they can do to make their arthritis more manageable.

    So I think we have some sort of specific instances where doing a better job of identifying the right messages, of working with groups, can produce benefits from that knowledge.

    Mr. BONILLA. I know I'm out of time now, but just as a closing comment, again, related to what we're talking about, I'm picturing now someone that I know back in San Antonio who has, is a single person, has no children, lots of time, and understands clearly what some of the negative impacts are of, number one, smoking, which this person does, and lack of exercise, which this person is guilty of not doing.

    Yet, in spite of being educated over and over and over again, she's now getting into her 40s, and still would rather be the couch potato.

    So I wonder, at some point, what do you say, give up on that person, there is nothing you can do. Can you spend that dollar instead to develop a great vaccine for something else? It's a tough choice, but to put it into something else.

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    I don't expect you to respond to that, because I'm out of time. [Laughter.]

    Mr. PORTER. Thank you, Mr. Bonilla.

    I want to advise members of the subcommittee that we're proceeding under the eight minute rule, and also that we are following the rule of the subcommittee that those who are here at the beginning of our hearing will be recognized first, and then those who arrive during the course of the hearing will be recognized in the order of arrival.

    The problem I have is that all the people who were here at the beginning are Republicans, and all the people that arrived late are the Democrats. [Laughter.]

    Mr. PORTER. So I guess perhaps—it's not usually that way. It's not usually that way, but let me say, maybe by enforcing the rule we'll change lifestyle here, and——


    Mr. PORTER. Mr. Dickey.

    Mr. DICKEY. Thank you, Mr. Chairman.


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    Hi, Dr. Broome. I've got an interest in prevention, and I note in your statement that we have only 1 percent of $1 trillion in our U.S. health care budget to spend on prevention. I'd like to talk about it in terms of it being an investment. And if I'm going to make an investment in something, I'd like to know if there's a return.

    Can you tell me just generally, not specifically about anything, if we as a Nation double our investment in prevention, what type of return will we get?

    Dr. BROOME. Well, I will avoid going into columns of numbers. But I would answer that we have two categories. First of all, we think it is very important to answer that question, to look at what is the cost effectiveness of our prevention activities. And in fact, we have a group which provides expert consultation to all of our programs in order to assess the cost effectiveness of those programs.

    Prevention interventions, you could broadly divide into two groups. One actually saves money. For every dollar that we spend on immunizations, the country saves money. Between $6 and $20 per dollar spent. So that's a pretty good investment, I think anybody would agree.

    There are other cost saving interventions, such as diabetes education for prevention of blindness and kidney disease, and treatment of chlamydia infection to prevent infertility and pelvic inflammatory disease. Those have been shown, with good documentation, to save money for every dollar invested.

    But I think it's a mistake to hold prevention to a higher standard than medical care. We don't ask, does heart surgery save money? We say, this person needs heart surgery, and we're willing to invest, as a society, the money in that heart surgery.
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    I would argue that prevention is a good investment, that people, I think, are willing to spend money to have a healthy life, to prevent the occurrence of that heart attack. What we are trying to do is provide the information about how much do you have to invest to get a year of healthy life for the different kinds of prevention interventions. And they compare very favorably to many health care interventions.

    Mr. DICKEY. Mr. Bonilla, my colleague, was saying people know what they should do, and still don't do it. Now, I'm still looking at this thing from an investment standpoint. Whether or not we can spend the money to inform is one thing, and but it seems that we should then somehow encourage and give incentives to change behavior.

    What we need to hear, or what I need to hear is, if we do that, can you say, looking at the whole picture, that we will in fact win the battle, or at least make some gains?

    Dr. BROOME. Well, this is an excellent example of why we feel prevention research is so important, that we don't want to just keep telling people over and over and over in ways that do not result in a change in improvement in health. And let me give you an example in the injury area of how we've looked at different ways of trying to change behavior. In this case, use of bicycle helmets.

    We have, first we supported the research that showed bicycle helmets are 85 percent effective in decreasing head injuries due to bicycle accidents. But then we said, well, it's not so easy to get kids to wear bike helmets. How can we encourage them to really use these helmets?
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    And first we looked at education programs, at giving away bike helmets, to make no cost to actually having the helmet. But we also looked at the impact of States and localities who chose to pass legislation requiring bike helmet usage in children.

    The State of Oregon did a very effective research project showing that not only did helmet usage go up after the State passed a bike helmet child use law, but head injuries went down. So we think it's important to look at the range of different ways we could use.

    Mr. DICKEY. Let's talk about obesity. You mentioned diet and exercise. Now, I don't want you to make any personal references to me in this answer, if you don't mind. [Laughter.]

    But there are numerous things, numerous diseases that you avoid by not having obesity in your life.

    Now, how can we give incentives for people who know, speaking from personal experience, who know it's wrong to be obese? What type of incentives can we give to get people to lose weight, to lose fat content?

    Dr. BROOME. We think the most effective strategies to reduce obesity are in fact the improved diet and physical activity, that those two strategies together have been, although it is a very difficult problem, it can be effective in reducing obesity.

    The issue of how to effectively have people understand that and implement it is very difficult.
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    Mr. DICKEY. Understanding is one thing. I'm not asking how we should inform.

    Dr. BROOME. Exactly.

    Mr. DICKEY. How do we give incentives to change behavior? How can we as a government give incentives? How can we as a Nation give incentives? Do you have any thoughts on that?

    Dr. BROOME. I think that this is an area which we really only recently had substantial funding for. And we've actually reorganized in the chronic disease center to put an emphasis on this. So I guess my answer would be, we don't have the answers. We do think this is a high priority area where we'll be looking at what works. If you could ask us next year, we hope we'll have some answers.


    Mr. DICKEY. Okay, let me do this. Name me some measurable items of good health. I'm probably saying it wrong. That you can actually measure without going into the hospital and being admitted to measure your blood pressure for example.

    Dr. BROOME. Blood pressure, you can take a history of physical activity, of use of immunizations——

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    Mr. DICKEY. Physical activity is subjective, though, isn't it? It's the report of the patient?

    Dr. BROOME. Right.

    Mr. DICKEY. Okay, now, let's talk about things that are objective, if we can.

    Dr. BROOME. Weight.

    Mr. DICKEY. Weight. Thank you.

    Dr. BROOME. Weight and height, which tell you together what the body mass index is.

    Mr. DICKEY. Cholesterol.

    Dr. BROOME. Well, cholesterol takes a lab measurement, but that's certainly one of——

    Mr. DICKEY. It is objective, and that's not a real big cost, is it?

    Dr. BROOME. No, and we think that's an important part of preventive health services.
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    Mr. DICKEY. And what other items could we measure objectively without a great cost? Is there anything else?

    Dr. BROOME. Dr. Gayle wants me to be sure and mention sexually transmitted diseases, which we can measure objectively.

    Mr. DICKEY. No comment. [Laughter.]

    Dr. BROOME. And I would argue that in fact, self-reporting, although not perfect, has been shown to be reasonably reliable. People, there's sort of a fudge factor, but you can——

    Mr. DICKEY. That's the problem. Well, is my time up? I'll come back later. Thank you.

    Mr. PORTER. Thank you, Mr. Dickey. Mr. Stokes, by reason of his being ranking on VA–HUD, has requested an exemption and is recognized next.

    Mr. Stokes.

    Mr. STOKES. Thank you, Mr. Chairman. For the record, that subcommittee starts at 9:00 o'clock in the morning. Therefore, I could not be here at 10:00. Otherwise I'd beat all those Republicans here. [Laughter.]

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    Dr. Broome, let me start with the question that was posed to you by Mr. Bonilla. And, I'm sorry Mr. Bonilla's not here now, because I think he asked a very important question. I think it's one we should address appropriately, and you're the appropriate person to address it.

    I've been sitting on this subcommittee for more than 20 years. For more than 20 years, I have had to, year after year, probe about the disparity between minority health and majority health in this country.

    In 1985, the Department of Health, Education and Welfare, under Secretary Heckler, issued a report that said that there are 85 thousand excess deaths in the minority community, and cited six specific areas: heart attack, stroke, cardiovascular disease, suicide, homicide, and I believe diabetes was the other where we have these excess deaths.

    Ten years, later in 1995, there was a ten year update. That report found that the country still had a serious health disparity between minorities and white Americans. The President's initiative, as I understand it, is designed to seriously attack this problem where African-Americans die seven years earlier than white Americans, in every category of disease from cancer, to cardiovascular diseases including heart attack and stroke. There's a very serious disparity between white Americans and black Americans. And the President is trying to attack these problems frontally with these types of initiatives.

    Now, I see in your budget you address this. Would you explain for Mr. Bonilla's sake, for my sake, and for the Nation's sake why the President is doing this, and why this is not pandering. This is a President trying to be sensitive and responsive to the kind of disparity I've addressed.
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    Dr. BROOME. Well, I think this goes back to something that we as an agency really believe that what gets measured gets done. And I think the difference is that we now have specific targets, both for the year 2000 and the year 2010, for decreasing and then eliminating the different, increased burdens of disease seen in minority populations.

    As Mr. Bonilla noted, we already have a number of programs which address the disproportionate health impact in minority communities. And we have made progress, but not enough, as you point out. This is something that has been known for a long time.

    We believe that having these very specific targets will help us work with our own programs and with our partners to measure our progress and to make those goals. So we feel that this really is raising this to a different level.

    And I don't know, I assume you are familiar with the Year 2000 goals for the Nation. It's another example of having goal setting. We haven't met all of those. But by focusing attention on those programs, we have made progress. And we have influenced how our partners and State and local health departments and community organizations measure what they are doing.

    The Year 2010 goals are under preparation. There will be no different goals for different ethnic and minority populations in the Year 2010 objectives. We will have a single objective for the country.

    Mr. STOKES. A few moments ago, Ms. Pelosi, who sits next to me, showed me your chart.
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    Dr. BROOME. We have a big one.

    Mr. STOKES. Can we refer to it for a moment?

    She was pointing out to me the disparity in terms of the AIDS case rate in persons 13 years of age, which is shown on this chart, where you can see the red block, which is marked white, and next to it the yellow block. I understand that in the next hour, seven Americans will become infected with AIDS. Three of the seven will be African-Americans. Is that correct?

    Dr. BROOME. That's right.

    Mr. STOKES. Talk about that chart a moment, so we can understand what the President's trying to do here.

    Dr. BROOME. Okay. The occurrence of AIDS in African-Americans is seven times the rate in white Americans. And we consider this an indication of an urgent health crisis.

    The prevention programs, there are two particular areas of activity that we're focusing on. One is prevention of new infections in the first place. And this obviously is a primary goal of CDC AIDS prevention activities.

    In the minority community, we have targeted prevention activities toward minority communities in several ways. Most fundamentally, we use the community planning process, which tries to have local areas identify their priority groups and how they should be approached in terms of preventing AIDS.
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    In addition to that, we have directly supported 94 community-based organizations to address minority AIDS and HIV issues. In addition to that, as has been noted in previous budget increases, it's very important for us to address the prevention of HIV/AIDS in populations who use drugs intravenously. And this has affected minority communities disproportionately.

    We feel that it's very important, because of the increased rates of HIV/AIDS in minority communities, that we be sure our prevention programs are reaching those populations and having an effect.

    The other major issue for minority communities is being sure that they have access to treatment. As you all know, we've had a very encouraging decline in AIDS deaths nationally. However, that decrease has been much more striking in white groups than it has been in minority populations, such as African-Americans. We're very interested in working with our colleagues in the health care area to be sure that treatment access is also addressed.

    Mr. STOKES. But, would you say from your chart that AIDS has reached what we would describe as a disaster area in the United States as it relates to African-Americans?

    Dr. BROOME. I think that it is a very serious crisis for the African-American community. Our surveillance data have identified this, and we are actively working with African-American organizations to address it.

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    Mr. STOKES. My time has expired. Thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Mr. Stokes.

    Mrs. Northup.


    Mrs. NORTHUP. Thank you, Doctor. I'd just like to respond, if I may, sort of in a statement form for a couple of minutes about some of the things that were discussed previously. And in emphasizing how important I think your education programs are.

    I think changing behavior is enormously difficult. I think every single person can think of resolutions, to go to bed earlier, to lose weight, to exercise every day. And you do it incrementally—two steps forward, one step backwards.

    I think it's very hard to measure change over three months as opposed to over three years. Do you, over three years, learn to eat less fat? Do you, over three years, start eating more vegetables? And those are the kinds of changes that humans can accomplish in the long term? But it's very difficult in a day to day basis.

    But I do think that education is very clearly effective. Overall, we know that the more health education a person gets, generally they adhere to better health processes. It slowly makes a dent into our subconscious. Anybody who is a mom or a dad and tries to help a child change a habit knows that you don't wake up one morning and give your child a one page explanation about why they should start studying or be more organized. You help them every day for years become a more organized person.
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    And that's why I think CDC's general effort to educate and target is so very important. I'd like to specifically apply that to tobacco.

    We can say that everybody knows that it's not good to smoke. And if you go into probably any classroom where you have 7 or 8 year olds, you will see every child raise their hand and say they're not going to smoke. We're so involved in the class of 2000's effort to have a smoke-free class of 2000. Every seventh grader was so proud to be a part of that class.

    Yet if you go to the graduating classes, the class of 2000 that are now sophomores, you find an enormous number of those children that smoke. So even though they get the information on health effects, they are also subject to $10 million of advertisements every day in this country, every day, $10 million of advertising, connecting being popular, being cute, being successful, being liked by everyone, related to smoking.

    And when you become 11 years old, knowing that your mom and dad think you're great isn't your only objective. [Laughter.]

    It was the most heartbreaking thing I learned when my oldest became 11. And when they're 12, they want to know in seventh grade, of course my mom thinks I'm handsome, does the kid that sits next to me in class think I'm neat. And the first time they show up at a mixer, they think, how am I ever going to stand out as a person? The shortcut of having a cigarette with their peers is something that is innate in them because of the years of advertising that exist in this country.

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    That is why it is so important that we have an effective counter-advertising strategy.

    Now, Mr. Chairman, I have to tell you I disagree, I don't know why the TV stations should bear the cost. I don't know why the tobacco companies shouldn't bear that cost. If they're the ones that have created this atmosphere that smoking is so neat, and they say they don't want 13 year olds to smoke, then why don't they also fund the program to effectively target 13 year olds.

    Mr. PORTER. Okay, I agree with that. [Laughter.]

    Mrs. NORTHUP. I just had to get that in. [Laughter.]

    And I'd like to point out that it's not public service announcements. The neatest ad I ever saw was the one in California where it shows on a park bench two 13 year olds starting to kiss, getting closer and closer, and at the very last minute, the little girl says, ''Yuck, your breath smells like smoke.'' [Laughter.]

    And you know, that message gets to kids in a way that a public service announcement doesn't.

    So I just want to really encourage you to continue your efforts with the States that have incurred this cost themselves and to make it available to help direct public policy in that direction.

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    You pointed out that adult smoking has declined. I think it's true, it's because of education. But you did not mention youth smoking, and the last time I saw, that was going up. Is it still going up?

    Dr. BROOME. This is something that is of great, great concern to us. Youth smoking has increased. That increase tracks along very well with increasing advertising and promotional activities on the part of the tobacco companies.

    The only somewhat hopeful sign is that in the States, California, Massachusetts and Arizona, that have had very well-funded, extensive tobacco prevention programs, the rate of increase is substantially less. It's not good enough. We want to prevent youth smoking. But it does appear that comprehensive tobacco prevention programs can be effective.

    I couldn't do a better job of describing what those prevention programs might look like than you already have. I would just add two additional points. Those media campaigns don't just emerge. They need to be part of a well-designed health communication strategy which tests the message, which sees whether it's having the desired impact and alters the campaigns as needed. The materials that we are distributing have been through that kind of process.

    Secondly, we're very optimistic about a campaign called Media Smart, where we try to educate teenagers about how they are essentially being manipulated and fooled by commercial advertising. Teenagers don't like to be fooled or to look stupid.

    We think there is some opportunity to make them smarter targets of advertising, and better able to discern what the companies are really trying to do.
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    Mrs. NORTHUP. Well, I'd like to also point out that we have heard so much from the people that have come before us this week in support of the Administration's position on the tobacco settlement that offsetting the tobacco companies advertising could be done cooperatively. That is by them agreeing not to do so much advertising, which has been so effective.

    But we cannot do that by law. That has to be a cooperative effort that was part of a negotiated settlement.

    Now, we all know, and they know, that we have to change that settlement. It doesn't have the support base it needs. But one of the ways of changing the atmosphere and the way kids think is by having them not bombarded, and by also quite frankly, having the tobacco companies have to incur a bigger penalty if youth smoking keeps going up.

    And if we don't have some sort of negotiated settlement that includes a cooperative agreement to reduce advertising and to share in the burden if youth access goes up, we are going to find ourselves doing one thing and having very smart companies that haven't bought in find another way through the cracks. I'd really like to encourage the Administration to, rather than just sign on a unilateral bill, to put together a bill that has the cooperative effort, different maybe, but cooperative effort of what was proposed. Because we cannot negotiate that through 435 members of Congress.

    Dr. BROOME. You made an absolutely crucial point, and that is our ability to monitor what's going on. CDC, particularly the National Center for Health Statistics, has developed in consultation with experts in the academic community a very specific proposal for how we could do effective monitoring of youth smoking, of youth starting to smoke. So we would know what effect our programs are having.
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    Mrs. NORTHUP. Okay.

    Mr. PORTER. Thank you, Mrs. Northup.

    Mr. Miller.

    Mr. MILLER. Welcome, Dr. Broome.


    Before coming to Congress a number of years ago, I was a professor at Georgia State University in Atlanta. I taught statistics. My first lecture in statistics was always how to lie with statistics. It's an interesting lecture I used to do, because it was entertaining and it shows how you can prove any point using statistics.

    There's no question there is a statistical disparity between blacks and whites, on, for example, AIDS. But is that really the best statistical measure? What about income, education, families? What do the statistics really show? what is the real cause?

    So answer that question, if it's income, then we should target all low-income people.

    Dr. BROOME. Well, I love to get these kinds of questions, because my background is actually as an epidemiologist. What I ask people all the time is have they separated out the effects of income, of particular geographic locations, or other variables?
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    In this instance, and I think it's also important to point out that we use race as a variable which can be a marker for many different and complex risk factors. Being clear about what the particular problem is lets us tailor an intervention to that particular area. Having said that, when you look at income, there still is an increased risk among minority populations for HIV/AIDS.

    There is also, and again, the issue of how to address that, you have to look at some of the different risk groups. Some of that is heterosexual transmission, some of that is transmission related to intravenous drug use. Some of that is transmission related to poverty. That means that it's not uniquely African-American or Hispanic. But we do need to look at the particular circumstances in a particular population.

    That's again why community planning has been so important in trying to design prevention strategies that are appropriate for individual communities.

    Mr. MILLER. I always have a concern about creating new programs, because I think we have too many programs in the Government right now. Are there not better variables than just race on these issues? Is that really the best variable to work with? What would be the best variable, for example, in AIDS?

    Dr. BROOME. We look at it in many different ways. One of the most traditional has been the particular risk groups and means of transmission. That's where you divide sexually transmitted, transmitted in the early days by blood transfusions, transmitted by intravenous drug use. And those are important ways of looking at it, because they suggest what's the appropriate prevention strategy.
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    But it's also important for us to understand the epidemiology which may be quite different. For example, in rural communities and in urban communities. There really isn't a one size fits all solution.


    Mr. MILLER. We can talk some more about the issue of what is the best variable, and whether are we are just creating programs. But in my limited amount of time, let me switch to another subject. An area that I personally had an interest in over the past years, and I've brought it up with Dr. Satcher at hearings, is the issue of blood safety, of our blood system.

    I have a special interest in hemophilia. In last year's report language, the committee encouraged CDC to enhance its support of a comprehensive blood safety surveillance and patient outreach effort to address the hemophilia product safety concerns, to ensure that these resources were available for broad implementation of this important public safety program. Additional funding was provided for this program in the conference agreement.

    It is my understanding these funds have been allocated, but that a first-time internal charge for administrative costs was assessed at the same time, essentially leaving the effort at status quo. Could you tell me more about the administrative assessment and why the hematological unit has been charged with this assessment for the first time?

    Dr. BROOME. Let me see if I can get the name of the bill right. The Federal Financial Accounting Improvement Act of 1996 required us to look at how we assess costs for our different activities, including grants and cooperative agreements. So we have had an outside consultant look at our accounting practices and recommend how the very real costs for administering grants are allocated.
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    And the recommendation identified that historically, for various reasons, CDC had not been charging overhead on grants and cooperative agreements. This was judged quite inappropriate from correct accounting practices terms. The recommendation was that CDC should be charging 1.97 percent overhead on grants and cooperative agreements.

    So not surprisingly, programs count on every dollar, and they would like to see that all dollars go directly into programs.

    Mr. MILLER. Are we making any progress in this particular area?

    Dr. BROOME. We are, actually. I would much rather focus on what we have been accomplishing. We have supported surveillance in federally funded treatment centers for hemophilia, and we're seeing decreased mortality in individuals enrolled in those treatment centers. We also are improving our ability to do surveillance on the blood supply for a range of organisms that might be risk factors. And the hemophilia population has been very collaborative and very anxious that we have effective and improved surveillance systems.

    I think it's worth emphasizing that the blood supply in the United States is exceedingly safe. And we have learned from the kind of emerging infection crisis that AIDS caused with the blood supply and the hepatitis B and hepatitis C concerns to rapidly identify new threats, to get the screening tools which will let us keep infectious blood out of the blood supply system.

    But we can't—this is a human product, so it's hard to guarantee absolute safety. But we have developed new diagnostic tools. We're looking very hard at Creutzfeld-Jakob disease to see whether there's any indication that this could pose a risk. We're looking at new tools for Chagas disease, for example.
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    So I do think we are working very hard to be sure that we have the safest blood supply possible.

    Mr. MILLER. Do you need any more resources to implement this safety program? I know everything needs resources, but is there something special?

    Dr. BROOME. We have certainly used some of the emerging infections resources to address the blood safety issue, and also the support for the hemophilia program has been very key in monitoring the safety of the blood program. There's always more we could do. But we consider this a very high priority.

    Mr. MILLER. Thank you, Dr. Broome. As I said, I look forward to getting some more information about the justification for statistically, that we're just not doing it for political purposes, but there is a real statistical validity to this method of creating new programs.

    Dr. BROOME. We'd be delighted to get you all the cross-tabulations.

    [The information follows:]
    "The Official Committee record contains additional material here."

    Mr. MILLER. Not too much.

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    Thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Mr. Miller.

    Ms. Pelosi.

    Ms. PELOSI. Thank you very much, Mr. Chairman.

    And thank you for the eight minutes. I hope it's the same eight minutes that my Republican colleagues have used. [Laughter.]

    Dr. Broome, thank you for your excellent testimony. I join with our distinguished Chairman in commending you on that statement, but also for your excellent work.


    As we all know, the charge of the CDC is promoting health, preventing disease, injury and premature death. So in the interest of promoting health, I think one of the issues before us that I hear my colleagues talking about is why do people not get the message. I think the answer is that we send mixed messages.

    For example, as I said yesterday, we tell children education is important, yet we send them to schools that are falling apart. If it's important, then let's make it important across the board.

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    We talk about health and we look at this chart, yes, we can probably extrapolate from that chart that many of the people in the yellow column are poor. But as you honor your charge in promoting health, preventing disease, injury and premature death, and we try to send a message to people to change their behavior, whether it's tobacco, which was appropriately emphasized here, or whether its unsafe sex practices, etc., we should also send a message to the communities of America, rich, poor or otherwise, that promoting health is important, and that we make it a priority by giving access to everyone to quality health care.

    Until we do that, I think we're fooling ourselves. First of all, our message is a confused one. Health is important, but you can't afford to have it, or we can't make it accessible to you. And if you happen to be minority, then you will have all these increased instances of poor health as well as our distinguished colleague, Mr. Stokes, pointed out.

    He emphasized that, as you will recall, in our visit to the CDC when some of our colleagues came down there, and you welcomed us and gave us a report on what you were doing. That was very beneficial.

    But it was also very important for us, as far as Mr. Stokes was concerned, to convey in the area of HIV that our prevention efforts have to be much more specifically targeted. I appreciate your emphasis that you have made on community-based solutions. Certainly Dr. Helene Gayle is an expert in all of this, and I commend the CDC for the extremely important work on HIV prevention that you are doing.

    Today that work is crucial, as we've discussed. At least one more American is infected every 13 minutes. With every passing day, the newly infected person is more likely to be a woman, a young person, or a minority.
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    CDC has been on the front lines in the battle against HIV. And given your effort, I was disappointed that CDC HIV prevention activities were flat funded in the Administration's budget.

    Mr. Chairman, with your leadership, and working with Mr. Obey, this committee has responded to the urgent need for more resources for care for people with HIV. That funding has made a tangible, real difference.

    But we must also prevent disease. That's the best dollar spent.

    So I would ask you, if you were able to find substantial additional funds over and above the Administration's request to help you respond to the epidemic, how would you use this additional funding to fight HIV?

    Dr. BROOME. I couldn't agree with you more on the crucial importance of prevention. We still do not have a permanent cure for AIDS. So the best approach remains to prevent getting AIDS in the first place, getting HIV infection.

    I think it's worth emphasizing that, there is some attention to prevention of AIDS in the President's budget request, specifically in the demonstration projects for eliminating disparities in health. Five million dollars is specifically directed to AIDS prevention.

    In addition, we are hoping there will be an additional $10 million specifically for syphilis elimination, which as you know, can have a dramatic benefit also in AIDS prevention, HIV infection prevention.
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    So there are two specific areas which will very much be targeted toward eliminating disparities.

    In addition I think that there are a number of areas where there are new opportunities for improving our HIV prevention activities. As you know, we have a very good tool for markedly decreasing perinatal transmission. We want to be sure that every pregnant woman in this country gets counseled and tested.

    We are already seeing over 50 percent declines in infant HIV infection. This is wonderful news related to the use of AZT. We also feel we've got very good levels of AZT treatment of pregnant women. But we want to be sure that's available.

    Ms. PELOSI. Dr. Broome, I appreciate your response. And I want, before my Chairman leaves, not to neglect to say how pleased I am with other increases in funding that the Administration has put in the budget, for new ADAP drugs and Ryan White care and other priorities. It's just the prevention piece I was concerned about.

    And in the interest of time, if I might just ask you about something you've mentioned a couple of times in relationship to the answer you're giving now, and that is, you've talked about the community prevention planning process as a model of local decision making, which allows each community to respond to its particular prevention needs in this diverse and dynamic epidemic.

    As you know, we've had some concern about who's getting the grant money, especially in the minority community where the competition has been keen. Can you tell me about how the CDC helps community-planning groups get access to the latest science-based prevention research at CDC and NIH? Because we believe that the prevention must be science based. We believe, though, that has to be conveyed to these groups making application for grants.
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    Dr. BROOME. Well, we agree with you as well, and we're doing that in several different ways. One is through the use of high quality surveillance data. We need to know where the epidemic is going, so that we can be sure our prevention messages are reaching the groups at highest risk. This is one of the reasons why we are putting forward a major consultative effort to be sure that we are tracking HIV infection, rather than AIDS cases.

    With the new improved treatments, AIDS cases are markedly delayed and do not reflect where the epidemic is today. So we and our partners are generally agreed that HIV surveillance is an important tool.

    There certainly are still ongoing discussions about exactly how that surveillance should be conducted. But we will be developing a guidance for State health departments for comments.

    In addition, there is certainly specific technical assistance that's important both for community planning groups and for community-based organizations. We do provide support both within CDC and also specific technical assistance groups who have the latest research information and can make that available to community planning groups.

    Ms. PELOSI. Thank you, if I may, on another subject——

    Mr. DICKEY [assuming chair]. Ms. Pelosi, I want you to know that you're proceeding only because I don't have enough nerve to keep you quiet. [Laughter.]

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    Ms. PELOSI. Well, anything that works. [Laughter.]

    I'll be brief, Mr. Chairman.


    The Administration's budget would direct $145 million to maintain State-based programs as part of the National Breast Cancer and Cervical Cancer early detection program. Can you tell us about your successes there and what you see as the most crucial needs and best prevention methods, and opportunities in women's health?

    Dr. BROOME. We think that this has been a very successful program, and we very much appreciate the support that it has received. Through 1997, we have screened over 1.3 million women for breast and cervical cancer. We have detected 23,000 early or pre-cancer lesions in the Pap tests. This kind of early detection directly saves lives. We believe cervical cancer should be a completely preventable disease.

    Now, in addition to the screening program, you can ask, well, why haven't we completely prevented cervical cancer deaths in this country. And that's why we think the cancer registry program is very important. What we're doing is looking at where cancers are occurring.

    The State of Rhode Island has done a very creative program which shows that in older women, the cancer deaths are occurring because they tend to see internists who don't think about doing Pap smears. So we can then tailor our screening programs to reach those women.

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    Ms. PELOSI. I think they're doing them every five years or so for older women now.

    The tyrant, the clock, not our Chairman, beckons us, Dr. Broome. But I want to thank you again for your extraordinary work. Certainly, we miss Dr. Satcher, but he's still there, in a new position. But he made a valuable contribution to CDC, we all agree on that.

    I also want to commend the Clinton Administration for the demonstration projects to reduce health disparities in minority populations. I think that is a very, very important initiative, science-based, and that promoting your mandate at CDC in that context is the most appropriate approach for you to take. I commend the Administration and you for that.

    Thank you for your testimony and your answer.

    Mr. DICKEY. Dr. Broome, I am certainly supportive of the Federal dollars——

    Ms. PELOSI. Are we having a second round?

    Mr. DICKEY. No comment. [Laughter.]


    I am certainly supportive of the Federal dollars that have been pouring into medical research. However, I am concerned that we might be investing too much in research and too little in the dissemination of facts to the general public.
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    In your opinion, are we bringing in the research in a fashion the public can use it? And then, as a second question, or do you believe we are investing in prevention at a rate that adequately complements our investment in research?

    Dr. BROOME. Well, given my scientific background, I do believe that additional research yields additional benefits. What we would argue is that it's crucial that the public gets the benefit of those research results, that it's complementary that we invest in turning research results into prevention programs.

    I think it's fair to say, when you look at the 1 percent of the $1 trillion dollar budget which is invested in prevention, that's not a reasonable proportion, given the value that I believe the public places on prevention.

    We've actually just seen a Harris poll in which 93 percent of persons contacted felt that it was very important that there were programs to prevent the impact of infectious disease. And the other 7 percent thought it was somewhat important. Similarly, 82 percent thought that it was very important to have programs which supported clean water, clean air and dealt with toxic substance health effects.

    So I think the public support is there for prevention programs.

    Mr. DICKEY. What I'm saying is almost heresy, that we might have too much research, but I'm not saying that. What I'm saying is that if we don't let it out, if we're constantly letting our research just exist in the boot camp and we don't go out and actually go to war, it doesn't do a whole lot of good.
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    Are you brave enough to really discuss that?

    Dr. BROOME. Well, as a health agency, we've always tried to avoid military metaphors. [Laughter.]

    Mr. DICKEY. Then let's talk about football. [Laughter.]

    Dr. BROOME. But we feel that CDC is really in an excellent position to take the results of research and put them into practice. We have, as you know, we were very appreciative of your visiting. I think you saw the range of programs that we have. We have an incomparably trained intramural staff. We have outstanding partners in States and in the private organizations to really use the research findings today.

    We are, I think, really very good at taking something like, for example, the smoke detector findings and using them to protect people. In Oklahoma City, we found that installation of smoke detectors in the highest risk part of Oklahoma City decreased burn injuries, hospitalized burn injuries, by 80 percent, while the rest of the city was going up 30 percent.

    We have taken the information and encouraged our injury prevention programs in other States to use that approach to decreasing burn injuries.

    Mr. DICKEY. Excuse me, we're going to have to declare a recess. Obviously my colleagues don't care about my voting. [Laughter.]

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    But one good thing is that this is not the second round. So no one knows about this if you won't tell them. [Laughter.]


    Mr. PORTER [resuming chair]. The subcommittee will come to order.

    I'm going to ask a question until members of the subcommittee return.


    Dr. Broome, let me ask you about needle exchange and needle distribution. As you know, our appropriations act that was passed last year prohibits the use of funds for needle distribution projects, but permits the funding of needle exchange projects after March 31st, subject to certain findings by the Secretary and certain guidelines prescribed by the Secretary.

    The Administration has been involved in the needle exchange debate for several years. Legislation that permits such programs under the circumstances I just described was signed by the President five months ago.

    Nevertheless, we continue to get mixed messages from the Administration about its policy on this matter. Recently, General McCaffrey was quoted as indicating that such programs were perhaps not the right way to proceed in fighting illegal drugs.
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    Does the Administration have a unified policy regarding needle exchange projects, and if so, what is it? If not, why, after all this time, does the Administration not have a unified policy on this important issue?

    Dr. BROOME. I don't think that I'm expected to speak for the entire Administration. I do think it's important that we emphasize that there is an epidemic of HIV/AIDS among intravenous substance abusers in this country. And I think the Administration's position really was summarized in Secretary Shalala's February 1997 report to Congress, which concluded that needle exchange can be an effective component of a comprehensive strategy to prevent HIV and other blood-borne infectious diseases in communities that choose to include them.

    The Department is continuing to look at the issue, and has not yet concluded that the conditions set forth by Congress have been met.

    Mr. WILLIAMS. I think it is as you stated, the evidence is fairly strong that needle exchange programs have an effect on AIDS. That evidence is less clear with respect to drug use. So I think the Administration supports continued looking at needle exchange programs that are started by local communities to continue to gather evidence on this. But until that evidence is more conclusive, I think the Administration continues to support the two-prong test as it has existed before.

    Mr. PORTER. Mr. Williams, I would direct the Administration to look at the program in Baltimore by Dr. Belinson. I think it has done very well in both respects, and might be the model.
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    Ms. DeLauro.

    Ms. DELAURO. Thank you very much, Mr. Chairman.

    We're delighted to see you here, Dr. Broome, thank you very, very much for your testimony.


    I was struck by this chart, investment in prevention. I understand while I was gone, my colleague Mr. Dickey made reference to the research budget. But I just wanted to comment that this is, total U.S. health care budget equals $1 trillion, 1 percent equals prevention.

    And it just seems to me that I think that we who are asking the questions are incredibly self-serving and maybe somewhat disingenuous and insincere when we talk about spending 1 percent of our health care budget on prevention and then we start to talk about how we are stopping children from smoking by what we're doing in terms of prevention.

    How are we stopping illness in a variety of directions, whether it's AIDS or whether it's any other area, that in many cases, when you think about it, we who do appropriate money and resources here, and then we stand here and sit here and say, why haven't you done all of this, why haven't you ended the AIDS epidemic, why haven't you stopped people, why haven't you changed your behavior with what you've done.
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    Again, I've made the point, I think this is really the height of the wonderful Yiddish expression, which is chutzpa, that we don't provide the resources, the serious resources, to deal with prevention on the scale that we need to in order to truly try to make a difference.

    That being said, that being said and what I want to do, because you have done an unbelievable job at CDC, and I compliment you for what you have done. You have made a difference in the lives of people in this country. And in fact, it is, how do we prevent disease. What is that cutting edge of medical research that is going to allow us to do that.

    I want to hear something from you about, you know, what are the prevention programs that have been the most successful? How do you measure those results? What is your sense of what we could be doing, what we are and could be doing that is in effect going to help us save money in the long term? And can that be accomplished, in your mind? Can we get to the goal that we would like to get to, if we have the will to do this?

    Dr. BROOME. Well, thank you very much for those comments. We do feel a real urgency in trying to apply the prevention tools that we have. Women should not be dying from cervical cancer in this country. Our senior citizens should not have the kind of burden from influenza and pneumonia that we could prevent with influenza vaccine.

    I think I tried to outline in my testimony only a few of the areas where we have interventions that work, and they're being used, but not as completely as they could and should be, whether that's influenza vaccine, getting the coverage up from 60 percent to, as with childhood immunization, we've reached 90 percent with the kind of substantial investment that has been made and the kinds of commitments on the part of all of our partners. We should be able to do the same with our seniors. Similarly, chlamydia is an excellent example, where we have shown by a very orderly approach, starting with the basic research randomized controlled trial, to show that detection and treatment of chlamydia works, and then implementing that in States as we've had the funding available.
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    And we estimate that the impact on preventing infertility, the impact on preventing pelvic inflammatory disease, is very substantial and cost saving. So that we have, as feasible, expanded those programs.

    There's a number of other examples I can give, but we do agree with you that we have tools, and we would be very happy to use those nationwide.

    Ms. DELAURO. Well, just a final comment on that, and then I'll move to one or two other things. But I think that we truly do, if we are sincere about this effort, need to work with you. We've got to, in a world of limited resources, but we've got to identify where our priorities our, if we do know how to save people.

    And it isn't a question of geography when it comes to cervical cancer, is that where you've got a center, that determines your ability to survive. We need to take a hard look, if we are going to sit here and evaluate, and we're going to sit here and make pronouncements on whether you are a success or a failure at what you are doing to stop these, then I think we have got to, you know, step up to the plate here and sit with you and others of you and our colleagues in this committee in particular, and figure out where we don't have that sliver of a line we're talking about prevention of illnesses and diseases in which we truly know today we can make an impact.

    So I think that we have to have that as a goal for those of us who are here.

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    Let me just mention, because you've answered lost of the questions on the tobacco control, we have today with all the outreach, etc., 3,000 youngsters who are smoking every day, a third of whom will die from tobacco-related illnesses. This is once again another area, 420,000 people die every year from a tobacco-related illness. My God, if we had an outside force coming in and killing 420,000 of our people every year, we would determine this an external threat we couldn't live with, and we would figure out how to mobilize and go after it.

    This is in fact what some of us are trying to do in this area, particularly to start with our youngsters. So I applaud your efforts here and the outreach that you are making. I would love to have a conversation with you at some point about something that we have done in the Third Congressional District in Connecticut, which is called the Kick Butts Connecticut Campaign with middle school children and the use of the broadcast media, as our Chairman has talked about. But the use of the community and of getting kids to go, middle school children going into elementary schools and help prevent their peers from starting to smoke.


    I am interested in the WISEWOMAN project, which established three demonstration clinics through the breast and cervical cancer program to more fully meet the health care needs of high-risk populations. And in fact, we do have high-risk populations. I understand that you have some preliminary results from the project. I wonder if you would share them with the committee, and what would be gained by expanding that project.

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    Dr. BROOME. Okay. I'm delighted to report back to you on the results of the demonstration projects that the committee supported. This is an attempt to actually be very efficient in delivering our prevention activities by combining other prevention services with the breast and cervical cancer screening program.

    The Well-Integrated Screening and Evaluation for women in Massachusetts, Arizona, and North Carolina, or the WISEWOMAN program, has been implemented in three States. In addition to breast and cervical cancer screening, it provides high blood pressure checks, cholesterol checks, physical activity, diet, and smoking counselling. We have provided those services to over 4,000 women.

    I think one of the most interesting results is that we have identified 50 to 75 percent of the women screened who have increased blood pressure, which is a very direct risk factor for cardiovascular disease and stroke. We've been able to refer those for treatment.

    Ms. DELAURO. Quickly, do we have enough results here to understand that what we could do in terms of prevention, If we expanded this program? If we were in 50 States, what our benefit would be in terms of reducing the risk here?

    Dr. BROOME. I don't have those numbers right at the tip of my fingers, but we would be very happy to get those for you.

    Because we do think we have some promising results.

    [The Information follows:]
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    In order to better understand the health benefits in many other populations, CDC needs to expand the WISEWOMAN program to target other populations such as Urban African-Americans, Western Native Americans, Cuban-Americans, and border populations. CDC would like to increase the number of States authorized to receive funds under the WISEWOMAN demonstration program from three to eight States. By expanding this program to five additional States, CDC will be able to develop valuable insights into the feasibility of and benefits of integrated preventive services and test other interventions, such as, the Arthritis Self-help Course.

    Health benefits of expanding the WISEWOMAN program are based on results from the three current demonstration projects:

    More than half of the uninsured and underinsured women who participate in the NBCCEDP WISEWOMAN sites have high blood pressure or high cholesterol and more than two-thirds are overweight.

    In Arizona among Hispanic populations, 1 of every 10 women have high blood glucose values.

    In North Carolina among white and African-American women, a simple counseling tool aimed at improving diet and physical activity was provided to participants. Their diet improved; physical activity increased, and cholesterol levels decreased on average by 4% within one year.
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    In Massachusetts among an ethnically diverse group of women, who participated in an intensive intervention that provided community education and support, diet improved, activity increased, and the percentage of women with high cholesterol will likely decrease on average by more than 25% within one year.

    Results from the Massachusetts program show that WISEWOMAN participants had a higher return rate for annual mammograms than did nonparticipants (60% vs 31%).

    Ms. DELAURO. Thank you very much, and thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Ms. DeLauro.

    Mrs. Lowey.

    Mrs. LOWEY. Thank you, Mr. Chairman, and welcome, Dr. Broome.

    I do want to express my personal appreciation to you and the CDC for all the important work you're doing. I want to move on to some other areas, but I do want to associate myself with my colleagues, our distinguished Chairman, and others on the committee, with our frustration with prevention, that we're not spending enough money. And the money we're spending, frankly, isn't working as effectively as it should.


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    I co-chair a teen pregnancy prevention task force in this Congress, which is bipartisan, with Mike Castle. We've seen many of the studies, and we're trying to fund additional studies to show what works and what doesn't work. An interesting report which recently was released from Harvard shows that the PSAs frankly don't have that much impact. The story lines, the programs which our Chair referred to, do have impact.

    We continuously ask public television and other members of the media what we can do to get positive messages in the programs that the kids watch, or if they're positive messages, why won't they watch. How can our creative talents be put to work encouraging programming that kids will watch.

    An interesting statistic which I just heard this morning, is that most people in America get their health information from a program called ER. Now, that's amazing. I find that extraordinary.

    So I won't pursue this line of questioning, and I'd love to talk with you and have follow-up meetings. But how can we better get the media involved, get our creative talent involved, in creating messages through programs that the kids will watch, so we can impact this critical question, what do we do about the health consequences?

    We know the information, why can't we get it across, to even people like us, whether it's obesity, smoking, or alcohol use, etc?

    Briefly, before we go on to a couple other questions, I know you are doing a study on teen pregnancy. And we would like to have any information available or would you prefer waiting until the study is released? If you have anything to share with us on what works and what doesn't work, that would be very helpful.
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    Dr. BROOME. We do have 13 demonstration projects. At this point, I think it would be premature to provide results, but we'll be very happy to get those to you as soon as they're available.

    [The information follows:]


    The 13 Community Coalition Partnership Programs for the Prevention of Teen Pregnancy funded by CDC entered the first year of their implementation phase in October of 1997. In this phase, the communities will field test and implement a broad array of interventions based on their needs and assets and on information regarding best practices and each community's values and expectations regarding youth. The implementation phase is for five years and will involve a process evaluation for each community as well as an enhanced evaluation of either outcome or programmatic impact in six communities. As results from these evaluations are obtained, CDC will disseminate the findings. CDC will also share lessons learned from field testing activities coducted in the communities.

    Mrs. LOWEY. I'd appreciate that, and then I'm hoping we can work together with the national campaign and with our task force.


    Another area that I think is so important, I was delighted to see your report on assisted reproductive technology success rates. We all have friends or family members that have spent enormous amounts of money on fertility treatment, plus going through an agonizing period. It's so important for them to know what works and what doesn't work.
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    I worry about charlatans, these people are spending, as I mentioned, enormous sums. Can you tell us something about this report, and frankly, since this report was released for 1995, where are you with the 1996 report? How are we progressing? Are there model standards on assisted reproduction laboratories?

    Thank you.

    Dr. BROOME. We also agree that this is a subject of enormous concern to a number of our citizens. We worked together with the Society for Assisted Reproductive Technology, and also with a parent's group, with Resolve, to define what kind of report would be most helpful. One of the particular targets was to have something that was really consumer friendly, where people could read it, and have comparable data collected and reported in comparable ways from the whole range of clinics across the country.

    And we worked with focus groups to be sure we were communicating effectively. I do think we have been successful in providing a source of information for our citizens about what they can expect, what are the success rates with the different techniques, what kinds of variables. I'm sorry Mr. Miller isn't here, because in fact age is a crucial variable for determining the success.

    Overall, we found that about one in five couples can expect to have a successful live-born infant when they go through a program of assisted reproductive technology. The document also provides information on where clinics are, and what the success rates are.

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    We are working on the 1996 report and hope to have that out, I believe later in the summer.

    The standards for clinics was another part of the bill. And we have worked, first of all, there currently are standards which have been developed by the professional society. And those are implemented.

    We have reviewed those and used our professional judgment as to whether the standards are appropriate, made some modifications, and we have developed a draft Federal Register notice for comment, which will outline the criteria, personal standards, professional issues, for a certification program.


    Mrs. LOWEY. Another number I found shocking, as a mother and a grandmother, in your testimony you note that folic acid can prevent at least half the cases of serious birth defects, spina bifida, if women of child-bearing age had adequate amounts of folic acid in their diet.

    This is an amazing scientific fact. Yet, as you state, three-quarters, three out of four women of child-bearing age do not get enough folic acid in their diet.

    Now, I know, as a recent grandmother, when a woman becomes pregnant, she wants to know, what can I do, what should I do. How can we reverse this? Why aren't women getting this information? What are we doing and how can we do it better?
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    Dr. BROOME. One of the complications with folic acid is that the women actually need to be taking it very, very early in pregnancy, because that's when neural tube defects occur. And as you know, many pregnancies are unintended, and women are not aware that they're pregnant during those first weeks.

    That's why our approach has been to advocate that all women of child-bearing age who could become pregnant need to consume this amount of folic acid.

    Now, it turns out that getting it just through diet is not very easy. You'd have to be a real spinach fan to be sure that you were getting enough folic acid. The most practical way to get it is, well, there are two approaches. One is to take a dietary supplement, a vitamin pill. And most pills do have sufficient folic acid. So one of our messages has been to take a multi-vitamin containing folic acid every day. The other way has been through fortification of cereal products. And as you may recall, the FDA, this year is actually the implementation of the FDA's requirements that cereal grains be fortified with folic acid.

    Because of a fairly complex scientific discussion, which is still going on, the level of fortification is relatively low and will not assure that 100 percent of women reach the recommended level. The National Academy of Science is re-examining this question and seeing whether changes in fortification might be appropriate. Because that would be the easiest way to be sure that women got this quantity of folic acid.

    There's also very exciting information coming out that folic acid may actually be very important in preventing cardiovascular disease. So this issue is not only relevant to pregnant women.
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    Mrs. LOWEY. Thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Mrs. Lowey.

    Mr. Wicker.

    Mr. WICKER. Thank you, Mr. Chairman.

    Dr. Broome, let me join the members of the subcommittee in welcoming you here today, and thank you for going on past the noon hour, as obviously you will.

    When we're on the Floor of the House of Representatives, we're not supposed to talk about C–SPAN and television. I don't know what the rules are before the subcommittee, Mr. Chairman, but I'm glad to see C–SPAN here today.

    Mr. WICKER. We never have to put anybody under oath here in this subcommittee, and we probably won't do anything controversial today. Somebody may be watching this at 2:00 a.m. tomorrow. [Laughter.]

    But it is an excellent opportunity for us to showcase what I think we all believe, on both sides of the aisle, is a terrific Government agency. You've been in existence 50 years, 51 now?

    Dr. BROOME. Fifty-one now.
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    Mr. WICKER. A half a century plus one. This subcommittee took a delegation to Atlanta to tour CDC just last year. We learned that in the 50-year history of CDC, we were the first Congressional delegation to go to Atlanta and see the very fine things you're doing there.

    I would just say to any of my colleagues, whether they're on the appropriations committee or not, that it would be worth their while to take a Monday off or a Friday or a weekend and go and see the very fine things that are going on there in CDC. I applaud you.

    Dr. BROOME. Thank you.


    Mr. WICKER. Last year we set aside some funds specifically for cardiovascular problems. I noticed that in your testimony you mentioned approximately 70 percent of Americans die as a result of chronic diseases. And cardiovascular disease is the leading killer for men and women, and it crosses racial groups.

    You've been kind enough to provide us some information about our own home States. I notice in looking at the statistics that heart disease and cardiovascular problems are certainly the leading cause of death in Mississippi.

    Of this money that we set aside specifically last year for cardiovascular, how are you doing with that, and what are you using the money for to address this critical health issue?
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    Dr. BROOME. We have started to support States for prevention programs. We think that we do know some effective tools for preventing cardiovascular disease, and that supporting State health departments to develop effective cardiovascular disease prevention programs is the way to go.

    In addition to that, our division of nutrition and physical activity is continuing its work to understand how we can be more effective in preventing cardiovascular disease. As you know, there are a number of different risk factors which are responsible. Prominent ones include tobacco use, lack of physical activity, poor diet, particularly, consumption of foods which raise cholesterol.

    Intervening with those risk factors is important. We are trying to develop in States an effective approach which pulls together what we know and pulls together the many partners. There are a number of organizations which deal with tobacco prevention activities; there are a number which are interested in nutrition. Trying to get those pulled together comprehensively into programs to prevent cardiovascular disease is what we're interested in.

    This year, we'll be able to fund six to eight States with the money that was appropriated last year.

    Mr. WICKER. And that's the fiscal year 1998 funding?

    Dr. BROOME. Right.

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    Mr. WICKER. Now, you've asked for $5 million extra for the next fiscal year. Where will this take us?

    Dr. BROOME. Well, we would be able to support, I believe, an additional three to four States with that increased funding.

    Mr. WICKER. I just wonder how much it's going to take, or what it's going to take to take a program like this nationwide. Have you had time to quantify that, or to look that far down the road?

    Dr. BROOME. Well, I'd like to, we will certainly be able to provide you with a figure as to what that would require.

    [The information follows:]

    Amount needed to take CVD prevention programs to all 50 states: $150 million total; a $139 million increase.

    But I think this is also an area where we want to use what we learn from the initial States that we've funded as to what works best and what are the most effective components of a cardiovascular disease prevention program.

    We know the range of risk factors, but how can we be effective in changing those.

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    Mr. WICKER. Well, I certainly want to encourage you on that. I want to thank the leadership down at CDC for working with us on this appropriations committee initiative.


    Let me ask you about another pilot project, demonstration project, that I know has saved lives in my own Congressional district. And that is with the injury prevention and control program in the area of fire-related deaths, particularly just the simple initiative of going into a county with high rates of fire deaths and educating the people, demonstrating and distributing smoke detectors.

    I know you've got the project going in Benton County, Mississippi. Do you know how many other counties we're using that in, and what we've been able to learn from that experience?

    Dr. BROOME. The smoke detector program, I think, is a very good example of how we support research and then turn it into programs. As I mentioned, in the State of Oklahoma, was where the pilot research project was done, a formal research project that was peer reviewed and carried out under very rigorous research conditions. That showed that a targeted smoke detector distribution program, and being sure that the smoke detectors were installed and active, was effective in decreasing fire-related injuries.

    That finding was then translated into programs in Mississippi and, I believe, four other States this year. We do think that this is a proven, effective program. We would like to see it added to injury prevention programs nationally.
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    And it relies on, it's not just, it seems simple to say, well, you put up a smoke detector.

    Mr. WICKER. Right.

    Dr. BROOME. The key aspects are, using our surveillance data to identify what are the particularly high-risk areas, where are those fire injuries occurring, so that you put your priority efforts into making the smoke detectors available in those areas.

    We are also trying to develop longer-acting batteries, so that we don't have to be as dependent on people remembering to change the batteries every year.

    Mr. WICKER. My Chairman obviously set the clock wrong. There's no way that eight minutes has elapsed. [Laughter.]

    Let me just say that in Benton County, Mississippi, in my district, we've gone from the highest death rate in the State to no fire-related deaths since this program came in. CDC is a good program, and it's a pleasure for me to work with the other members of this subcommittee on things like that that are saving lives and enhancing the quality of life.

    Dr. BROOME. Thank you.

    Mr. PORTER. Thank you, Mr. Wicker.

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    Mr. Hoyer.

    Mr. HOYER. Dr. Broome, I want to welcome you to the committee. I apologize for being late. As you know, some of the rest of us are also either ranking or chairs on other subcommittees. So we have to be there, try to do both of these.


    I want to ask you three quick questions, if I can. Pfiesteria, as you know, is a very high concern in Maryland and North Carolina. We have put some additional resources into CDC on other objectives.

    Can you tell me where we stand on this, and update me on what you foresee the CDC will need for fiscal year 1999 to ensure that the public health response to Pfiesteria and like toxins is effective?

    Dr. BROOME. Thank you, Mr. Hoyer.

    This is, Pfiesteria is a very good example of a new emerging health threat, where we have to first answer the question, how big a problem is this? Can we scientifically define what particular health problems are being seen, and then, can we figure out how that could be prevented?

    So the money that was appropriated last year, which I believe is $4.7 million, first of all, we did supplement that with CDC one-time funds from the Director's discretionary money of $2.3 million. So we have committed substantial resources to this activity.
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    We're working with the States to define the magnitude of the problem. We had a large meeting to kick this off, and then we've had work group meetings with the States, the seven southeastern coastal States that have Pfiesteria identified.

    We'll be doing surveillance. First of all, we had to agree on what sorts of health effects we think are likely, which ones are we looking for. We got agreement on what we call a case definition.

    Then we established surveillance. We're trying to identify any cases of health effects that might be related to Pfiesteria, so that we can both count those cases, characterize them, and also do any testing of, for example, neuro-behavioral changes which might be related to Pfiesteria.

    We're also defining what we call exposure cohorts, groups of people such as watermen who are exposed to Pfiesteria in the course of their work. We will also be working with our State and academic partners to identify when they are potentially exposed to Pfiesteria, and to look at any changes in their health status related to that exposure.

    Another major issue is trying to have accurate environmental data, what is happening with the microorganism at the same time that there may be health effects in the groups of people who are occupationally exposed.

    We feel that these studies are moving forward very effectively, and we hope to have much better data on Pfiesteria and the potential health risks because of these studies. We certainly feel that it would be important to continue these activities, at least at this level, and if there is any evidence of increasing health effects or increasing distribution of the organism, additional funds might be needed. But certainly the $7 million would be an appropriate level for support.
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    Mr. HOYER. Thank you, Doctor. CDC, and of course this committee, has been very concerned about STDs. In particular Doctor, we had report language in last year's bill concerning syphilis. We asked for a report to this committee by January 1st outlining the additional investment necessary to eliminate syphilis.

    It is my understanding we do not have that report. Can you tell me its status, where it is and how soon we might contemplate its receipt?

    Dr. BROOME. The report is in the review process. It is currently at OMB, and we hope that we will be able to deliver that report fairly soon.

    Mr. HOYER. Doctor, what do you mean by fairly soon——


    Mr. HOYER. We use that term all the time ourselves. So it is important for us to explain it a little more.

    They want me on the Floor.

    Mr. WILLIAMS. I'm not sure exactly when it went to OMB. As far as I know, there's no particular reason to hold it up. We can get you a very specific date right away.
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    Mr. HOYER. And the reason I ask that, obviously I would like to have it, the Chairman is moving us along, all of the chairmen would like to mark up earlier than we have marked up, and therefore I'd like to have that information so we can use it for that.


    One last question. The National Center for Health Statistics, can you tell me what level of funding you believe they need—you may not know this at this point in time, you may want to submit it for the record—to provide the American public with a complete and accurate health survey?

    Do they participate in this document?

    Dr. BROOME. Yes

    Mr. HOYER. I am sure all of us have found this very interesting. I've just leafed through it briefly. Obviously in Maryland, we have some particular challenges, cancer in particular, where we have a higher incidence than the national average.

    Can you tell me what level of resources are necessary, so that the statistical picture of where we stand is available to us?

    Dr. BROOME. We'll be happy to provide you a more detailed response.
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    [The information follows:]

    But I really appreciate your bringing this up. Because we feel that having accurate health statistics and health data is crucial to doing our job. We want to be held accountable of making a difference in health status, and that can only be measured if we have good, quality health information and data.

    There's one very particular area that we're concerned about, and that's the National Health And Nutrition Examination Survey, NHANES. This is really a national treasure. It represents a statistical sample of the United States, people who volunteer, they're selected randomly but then they agree to participate in a full examination, including providing a specimen of blood, and answer an extensive questionnaire about health-related issues.

    These NHANES data have let us show our successes in decreasing childhood lead poisoning. We have shown dramatic public health successes. At the same time, we've been able to identify areas that still have risk.

    We've been able to show how widely exposed our citizens are to secondhand tobacco smoke. We can take these specimens and measure cotinine, which is a metabolite of nicotine, in the specimens from participants. This shows us that over 85 percent of people in this country had detectably elevated levels, these are non-smokers, had detectably elevated levels in 1991 to 1994.

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    Now, I'm going into some detail because, well, for two reasons. First of all, we have requested funding to support the survey, we're starting a new round of this survey. And we do not have the appropriations support that's really necessary for conducting this extremely valuable survey. It's estimated that $3.6 million would be needed to assure a firm funding base for NHANES.

    I would also like to welcome committee or staff visits to the NHANES examination centers. I'm glad you like the book, but people tend to think of statistics as very dull and dry and they just happen. But understanding how central they are to what CDC does, and how central they are to improving the health of the Nation I think is very important for prevention.

    Mr. HOYER. Doctor, thank you very much for that response. I would agree with you 100 percent. Whether they be economic, health, educational, the statistical analysis of how effectively we are responding to problems and how big those problems are is critically important to us making credible decisions.

    So I agree with you that we need to keep up our statistical capability of providing us, and the American people, American business, farmers, with statistics daily to be more effective in whatever we do.

    Thank you, Doctor. Thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Mr. Hoyer.

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    Dr. Broome, those are the easy questions. Now we get to the GPRA questions and the administrative expense questions.


    We're very serious about the implementation of the Government Performance and Results Act. We understand that every agency is grappling with the problem of developing performance goals and measures for ongoing programs. But it seems to me, given the requirements of the law, that any new program ought to include as an integral component a strong GPRA plan.

    Regarding the health disparities initiative, the budget justification does not list a single performance measure. For instance, regarding heart disease, page 182 of the justification indicates seven performance measures, not one of which relates to closing the gaps between black and white.

    Does CDC have any specific performance measures relating to closing health disparities, and if so, can you insert them in the record?

    Dr. BROOME. We would be happy to do that. We have actually found the Government Performance and Results Act strategic planning to be very valuable. We have in fact been complimented on the CDC plan because of its reliance on outcome measures showing the impact of our programs on changes in the health of the population in many of our areas.

    We've also, I think, identified good GPRA measures for our new initiatives. We will certainly, and my understanding is we have very clear targets in rates of the health conditions for the eliminating disparities initiative. But we will look again at that.
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    Mr. PORTER. Please put those in the record for me.

    Dr. BROOME. Certainly.

    [CLERK'S NOTE.—The witness did not provide the requested information and clarified her oral testimony as follows: ''We will be happy to discuss our approach to developing performance measures for eliminating racial and ethnic disparities for the record.'' The information follows:]


    We are gratified that there is such an interest in CDC's individual performance measures and our plan. We found the planning process associated with GPRA to be very valuable, and we're pleased that OMB and various other experts on GPRA recognized our plan as being one of the best in the Government. There are three reasons why our plan was recognized as being good. First of all, we identified and used outcome measures wherever possible. Second, we have the data and existing systems to support our measures. And finally, we viewed our performance plan as a way in which we could ''tell our story.''

    When developing our agency-wide Performance Plan, we did not include specific measures for eliminating racial disparities in health status. We are currently working on the development of such agency-wide measures, and with the appropriations the President has recommended for the Community Demonstration Projects, we will continue to work with our partners to ensure that these measures are achievable and mutually acceptable.
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    We believe that CDC's commitment to the reduction of health disparities among minorities is reflected throughout our programs. Early in the development of CDC's Performance Plan, performance measures from four sources were reviewed and considered for incorporation into the Plan. These sources included: Healthy People 2000 Midcourse Review and 1995 Revisions, Healthy Communities 2000, proposed outcome measures for Performance Partnership Grants (PPGs), and draft Health Plan Employer Data and Information Set (HEDIS) 3.0 Effectiveness of Care Measures. Based on our review of these existing measures, a concerted effort was made to include only the ''vital few'' in our final performance plan.

    Although specific measures to reduce disparities among particular minority groups are not specifically stated in the agency-wide plan, they are an integral part of the plans which exist at the program and Center levels within CDC. It is our intent to further develop (and make explicit) such agency-wide measures in our Performance Plan in the future and to share these with the Subcommittee.

    Mr. PORTER. As you said a moment ago, I think you have some very good performance measures at CDC. I think you also have some very bad ones. I'm talking about whether you choose a good measure, not whether you pick the right target to reach by a certain time.

    In HIV/AIDS, you set the objective of reducing the number of AIDS cases related to injecting drug use by 15 percent from a base of 17,800. In STDs, you have an objective of reducing the prevalence of chlamydia among high-risk women under 25 from 11.6 percent to less than 8 percent. In immunization, one goal is reducing the number of cases of pertussis from 7,796 to 1,000.
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    I don't know whether 1,000 is the right goal, but this is the type of measure that we are looking for, quantitative outcomes.

    On the other hand, in chronic disease, CDC lists seven performance measures for heart disease and health promotion, none of the type I just indicated. The agency proposes to establish coalitions, conduct educational activities, develop resources centers, and perform community outreach. These may be very important things to do, but they don't tell us whether we are achieving goals or reducing heart disease in certain populations or increasing the number of healthy Americans.

    Now, I understand there are difficulties in developing outcome measures for many activities. But I want to send a very strong message that we want you to adopt measures of the kind I described first, and we don't want you to adopt measures of the kind I described second.

    When do you plan to modify and update the GPRA plan, and will you include quantitative outcome measures in the fiscal year 2000 GPRA plan for all major activities at CDC?

    Dr. BROOME. We actually, I think, just finished the final revision of our current GPRA plan. So I must confess, I haven't focused on when the next one will be due.

    [CLERK'S NOTE.—The witness clarified her oral testimony as follows: ''We will quickly be starting work on our fiscal year 2000 plan which will build upon and enhance our fiscal year 1999 performance plan.'']
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    But we will absolutely take your concerns into account. And I agree with them. We definitely want to be measured by the impact on disease.

    We do, I think, also have to have appropriate process measures to be sure that we've got the right steps to get there. So we are trying to look at the right mix of both process and health outcome.

    Mr. PORTER. All right. I'd like to look at one more example of what I consider to be a performance measure that is really off the mark. I'm singling out a specific example, but unfortunately, the justification contains many like it.

    In the area of violent crime, page 189 of the justification, CDC sets a goal of increasing the number of State and community based intimate partner and sexual assault projects from 7 to 31. Shouldn't we instead be looking at the crime reports for communities that have projects to determine whether domestic violence is decreasing, so that we know whether the projects are having a significant, positive effect on people?

    Ultimately, we're not concerned with how many Government projects we can have. What we want to make sure of is that people aren't being abused. That's the kind of thing that I think you've got to focus on at CDC and make certain that we're not going in a direction that really doesn't affect the lives of people. Having projects is fine, but what it means to people is what we're really looking for.

    Dr. BROOME. I agree with you. I do think some of the work we're doing in defining, trying to have accurate measurements of the level of, for example, domestic violence, not all of that ends up in the criminal justice system. So that we are, at this stage in our knowledge in this area, working to refine measurements, get general agreement on that, get data which will tell us where we are.
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    That will help us in then using an outcome measurement and looking at the impact of our programs.

    Mr. PORTER. Correct. I would caution that we shouldn't let the measurements that are easy drive the goals or the performance standards, just because the data is there. If we aren't using good performance standards in the first place, then the data may give us something that really isn't useful. What we need to do is find out where we want to go, and then we might have to develop whole new performance standards in order to determine whether we're getting there.


    Dr. Broome, we've had a very difficult time getting a handle on CDC's administrative costs. Let me give you an example. On page 9 of the fiscal year 1998 justification, you listed total administrative costs of $494 million for fiscal year 1997.

    This year's justification lists total administrative costs of $611 million for fiscal year 1998, a jump of $117 million, or over 20 percent in one year. Keep in mind that the entire appropriation for CDC was increased by less than $100 million between the two years.

    The fiscal year 1998 House Report directed CDC to limit any increase in administrative costs to 1 percent, consistent with the bill-wide policy on such costs. Can you explain why the budget justification reports such widely varying figures? Why doesn't the justification include some explanation of these figures?
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    Dr. BROOME. We would very much like to clarify that and give you a detailed explanation for the record. I am reasonably sure that it is a comparability issue. As I had explained earlier, we did have an external consultant review how we were classifying and paying for administrative costs, relative to, for example, grant support, cooperative agreement support and support for our intramural activities.

    And there also has been some definitional changes. But we will get you a detailed report for the record on that.

    [The information follows:]
    "The Official Committee record contains additional material here."

    Mr. PORTER. I have a staff that thinks we're not getting accurate data in this regard. What I'd like to know, and you could provide this for the record, what are the actual figures for administrative costs for fiscal year 1997 and fiscal year 1998? And did the agency limit the increase to 1 percent, as directed by the House Report?

    That's what I really want to find out.

    Dr. BROOME. We'll address that.

    [The information follows:]

    Chairman Porter, my staff and I are carefully reviewing the actual administrative costs for FY 1997 and more accurately projecting our true FY 1998 costs. Mr. Chairman, the FY 1998 estimate for administrative costs as reported in the FY 1999 budget justification, exceeds a 1 percent increase over the FY 1997 costs. As outlined earlier, CDC's FY 1997 administrative costs exceeded the original estimate that was submitted in last year's congressional budget justification.
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    The actual administrative costs for FY 1997 was $532 million, or $38 million above our original estimate. The actual administrative costs for FY 1998 will not be available until approximately November 1998. CDC anticipates that the FY 1998 actual administrative costs will be less than the estimate. However, it is estimated that it will be more than 1 percent and CDC plans to keep the Appropriation Subcommittee informed.

    Mr. PORTER. Mrs. Lowey, do you have additional questions?

    Mrs. LOWEY. Thank you, Mr. Chairman, and thank you again, Dr. Broome.


    I know the hour is late, and I'll be brief. But I just wanted to discuss two issues of the many that you are involved in, for the record, because I have been very concerned with our policy and our actions on colorectal cancer.

    As you know, an estimated 55,000 Americans will die from colorectal cancer this year. The good news is that when detected early, the cancer can be treated successfully. Yet despite the existence of screening tests, many people still do not get screened.

    Last year, we did appropriate $2.5 million for the CDC program to promote public awareness of the importance of colorectal cancer screening. If you could give us your assessment of how the program is progressing, what plans does the CDC have in this regard to expand your efforts. This is the number two cancer killer. We have the procedures but people are not taking advantage of them. Could you help us?
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    Dr. BROOME. We agree with you that fecal occult blood testing and other measures are effective in early detection of colorectal cancer, and have been proven to reduce death rates from this very common cancer.

    We will, the amount appropriated is being used to develop both the messages that we hope will be effective in reaching the whole range of populations at risk, and also developing what kind of programs will be effective, whether it's just a matter of messages, or whether we need to maybe work more actively with the Health Care Financing Administration to make sure that Medicare beneficiaries and Medicare providers are aware of the need to make those preventive services available.

    Mrs. LOWEY. I thank you, and if you could keep this committee up to date, that would be very helpful to us, because as we put together our proposal for this year, this appropriations process, we'd like to get this information and understand whether the money appropriated was sufficient, what impact it is making, and what you really need to change these statistics around.

    Dr. BROOME. We'll be happy to provide that information.


    Mrs. LOWEY. Another area, I notice in your booklet on prevention, you mention asthma as one of the areas where you're doing research. I happen to have a bill which is directed towards frankly, 6 percent of New York City's population, which suffers from asthma, and to the other populations across this country.
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    In fact, this really, rather than a question, is an invitation to work with me. Because so much remains to be done, education, educating parents, how do you know what's happening, what can we really do. You look at the number, the number of Americans suffering from asthma has grown 30 percent over the last 7 years, while the number of people hospitalized due to asthma has grown by 24 percent.

    And as I mentioned, this is particularly serious in the New York area. We can continue our discussion of asthma in follow-up meetings, or if you care to share with us what you're doing, you're aware of the crisis that has received a great deal of publicity, certainly, in the New York area.

    Dr. BROOME. Well, this is a national problem. We've seen a dramatic increase in the number of hospitalizations due to asthma. And at least 4.8 million of those are in children.

    Asthma is another of these areas where we know some of the approaches to education and medical management which will decrease the need for hospitalizations, decrease the deaths. But we need that information to be much more widely available.

    There's also an environmental component that's really under investigation as to what role household dust mites and allergens, animal hair, etc., may play in exacerbating asthma attacks, and can we intervene to prevent that exacerbation. We have an innovative program in the Atlanta Empowerment Zone, where we are actually training community health workers to work with families to improve both the environmental and the clinical management of asthma.
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    We'd be very happy to work with you in this area.

    Mrs. LOWEY. I thank you very much, and as I said, I'm planning to introduce a bill that will deal with the education component, the response of health departments and local schools, promote Federal guidelines on asthma prevention. I want to be sure that the CDC has the resources needed to address these and other critical problems associated with asthma.

    So as we're putting this process together, as this process is moving forward, if you could keep us posted and give us your best judgment on this, it would be very, very helpful.

    I thank you, Mr. Chairman. The hour is late.

    Mr. PORTER. Mrs. Lowey, let me make an editorial comment at this point. I think we also ought to look into the role of stress, and what it does to create many of these kinds of diseases. Because I think, and I have, I know I'm not a scientist, but I think stress has a lot to do, or rather the reaction of the individual to stress, has a lot to do with a lot of the diseases that affect us. And asthma may well be one of those diseases.

    Mrs. LOWEY. I want to thank you, because I know that we share those concerns. We feel that stress is certainly a factor in so many of the illnesses that we are currently working on. I thank you for bringing that up.

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    Mr. PORTER. Including chronic back pain. [Laughter.]

    Mrs. LOWEY. I wasn't going to mention that one.

    Mr. PORTER. Dr. Broome, you've done an excellent job today. Your opening statement was outstanding, you've answered all of our questions candidly. We appreciate your coming here to testify, and the fine job that you did. We got the message, with your help, we can do it.

    This subcommittee has placed CDC at a very high priority. As you remember, back in 1995, when we were required to make very severe budget cuts in order to be within our allocation, CDC was one of only 10 line items that got an increase or was level funded. We pulled CDC and NIH out of the budget wars and passed them separately because we valued the work that you do so highly.

    We will continue to make a maximum effort to give you the resources you need to do the job. Because I believe, as you've said, that with the help of resources, you can do it. And you're doing a wonderful job, and we thank you for coming to testify.

    Dr. BROOME. Thank you very much, Chairman Porter. And we would be very happy to extend an invitation for you to visit CDC at any time with any members of the subcommittee.

    Mr. PORTER. Now that my back is better.

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    I really missed having gone on that trip, because I really wanted to come down. So I'll take you up on that.

    Thank you so much.

    Dr. BROOME. Wonderful. Thank you.

    Mr. PORTER. The subcommittee stands in recess until 2:00 p.m.

    [The following questions were submitted to be answered for the record:]
    "The Official Committee record contains additional material here."

Wednesday, March 4, 1998.






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Introduction of Witnesses

    Mr. BONILLA. Good morning. For those of you whom I have not had the pleasure of meeting before, my name is Henry Bonilla. I represent a congressional district in South and West Texas. Chairman Porter, chairman of this subcommittee, is delayed down the hallway testifying before another subcommittee, and I have been asked to go ahead and start this morning's hearings.

    I want to welcome Dr. Claude Fox to begin this morning, Acting Administrator for the Health Resources and Services Administration. Welcome, Dr. Fox.

    Dr. FOX. Thank you, sir. Glad to be here. I am accompanied by a number of staff. On my right is Dr. Joe O'Neill, who is the current Associate Administrator for HIV/AIDS and Director of the Office of Special Programs; Dr. Audrey Nora, who is Associate Administrator for Maternal and Child Health; Dr. Dena Puskin, who is the Acting Director for the Office of Rural Health; Mr. Dennis Williams, Deputy Assistant Secretary for Budget in the Department of HHS. And on my left is Mr. Tom Morford, who is the Acting Deputy Administrator for HRSA; Dr. Marilyn Gaston, Associate Administrator for the Bureau of Primary Care; and Mr. Tony Hollins, Jr., who is Acting Deputy Associate Administrator for the Bureau of Health Professions.
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Opening Statement

    I would like to just make a brief opening statement and then we will be available for questions.

    Let me start by saying that I have been at HRSA some 11 months, and trying to think of any common theme that really cross-cuts what this agency is all about, and if you had to pick out one area, it would be access—access to care. Virtually all of our programs have implications for access for people, in many instances low-income and special populations, but not all. We are about access to care for people who need organ transplants. We are about access to care for people who live in rural areas, access to children with special health care needs, access to individuals with AIDS, access for communities that don't have health care providers, access for primary care. So it really does cut across the whole agency.

    One of the things that I think continues to argue for continued support for these programs is the fact that over the last number of years, despite all the changes in managed care, the number of uninsured in this country really has not gone down. In fact, it has gone up.

    We know that for the most part, even the States that have had 1115 Medicaid waivers, the initial States like Tennessee, did attempt to expand populations, but the later waivers did not. And, overall, we have seen a continued need for access to our programs.

    There have been also a number of other factors that we think mitigate for that, and we are currently asking in our present budget request for approximately $3.8 billion.
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    We also think that we are having an effect and can show through a variety of performance measures that we have in the agency that HRSA programs are working. I would like to start out and share with you some comments about the area that invokes the primary care coverage, the Community Health Centers. We are currently asking for a $15 million increase in that area, primarily to deal with racial disparities. As you probably know, in this country we have a number of areas where we are not doing well, infant mortality being one, but we have a number of areas where the disparities among various racial groups—blacks, Hispanics, Asians, others—is far above the general population, and these dollars are to help target that.

    We currently serve about 10,000,000 people through the Community Health Centers and the National Health Service Corps, and, again, we have seen over the last several years an actual increase in the number of people coming to us that don't have insurance. One of the things that has happened has been that with the changes in managed care and the ratcheting down of costs, which have obviously benefited the general population in some ways, what it has done is it has prevented cost-shifting. And many people that were able to go to facilities where costs could be shared by other payment mechanisms are coming to us now. In fact, our first chart over on the left compares the percent of uninsured in the general population to the percent of uninsured we are seeing in the Community Health Centers.

    You can see that we are having a disproportionate number of people come to us now that don't have insurance or have limited coverage, which we think will continue, at least for the near future.

    The second thing—and I can give you more details about that if you would like. The second thing is for those people that we do see, we think we are doing a better than average job. We have recently instituted—and Dr. Gaston can talk more about this—a data collection mechanism with the Community Health Centers that gives us information on the care we are providing. Just one example, which is the second chart, is in the area of mammograms. We do through the Community Health Centers a better job of providing mammography to women that come through our centers than the general population. This is compared to the National Health Interview Survey that is done by the CDC.
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    We think we are doing a better job in a whole variety of areas. This is one. Pap smears is another, immunizations, you can go on down the list. But the bottom line is that we think we are having an effect within the community.

    The second area where we are asking for an increase is the area of HIV/AIDS. There are two things that have happened in this area, one, bureaucratic, and that is that we have reorganized; and since I arrived at the agency, we placed all the Ryan White programs under one area, Dr. O'Neill's area. We think that will provide for better coordination and help us in thinking through the kind of things that we do for one title, we can do for the other. The second there has been a dramatic change in the care recommendations, as you are probably aware, and just in the last year or so, now there are treatment options available that have significant implications for survival. And so we are requesting an additional $165 million in the Ryan White budget; $25 million of that to Title I, which is grants to cities; about $127 million to Title II, most of that for the HIV/AIDS drugs. And I might mention here we have taken several steps to reduce the cost of drugs that I can, again, share later with the committee. But the bottom line is there continues to be a need there and the $100 million will help address that; $27 million for Title II increase will actually go to States for other care; $10 million to Title III for primary care; and $3 million to Title IV for pediatric care.

    The bottom line is that there is a need for drugs, but because effective treatments are available now, there is a need for medical care as well. And we have to have a system to provide that, and, again, many of the people that are being seen are uninsured.

    The third area is health professions, and although we are not requesting an increase there, I want to make some comments about this because I think there has been some misconception about what we do in health professions. We really are targeting health professions' budget in HRSA to distribution and diversity. We know there are many communities and there is overall a physician glut, but the physicians are not in the right place. We know that the providers that are out there don't reflect the community they may be trying to serve. And so we are targeting our dollars to address those two issues.
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    We have increased our funding to minority institutions, to Hispanic-service institutions, to historically black colleges. And if you look at the charts here, the first one is on diversity, and the line that you see through the graphs is the average percent of diversity within the professional population and the graduates that are in general across all programs. The actual yellow lines are our numbers for the programs that we fund, and the bottom line is we are graduating more minorities to go out into various communities to provide health care.

    The second chart is on distribution. If you look at those numbers, with the line being the average of all programs, you can see for HRSA-funded programs, we are having a disproportionately positive effect on people going into rural and underserved areas.

    Also in the area of public health and preventive medicine, we are addressing issues that are not being addressed by the market.

    The fourth area is maternal and child health, and, again, although we are not requesting an increase in funds there, we are doing things that in my opinion are complementary to the CHIP, the Child Health Insurance Program. We are looking at systems of care, services that are not necessarily going to be provided through Child Health Insurance, including genetic issues, perinatal systems issues and, population-based issues. For example, the Back to Sleep Campaign that MCH has supported through its clearing house has had a major effect on the death rate in infants over one month of age, would not be something funded through the Child Health Insurance Program, but is having a major effect on infant mortality in this country.

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    Organ transplantation, we are requesting an additional $1.3 million in that area for organ donation. You know all the number of controversial issues around organ donation in this country and organ transplantation. But the sad fact of the matter is that for the last 2 years we had an increase of organ donations of two—not 2 percent, but two. And so the bottom line is that we are having a huge demand, increase in demand for transplantation, and the organ donations are not keeping up with that. And the $1.3 million we are requesting will help us do that.

    The area of rural health, again, telemedicine and State offices networking, we want to continue to support. I come from a rural area, and I tell you that, again, managed care is not going to take care of the problems in the rural areas.

    Then the final area where we are requesting an increase is the area of family planning, and there is a request for an additional $15 million to address the issues of family planning, to look at providing additional services to teens, to involve males in the contraceptive issues in many ways that they have not been involved.

    Finally, let me say that we have been working hard on our performance plan. We know Congress has mandated under GPRA that we look at performance measures. All the people you see sitting at this table have been personally involved in developing the HRSA performance plan. We have not delegated it to mid-level staff. We all have been involved together to try to think through what are the things in HRSA we need to be looking at and what data systems do we need in place to be able to tell you and us when we are succeeding.

    So the bottom line is we are very proud of the activities we provide. We think the need is increasing, not decreasing, for HRSA programs, and we look forward to any questions that the committee might have.
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    [The prepared statement follows:]
    "The Official Committee record contains additional material here."

    Mr. BONILLA. Thank you, Dr. Fox.

    What I am going to do at this time, I have some constituents out in the hallway that I am going to meet with very briefly, and I am going to go ahead and yield to Mrs. Northup at this time for questions.


    Mrs. NORTHUP. Thank you, Mr. Bonilla.

    I have a couple of questions that I would like to ask you. I had the pleasure of visiting the Family Health Centers of Louisville, Kentucky, earlier this year and met with the director, Oscar Canus. The Family Health Centers play a critical role in the community, providing access to health care to individuals who would otherwise go without basic health care.

    Part of the success of these centers is that they are governed by a local board which includes both patients and community leaders. Nevertheless, the Family Health Centers, like other health centers, is having difficulty meeting the needs of the uninsured because its grants have remained the same for over a decade.

    What suggestions would you have for these health centers to meet the growing number of uninsured?
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    Dr. FOX. Well, we are doing several things, and, again, Dr. Gaston can comment further. But we have provided a tremendous amount of technical assistance to the centers, both in strategies to help them be more effective with the dollars they have, how to make sure that they are being as efficient within the health centers as possible. We provided even on-site technical assistance to help them negotiate with managed care plans and others within their community. We provided a lot of technical assistance for them to understand where managed care is, where it is going, again, what the implications are for them.

    There are actually dollars that have been made available to help them become part of networks within their communities so they can survive. And we basically feel that the strategies we have invoked have hopefully helped them, one, be a part of the evolving system within their community in a way that they can survive and be competitive and provide what assistance we can from the Federal level to give them the information and even the on-site technical assistance down to helping them negotiate to do that.

    Mrs. NORTHUP. Well, I can assure you that, in visiting, they were very popular. People had nothing but good things to say about them. I think that they have actually internally increased their relationship with the community and built a lot of confidence. That is why I am concerned about whether they are going to be able to continue providing the services.

    Dr. FOX. We are as well, and, again, we want to do everything we can to assist them. Marilyn, I don't know if you want to comment any further. But I can't tell you how much time and effort we have spent in trying to think through the kinds of things that we can do to help them. Obviously there are some 3,000 sites in this country, and it is difficult to generalize because each State, depending on what is happening with managed care, is at a different place. But what we are trying to do is give them the tools for wherever they are and whatever is happening in their community to be able to negotiate, to know how to spend what money they have well, and anticipate kind of where the market might be going.
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    Dr. GASTON. As Dr. Fox said, yes, we share your concern. There is no question about it. As their uncompensated care has increased, we have also seen a decrease in their Medicaid dollars. There has been a 30 to 50 percent decrease in their Medicaid cash flow, and so they are really getting squeezed from both of these things that are happening.

    It is having a major impact on the centers. As a matter of fact, about 5 percent of the centers are either in bankruptcy or will be soon, and we are watching that very closely. There is another 5 to 10 percent that are at risk. There is another strategy that we have put into place over the past couple of years with the increase in the appropriation that you have given to us. We have tried to really target those health centers that have had a major increase in uninsured. And we have given them extra dollars to try to bolster what they have to do.

    Over the past 2 years, we have been able to give extra money for uninsured to about 259 centers across the country. That has really helped them.

    Needless to say, we are looking forward to and are very excited about the Child Health Insurance Program because 44 percent of the 10,000,000 people we are currently serving are kids, and we have upwards of 2,000,000 children that are uninsured. So to get them insured—those are kids that are in care right now—that would be a major help to the centers, not to mention the outreach they can do to get more kids in.


    Mrs. NORTHUP. Last year, I brought to the attention of this committee and worked with the committee to make sure that there was language included about the stroke bill. There is an area of the country where the incidence of stroke is very high, and certainly Kentucky falls into that, especially in rural health.
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    What the committee language suggested is that there be established a program that links a medical school, cardiologists, and a communications system with general practitioners that are actually out in the rural community. We know that there are far less specialists in those areas, but we know that they need the expertise really in preventive medicine to try to avert this high incidence of strokes that exists.

    I think that our community is a little concerned about whether or not that project has gone forth. I really want to ask you to work with that office, think that you can provide expertise and direction, and see that go forward.

    I think that, you know, it would be a good model for trying to provide more advanced care into areas where there aren't advanced practices that actually exist in those communities.

    Dr. FOX. I will ask Dr. Puskin to comment since she is in charge of the Rural Health Office, but obviously within the primary care area, we take care of a number of people who, by controlling the hypertension, hopefully we can avert stroke through the things in the Office of Rural Health as well as in health professions where they have the telemedicine issue. We are trying to link rural communities up with providers so that if people need a consult to find out why somebody who is on three medications is not responding with their blood pressure coming down, and making that kind of connection available, where needed.

    Dena, do you want to comment specifically on this area?

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    Ms. PUSKIN. Yes. As you may know, there was some difficulty in the fact that that project didn't get into the conference report. But what we have been doing is we have been—Jake Culp of my staff has been in contact, I believe, with the folks. This is in Louisville where you are thinking about the project, I believe. Is that correct?

    Mrs. NORTHUP. Yes.

    Ms. PUSKIN. And he has been in contact to provide some technical assistance in terms of the outreach grant program.

    I would also suggest that Kentucky Telecare, which is a telemedicine project that is currently being funded by the office, has tremendous outreach in a number of specialty areas, including cardiac and stroke. And I would hope that as we provide some technical assistance we might link up that project so that we get some synergy, because I think they are aiming through telemedicine to get at some of the same issues.

    Mrs. NORTHUP. Good. Thank you. And so you will be continuing your work with them?

    Ms. PUSKIN. Right. And I think that we would welcome any help from your office.

    Mrs. NORTHUP. Thank you, Mr. Chairman.

    Mr. BONILLA. Thank you, Mrs. Northup.
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    Dr. Fox, before I begin my questions, because I am very concerned about a couple of the issues that you have outlined—and as you know, I have been very supportive of HRSA for some time now—I just want to make a comment on the aspect of organ transplants, because I think that is actually one of the greatest tragedies that currently exist in our health care system, and it is not so much a systematic problem, but I am not sure what the answer is to create more awareness among the general public of how significant it is to make your organs available upon death when, for goodness sake, nothing else, no other good can come of it. So I would be interested in some of the initiatives that you are undertaking, because that is very important and I just wanted to mention that very quickly before we started into the questioning.


    The area I would like to start out with is health professions. As you know, Dr. Fox, in the past I have been frustrated with the administration's lack of support historically that it has shown for HRSA, and this subcommittee has had to take care of HRSA in spite of what the administration has proposed in recent years. And I am encouraged that the administration is now proposing a $155 million increase in the budget, but I am concerned that this is not enough to truly make a difference in providing primary health care services to folks out there in severely disadvantaged areas.

    Each year one of my primary concerns in the HRSA budget is the health professions program, and last year the President proposed cutting health professions by over $82 million. I am pleased that the President's budget has recognized the importance of health professions training by providing nearly level funding. This is a good start, but we still have a long way to go toward ensuring that underserved Americans receive the quality health care that they deserve, as you outlined in your opening remarks.
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    On page 8 of your testimony, Dr. Fox, you state that the return on the investment in the health professions program is considerable. Then you go on to state that the administration's budget request for health professions for fiscal year 1999 is $291 million, the same as the fiscal year 1998 appropriation.

    In fiscal year 1998, this subcommittee approved funding of the health professions program at $306 million. The final fiscal year 1998 appropriations for health professions was $293 million, not 291. If I read these numbers right, the administration is actually proposing a cut, not level funding, of health professions. Could you explain the difference in the figures?

    Dr. FOX. We will double-check the figures while we are talking. I am not aware there has actually been a cut proposed. Obviously, the committee's support for health professions we appreciate, and we do in some areas affect supply, of course. We are a drop in the bucket compared to the GME funding, but we are one of the singular sources of directed funding of health professions. GME, as you know, is blanket funding, I guess is the way you could look at it, that goes out in a way that is totally different than the kind of funding we have within the Department within HRSA.

    The dollars that we have within the Bureau certainly will allow us to continue to do the things that we have done and maintain our institutional capacity. There are a number of areas where we could do things a little differently than we do right now, but the bottom line is that with the funds in the current budget, our ability to maintain our expertise within the agency and within the Department to look at graduate medical education issues through groups like COGME and others is certainly maintained.
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    Tom, do you want to comment on—I wasn't aware that we had an actual decrease, but the recommendation coming forward from the Department was for level funding.

    Mr. BONILLA. Before you answer, Mr. Morford, I would like to point out that I mentioned the figure was $293 million. It is actually closer to $294 million. So there is a discrepancy here as we have gone over the numbers, and I just wanted you to clarify whether or not this is a proposed cut or not.

    Dr. FOX. Oh, there are two areas in there that are very high that are the two areas that would be reduced, and that is community scholarships and nurse training. Those are two areas, fairly small areas, within the budget that we had proposed picking up, and hopefully doing a better job with that through the Community Health Centers and through the National Health Service Corps. Both of those programs required a fairly high match. One of them required a 60 percent State or local match and had a fairly high administrative cost with it. So we were proposing that we would not fund those and actually pick those up through some of the other things that are going on in Dr. Gaston's Bureau.

    Mr. MORFORD. That is right. As a technical matter, they were moved from the budget lines that reflected health professions over into the primary care line. So that is why our budget tables technically showed a level funding amount, and as I said, it is really sort of a technical issue where the two items were moved over under the primary care line. And you are correct; those two areas have a decrease.

    Mr. BONILLA. I am glad we clarified that because we wanted to make sure that the members of the subcommittee understood exactly where the administration is coming from in this budget request.
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    In my rural southwest Texas district, Dr. Fox, the need for all health professionals is tremendous. In some communities, non-physician allied health professionals are the only source of health care for many of the constituents in my area, and in many areas of this country.

    Which of the health professions programs focus on training allied health professionals?

    Dr. FOX. Well, we have several within the Bureau of Health Professions. Tony Hollins here, with the Bureau, I will ask him to comment. But we have approximately 42 line item budgets of which there is more than one that actually is involved in this. Tony, do you want to comment?

    Mr. HOLLINS. Good morning. Yes, we do, a number of our programs focus specifically on other than doctors, dentists, and nurses. We are looking at all of the health professions; nurse practitioners, PAs, dentists, as well as other practitioners.

    What we are focusing on is trying to get individuals from underrepresented areas to go into these programs, such as our HCOP program and our COE program. We are finding that if we can get people from the communities to go into training that the likelihood of them staying there is very high. The programs that we fund have shown a significant increase, and that is where we are focusing all of our efforts. We are even making preference in the priorities in these areas.
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    Mr. BONILLA. As a follow-up to that, with the need for allied health professionals so great, is the $3.8 million—and maybe Mr. Hollins would like to answer this as well—provided for allied health special projects really enough to meet this need?

    Dr. FOX. Well, one of the things I wanted to share with you, we have about 32 percent of mid-levels that we also help fund through the National Health Service Corps. And, again, I think the issue in many of these areas is not so much the numbers; it is where they are, and the distribution within this country. We know even within the physicians we have not the right kind. So you could obviously spend more money in virtually any area, but I think it is more of an issue of trying to direct those funds to try to get them into communities, the rural communities, inner-city communities, where there is not enough mid-level or primary care providers.

    So, again, we can do whatever this committee would like, but the bottom line is I think that the issue of distribution for all the health professions, particularly within rural and underserved areas, is a real problem.


    Mr. BONILLA. I am going to move now to some questions I have about health centers, and I appreciate the opening comments that you made about the significance of what they are doing and how they are serving more people now.

    As you know, I have been a strong advocate of community health care centers across this country. It is a program that serves a vital need for 10,000,000 low-income children and adults in every State. The Community Health Centers play an important role in my home State of Texas. I am proud of the work that Rachel Gonzales is doing with this group, and I am going to elaborate on what she is doing a little more in just a second.
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    I would like to commend HRSA for recognizing the overwhelming medical needs in the severely underserved regions of Texas. As you know, my region is one of the very few that received an increase in grant funds for Community Health Centers. I look forward to working with you in the future to ensure that these centers remain viable to care for the growing number of uninsured and underinsured in the South and West Texas area.

    I have visited the community health care centers numerous times in my congressional district, and I have got to tell you that is where the rubber meets the road. That is where a lot of folks that would have no place else to turn show up on the doorstep of these Community Health Centers, and they are doing good work for people who truly need this health care.

    Last year this subcommittee provided a $24 million increase for health centers, Dr. Fox. How has this increase been allocated?

    Dr. FOX. Marilyn, I am going to ask you to comment on the specifics of the program.

    I will tell you that we have funded new centers and continue to try to provide support. We actually within your area, Congressman, are working on the border with some specific initiatives down there, trying to pull together the health centers and the other funding within HRSA to look at particular needs along the entire border area for areas where we currently have some health centers, but in an attempt also to bring together other resources in the agency such as the AHEC projects and health professions rural health projects that Dr. Puskin is dealing with, and, of course, MCH and AIDS as well.
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    So we have had—in fact, we had a meeting in our upper-level staff this past week on the Texas border area trying to look at things that we can do during the next year that will bring together the HRSA grantees at the local level to provide better service.

    I will let Marilyn comment on the specifics of the funding.

    Dr. GASTON. On the $24 million, in keeping with your congressional intent, we have tried to balance the dollars that go to the existing centers to help them with the uninsured, but also try to get more access points to serve people that just absolutely don't have any care. So, of the $24 million, about $12 million to $13 million went to existing programs that had a disproportionate share of the uninsured. About $9 million went to brand-new sites throughout the country where there is no health care at all.

    The small amount of remaining——

    Mr. BONILLA. What is an example of one of those?

    Dr. GASTON. Some sites in the Delta, Mississippi Delta. As you know, there are still places along the border where there is absolutely no care. Some places in the frontier areas also have no providers and no system of care.

    The small amount of remaining dollars went, as you heard Dr. Fox talk about, our technical assistance we give to them, also helping them become more and more competitive as they are moving into network arrangements with other programs. So that is about the extent of the $24 million.
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    Mr. BONILLA. Thank you.


    As you heard me mention earlier, we are proud to have Rachel Gonzales, who runs the Uvalde County Clinic in my congressional district. She testified before this subcommittee a few weeks ago. She has done a great job running the health center in that community, and it is one of the most economically depressed areas that she serves. She undertook an impressive fundraising campaign and will build a state-of-the-art center that will enable more patients to be served. I had the honor of participating in the ribbon-cutting ceremony for that new center, and I look forward to its opening sometime this year.

    I invite and urge you to tour Rachel's center if you ever have an opportunity when it is complete and visit the other centers in my area, and we would be glad to host you anytime down there, because they are doing an outstanding job and we are proud to show it off.


    Rachel's testimony of the state of health centers in this country is alarming. On page 2 of your testimony, you reference the ''growing numbers of uninsured persons around the Nation,'' Dr. Fox. As I understood it, over 1,000,000 new uninsured patients have been added to their rolls in the past 3 years alone. Clearly, the small 1.8 percent increase the administration has provided in its budget for health centers will not address this problem.
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    Dr. Fox, what was your professional budget judgment for Community Health Centers as submitted to the Secretary and then to OMB?

    Dr. FOX. Well, Mr. Chairman, let me first say that if you look at the dollars for Community Health Centers, we are spending about $100 per new patient served, so we are really leveraging a lot of dollars out in the community. We are leveraging Medicaid. We are leveraging other dollars. And in some instances, we make up a large part of the budget of the health centers sum. But across the country, if you figure we are serving about 10,000,000 people with $800 million, it is a little less than $100 per patient.

    Obviously with 41,000,000 people in this country who don't have health care, there is a lot of room for additional care through a whole variety of sources. It depends on whether or not you want to fund it from what source. We did submit an additional $200 million request as a part of Community Health Centers for this year, again, knowing that there are limited dollars. But there is certainly 41,000,000 people out there that rely in many instances, as you have already alluded, on us for care.


    Mr. BONILLA. On page 68 of your budget justification, Dr. Fox, you state that there are only 10 full-time employees for the Consolidated Health Center Program. If that is the case, there is only one FTE per 1,000,000 patients served by the program. That is a very impressive number and testament that these Federal dollars directly benefit the patients.

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    Are these statistics accurate?

    Dr. FOX. We have within Dr. Gaston's bureau the total funding, and, again, remember, we have the Community Health Centers, the Health Care for the Homeless, the National Health Service Corps, the Migrant Health Centers, and some other projects—I know I am forgetting, Marilyn—and we have approximately 300 people total in the bureau for all of the programs. How they are allocated, I will defer to Dr. Gaston to comment.

    Dr. GASTON. Those are the FTE's associated with the loan guarantee program.

    Dr. FOX. The loan guarantee.

    Dr. GASTON. We do have more FTE's that are administering the Health Centers Program—both in headquarters and in field offices.

    Mr. BONILLA. I am glad you cleared that up.

    Dr. FOX. I knew there were more. I didn't know—again, the total number is beyond that, but that was for the loan guarantee program, which is one fairly circumscribed program within the bureau.

    Mr. BONILLA. Thank you very much.

    At this time I am going to ask Mrs. Northup if she has further questions, and if she does, we can continue. If not, we are going to recess until Chairman Porter arrives.
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    Mrs. Northup, do you have further questions at this time?

    Mrs. NORTHUP. Just a few brief ones.

    Mr. BONILLA. Okay. I will then allow you to take the chair. I have got to go to another hearing at this time. Thank you.


    Mrs. NORTHUP [presiding]. Thank you.

    I would like to ask you a question about the Health Care Integrity and Protection data bank that was part of the memorandum of agreement that you signed with the Office of the Inspector General last year. I am interested in knowing how the development of that data bank is going and then to ask you to tell me how that works with the fraud and abuse efforts.

    Dr. FOX. The Federal Register notice to move forward on that we have been working with the inspector general on. It has been looked at and worked on with a great deal of time and effort within our Department and within HRSA.

    We are, as I understand, moving forward with that. Tony, I don't know if you want to comment on it, but we do plan to move forward with it. We have been—I think the last set of discussions we had, we were going to jointly issue that notice. But we are moving forward, and it will be a part of the overall effort that is combined with the data bank, with the National Practitioner Data Bank.
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    Mrs. NORTHUP. And is the goal to establish sort of parameters of practice and to then be used collaboratively with the fraud and abuse efforts?

    Dr. FOX. Well, again, we are working with them so that they have some input into where we are headed with this. We do plan to make it a part of the overall effort, and, again, even though the National Practitioner Data Bank is a separate effort, it will be a part of that whole unit. And we will be working closely with the IG so that we are doing the type of things that were a part of the congressional language.

    I think we are moving forward on that. We have had some discussions in negotiating with the IG exactly how to go forward, but I don't know there is any disagreement on whether or not to go forward, and, in fact, we actually have a set of regs that we are working on together and will probably jointly put out.

    Mrs. NORTHUP. Well, is there a time line? I am sort of trying to get a better feeling for it.

    Dr. FOX. There is a time line. Again, I can't tell you specifically when it will be done, but, you know, we are moving to get it done expeditiously. We are hoping sooner rather than later. I am not going to try to predict the time line within the Government because, lest I do that, since not everything that is involved with this is under my control, I couldn't give you a specific date. But we are planning on moving forward with this, and hopefully within the next month or so we will have something on the street. But it is not——
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    Mrs. NORTHUP. Would you be able to provide my office with the time line and what the parameters are?

    Dr. FOX. Sure. We would be glad to.

    Mrs. NORTHUP. You know, what are sort of the limits of what you intend to do?

    Dr. FOX. Sure. I would be glad to.


    Mrs. NORTHUP. I wanted to also ask you about the HEAL Program. I know with all of our Government programs we are concerned about default rates, and I wondered about the estimates of defaults and what the total amount of the defaults has been and what actions you might be taking.

    Dr. FOX. Well, as you know, the HEAL Program goes back a number of years. We have had overall—for the entire program a 4.2 percent default rate. There has been a big spread between disciplines, however, and the default rate has varied as much as 14 percent for chiropractors and 1.8 percent for allopathic physicians.

    We are doing everything we can to collect that money, and in fact, I would point out that 96 percent of the people that get HEAL loans repay them as they have agreed.
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    We have recently issued a Medicare/Medicaid exclusion list of HEAL defaulters. We are working with DOJ to follow up on that, and, this is the third time we have excluded defaulters. The first two times netted $31.5 million for the Federal Government in money that was recouped. We have posted these names on the Internet, and we will be continuing to update and modify that list.

    I think, quite frankly, short of taking the firstborn child, we have done about everything we can, and we don't necessarily want that firstborn child because then we would have to support it.

    The requirements for filing a default claim are that there be a State judgment, then it is turned over to a collection agency. We then go after them, and DOJ can seize their assets. But the bottom line is we have about 1,400 individuals that are in default and excluded from Medicare/Medicaid.

    We have a total loan guarantee of $4 billion-plus, and only about $430 million that we are in contention with right now. We are making every concerted effort to collect that. As you know, we are not in the process of making new HEAL loans.

    Mrs. NORTHUP. That is great.


    Another question about the Ryan White funds. I think last year there was some concern that the Ryan White funds are supposed to be the payer of last resort, and, of course, if they aren't the payer of last resort, they can offset some other money, and so the total amount of money that goes to serve the AIDS community is reduced overall.
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    Can you give me an update on what sort of information you are providing States and how carefully you are monitoring that?

    Dr. FOX. Well, I guess, again, it depends on which title you are talking about. I would just say in general, particularly for Title I, remember that Title I is provided to cities, and those dollars are really expended under the direction of a community board. And so there is a lot of community input as to what happens there.

    On the ADAP for the drug funding, if that is an area of concern, then I will ask Joe to comment. On the ADAP, we again provide the funds to States. The States then basically buy those drugs through a variety of mechanisms. We have been working with them, quite frankly, through a number of mechanisms, including going to a national rebate program to provide the States additional options to lower their cost, and, in fact, are in the process of publishing a Federal Register notice that really requires them either to do a rebate or direct purchase unless they can show that they can get a lower price.

    So there are a number of strategies that we would be glad to give you additional information on that we have done to try to lower the costs for particularly the medications.


    Mrs. NORTHUP. I was actually referring to the IG's report last year on the Ryan White funds, and I am not sure what area that was.
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    Dr. O'NEILL. Let me say that this is an area that I personally and HRSA are very concerned about as well. We are so appreciative of the resources that we have to do this, and it is absolutely clear in my mind that any time we are allowing any other resources to be supplanted by these, particularly private insurance or entitlement programs, it is taking medications, life-saving medications and treatment away from people who desperately need them. So we really have, I think, a strong sense of passion about really trying to tighten up as much as we can on this.

    Now, the mechanisms that we have in the Ryan White program to varying degrees allow us to do this. We have been very aggressive about monitoring across all of the programs. We have worked with the inspector general, and it has been actually a very good relationship, and we have appreciated their help.

    There was a particular study they did in one State that looked at some of the issues that you mentioned, and they did point out areas to us where we were—they weren't huge areas, but they were areas where we did need to tighten up, and we have. And I would be glad to give you some additional information in writing later about, you know, the various steps that were taken. But I do really want us to go on record as saying that we see this as a very important issue and not one that we will ever be comfortable with.


    Mrs. NORTHUP. Okay. The budget increase for $1.3 million for the Organ Procurement and Transplantation Program is targeted towards increased organ donation and education. I asked, I believe, last year about this. I am concerned about whether or not this is going—how these are targeted and what audience it is targeted to.
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    Dr. FOX. Well, let me first say we are not trying to remake the wheel here, and just to tell you some of the things we have done in the last several months, we have had intense discussions with the Coalition on Donation, as you know, a national group that has done a lot of work in this area, and actually have an agreement with them to work with them on further dissemination of the message, have them actually help man a 1–800 line to take calls and referrals.

    We are looking at working with other groups, again, just to give you some examples, the AMA, with the various medical groups, to try to get physicians to obviously take this message to families and patients; with the Bar Association, to try to have people think about this in advance directives; and with other groups, churches.

    The bottom line is that it is not so much—I mean, we need an increase in the number of people who are willing to donate, but the big problem is that people don't tell their families; and for those people that do agree, even if the family is not informed, many times the medical providers is hesitant to do that at the time of death.

    So we have a variety of areas we, again, are trying to use the mechanisms that are out there, not create a new system, and I am confident that we will be able to see change.

    As you know, the other thing that the administration is doing is looking at the conditions of participation, the hospital conditions of participation, and really looking to require that hospitals refer to the organ procurement organizations those individuals where they think that might be a potential so that somebody who is trained can talk to the family and do it in a way that is sensitive to their needs at the time.
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    So we have a lot of this going on, and obviously we are very concerned about this, because despite all the controversy in the organ transplantation area, if we had increased donation it would really lessen a lot of the other pressures.

    Mrs. NORTHUP. I think I was worried last year about you were targeting children that were in grade school and high school, and I guess my feeling is, first of all, they are probably the least likely group of people you are going to get donations from in the immediate future, but also I think their parents have to co-sign, and that seemed like—if we have not enough resources, that might not be the target audience. So I think it is important that we do target the money well.


    I also was aware that you all—I thought you had a pilot project with the IRS where people had a check-off system, and I just wondered how that went and what sort of response you got.

    Dr. FOX. Let me ask Joe if he wants to comment. Let me tell you before he does that we also have had a general effort across all Federal employees, and we have had information that has been sent out in pay stubs to all Federal employees, information in employee bulletins. And so we are really targeting all of the Federal workforce in addition to other specific groups that we might do something special with.

    Dr. O'NEILL. I would just add there was a model which included information with the IRS tax refund checks. I am not sure how we can really—we could have really evaluated the impact of that. In terms of the Federal program, we are actually—when people call in, there is a way when the calls come in that we can determine whether those calls are coming from the Federal workforce presumably as a result of the campaign versus coming from the general public. So we will have some better information about the effectiveness of that kind of activity.
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    Mrs. NORTHUP. Okay. Well, thank you very much. I know that you serve a lot of people that need your services. You certainly have made a difference in my community, and I sometimes think we have some examples of health services that have been very effective, very efficiently delivered, and very appreciated and high quality. Certainly in my district, I have seen an example of that. I sometimes think we don't value and increase those efforts as much as we should.

    Thank you very much.

    Dr. FOX. Thank you so much for those comments.

    Mrs. NORTHUP. We will now recess until Mr. Porter gets here.

    Mr. PORTER [presiding]. The subcommittee will come to order.

    Dr. Fox, let me apologize to you. I was at one of my other subcommittee hearings. The Secretary of State is here to testify this morning, and I wanted to have the opportunity to ask some questions there. I understand Mrs. Northup has been in the chair, and we appreciate her taking the chair and covering a lot of the material that we wanted to cover with you.

    Mr. Stokes, I would be happy to recognize you right away. I realize you have other obligations as well. Why don't you proceed?

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    Mr. STOKES. Thank you very much, Mr. Chairman.

    Dr. Fox, I am pleased to see you here this morning, and I apologize for not being here earlier. However, I am on another subcommittee that meets at this same time, As the Chairman was saying, he had to go to another subcommittee, too. We are balancing our activities this morning.

    Dr. Fox, I am advised that since your arrival at HRSA you have worked very diligently to ensure that this committee's recommendations with respect to minority health and minority health schools have been carefully adhered to. I want to thank you for your leadership and your responsiveness to that.


    How do you see HRSA playing a continuing role in reversing health status disparities between the races?

    Dr. FOX. Mr. Stokes, I appreciate those comments. We feel strongly about our support to the various institutions and groups out there that we have and will continue to work with.

    HRSA really has a major role in the health disparities issue. If you think about virtually all of the funding that we do through primary health care, a large percent of the populations we serve, we feel like we have some impact, and I had shared earlier that actually some of our numbers show that we have a disproportionate positive impact on various groups who are disadvantaged.
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    The MCH area as well, Ryan White obviously, and I think even within what we do around working with providers—as I understand it, 50 percent of our providers in the Ryan White Program are minority, which I think is a pretty good record. The health professions area, we do a better job in almost every situation than the community as a whole in training and placing out African American, Hispanic, and other providers. Again, rural health, we know that—so I guess overall, of our almost $3 billion budget, a lot of our services do go to deal with health disparities, and we think we are having a disproportionately positive impact on that, and we certainly appreciate your support for HRSA and for the programs that we deal with, and the other programs that we work with, like public housing and various training efforts that really help us get the job done.

    So we have a lot to do, obviously still a significant problem with disparities. I will tell you that the Healthy People 2000 effort is looking at trying to not necessarily narrow disparities in the next 10 or 15 years, but we want to eliminate them.


    Mr. STOKES. Dr. Fox, during this year's public witness hearings, we heard testimony about a medical technologist training program being supported at the University of Maryland in Baltimore that has a 52 percent minority student enrollment at a majority institution and an average 95 percent student retention rate. This impressive effort, as I understand it, is supported by the Allied Health Project Grant Program.

    Is the Allied Health Project Grant Program geared at helping to support efforts to solve national problems like the shortage of minority health professionals?
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    Dr. FOX. Let me make a comment, and then I also want to ask Mr. Hollins with the bureau to comment as well.

    We really are trying to look at every funding source within the Bureau of Health Professions and ways we can leverage that to increase the representation of minority providers. We are doing that now. We have had some discussions since I arrived at HRSA at how we can place additional preference within the grant awards, what we can do with our requests for proposals to try to do this in all areas, and I think there are some ways we can further leverage that we are working on.

    So it is on our radar screen, and we are trying to think of all the levers that we can pull within—all of them, as you know, have a variety—we have some 42 authorities with the health professions that cut across a number of areas to try to do that. We are not about supply. We are about diversity and distribution. Again, we feel like within programs like that and others we can continue to do that and probably have some ways we can actually put a little more pressure on. There are training programs that exist in this country to do a better job.

    Tony, do you want to comment as well?

    Mr. HOLLINS. Thank you very much. Yes, we are making a concerted effort to focus funds so that we can try and close the gap on diversity, especially in the allied health programs. These are areas where we can make a difference.

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    As Dr. Fox said, we are making special considerations for funding preferences and priorities. We are going out to make sure that we provide the necessary technical assistance to these institutions so they will qualify for our funds. And the focus here is to get people into school and get them trained.

    Mr. STOKES. Dr. Fox in your professional judgment, if additional funding were put in this area, would that help?

    Dr. FOX. We certainly could do more in this area. Again, the workforce overall, as you know, does not reflect the populations that are out there that are being served and that need to be served, and certainly additional effort could be made in that area.


    Mr. STOKES. That leads me to my next question. Health professions training studies have revealed that minority physicians are much more likely to serve minority poor and Medicaid populations, and care for significantly more patients of their race and ethnic group than other physicians. How critical is the expansion of the number of minority health care professionals to addressing the health care needs of those living in these underserved inner cities, and rural communities across the Nation.

    Dr. FOX. We think it is very critical. There are obviously a lot of reasons why we don't have health professions in the communities in need in this country. Part of it is the kind of support systems that are out there. Part of it is funding to make that available. Part of it for them having a system to work in. And part of it is having somebody who understands the community and can work with the community in ways that are culturally sensitive. And we think HRSA programs do that and are committed to continue that effort. It is very important.
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    Mr. STOKES. During last year's discussions with your predecessor, Dr. Sumaya, he indicated that the Administration is very concerned about the low representation of minorities in the health professions and is committed to improving the situation. How is this commitment reflected in the Fiscal Year 1999 budget request?

    Dr. FOX. Well, of course, Mr. Stokes, we have been able to maintain and we are very pleased that we were able to maintain funding for health professions overall. I will tell you that having reviewed the HRSA budget prior to coming to this hearing, we have increased in virtually every area within health professions our funding for minority training.

    If you look at the COEs, HCOPs, for African American, for Hispanic, all those numbers have gone up—and we can provide those to you—within the health professions. So we are actually going beyond what the law requires as far as the set-aside, and we are going beyond what we have been asked by this committee to do.

    Obviously, again, there is always additional need that you could fund, but we are doing everything we can with the monies we have available to really sincerely target this area.

    Mr. STOKES. Please feel free, Dr. Fox, to expand upon that in the record, if you would like, to provide any additional data.

    Dr. FOX. Yes, sir.
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    Mr. STOKES. Enacted by the Congress, what impact has recently enacted welfare reform legislation had on the services provided by your agency?

    Dr. FOX. It has increased the demand on our service overall, Mr. Stokes, and obviously each area is a little different as to how those nuances play out. But we are seeing overall an increase in the number of people who are depending on HRSA systems because they do not have Medicaid. We know that for mothers who might be illegal aliens and have a child who is born a U.S. citizen, those individuals we feel like probably are not coming into care. So there is an issue of that plus the fact that a lot of people were on Medicaid in the past who might not be now and the need to find those people, and part of the HRSA effort is to not only provide the care but get out and find them.

    One of the major things we do in the Maternal and Child Health Bureau is involved in outreach where we go out and find the people who are eligible for services. It is one problem to not have health insurance or Medicaid available, and another for people who might be eligible to have it and who aren't enrolled. And so we try to find those people who could qualify, and many of the people who might still qualify for Medicaid who perhaps are not on it now because of changes in welfare reform. We are really trying to use our systems to find those people and provide care, and even those not covered that were previously, are depending on our system.

    So it is really increasing the demand for almost all of our systems within HRSA.
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    Mr. STOKES. Do I still have some time, Mr. Chairman?

    Mr. PORTER. Go ahead.

    Mr. STOKES. Dr. Fox, to what extent will your Fiscal Year 1999 budget request allow you to be able to respond to this demand that you have just spoken to?

    Dr. FOX. Well, of course, we understand there are limited funds and are trying to stay within a balanced budget, have the funding areas within, again, some additional money to reduce racial disparities as far as the Health Centers, and the largest amount of funds for the Ryan White area. But, again, there is obviously a need across a number of the programs and within the budget constraints we try to do the best we can with placing dollars within the agency to address those needs, knowing that there are still unmet needs. And, you know, we will work with this committee in any way we can to try to address those.


    Mr. STOKES. Dr. Fox, I understand that over the past year, in Ohio, which is my State, of course, the amount of Medicaid dollars available has decreased by 11 percent, while the number of uninsured has increased by 18 percent. This situation, of course, is alarming. As you know, Health Centers are the primary preventative health care providers serving the uninsured.

    It would seem that to help alleviate the growing problem of the uninsured the investment in Health Centers should be significantly strengthened. In your professional judgment, is the amount requested sufficient to do the job? And, how does that compare with the funding level for Fiscal Year 1998?
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    Dr. FOX. Well, again, obviously, there is need out there, as I alluded earlier. We are spending approximately $100 per patient per year, but what that means is not the cost is $100 per patient per year, but the fact that we are leveraging a lot of dollars within the community.

    With 41,000,000 people who exist in this country now who are uninsured, it really is, I guess, a professional judgment call on the part of both the administration and Congress of how much of that we want to try to address with the Community Health Centers. We are working to try to, again, encourage States to expand Medicaid programs and other things. We, again, know that there is a tremendous unmet need for additional dollars, but it kind of depends on which way you want to try to fund that, whether you want to go through expanded Medicaid or through other programs. The Community Health Centers, again, are—we are serving about 10,000,000 with the programs right now today with an estimate 41,000,000 people who don't have health coverage in this country.

    You can see the unmet need, that whatever mechanism this Congress or the country decides to take to cover that, there is certainly need there.


    Mr. STOKES. Someone may have covered this issue since I was not here earlier this morning when you were being asked questions. I am quite concerned about the current situation in the African American community relative to the disproportionate number of AIDS cases. And, as you know, this is a major national problem.
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    I am concerned about the degree to which Ryan White initiatives under your agency are being responsive to this national emergency.

    Dr. FOX. Well, again, in Title I, 50 percent of our providers—and these are round figures, not exactly, but approximately 50 percent of our providers in Title I are minority, about 25 percent of our providers in Title II are minority, and that is certainly greater than the general population. And Dr. O'Neill is in the process of—and I had mentioned before you came in that we have recently pulled all the Ryan White programs together in a single bureau. And we have a goal of having—and, Joe, you may want to elaborate on this, but we have a goal, as we bring leadership into the agency, to have a majority of that leadership within the Ryan White area to be represented by minorities.

    But in our own leadership structure, we are trying to be attentive to that. Within the community, we feel like that there is certainly a good representation of providers. But also the things we are doing, we hope that will set the stage for us and the community to work to ensure that the groups that are adversely affected out there, that the emphasis is appropriately placed to try to get at those groups, to provide the services that they need. There may be another strategy you might want to detail, Joe, but I think it is an issue of very much concern of ours, and I think we do have some strategies that we are attempting to do to address that.

    Mr. STOKES. Dr. O'neill, would you like to respond?

    Dr. O'NEILL. Mr. Stokes, yes, thank you for that question. As you may or may not know, I volunteer one half-day a week and have for about the last 10 years working as a physician providing AIDS care in the inner city of Baltimore, and I have watched this epidemic in the African American community explode. And I absolutely share your concern on this issue.
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    Approximately, in the last year's report to the CDC, about 64 percent of new cases of AIDS were among African American and Hispanic Americans; 43 percent, actually, among African Americans and 19 percent amongst Hispanic Latinos. I don't need to tell you that that is a huge—given the percentage of populations in the overall area, that we are looking at a tremendous disproportionate impact.

    For calendar year 1996, in the Title I program, 62 percent of clients served in the Title I program are African American or Hispanic. In the Title II program, 56 percent are African American or Hispanic. In a survey of our largest providers, meaning institutions which serve over 6,000 clients, 77 percent of people served in that group were African American or Hispanic.

    Now, we are not complacent about that. I think we are doing—I mean, I am proud that we have good representation, but when you step back and look at the social fabric upon which we are trying to provide these services, the changes in health care financing, the changes in welfare, the general lack of other services to these communities, I think we need to—I still challenge ourselves to do a better job in a number of areas. One is in terms of providing high-quality clinical services to this population of people such that the tremendous benefits of these new treatments are equally distributed. In other words, it is one thing for us to count numbers of people served, which I think we look good, but I do want to put on the table that I think we have to do a lot of work in the area of making sure that the quality of care that is provided in these communities is every bit as good as the person with the best private insurance in the country.

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    Mr. STOKES. I appreciate that, and I guess one of my concerns is whether or not your budget request is going to enable you to be able to follow the trend of the disease, which I think is equally important here.

    Dr. O'NEILL. I have been saying for a number of years that what we really need to be doing is designing a program that is going to be in place for where the disease is going to be in 5 and 10 years, given the tremendous medical and social complexity of this illness. This is no longer a simple—I guess it never was simple, but the clinical aspects of this disease are such that we are challenged to have to develop fairly sophisticated health care systems that are also culturally competent and placed in communities where they can be accessed.

    Those things take years to put together. I think we have—I guess I would sort of echo what Earl was saying earlier. With more we can do more. But with what we have, as an administrator I am very challenged to just make sure that we can do the absolute best and achieve the best social justice and equity we can.

    Mr. STOKES. You mentioned the social fabric, and in that respect, I am concerned about the small service organizations, particularly those who operate in the inner city, and those who are geared toward minorities.

    What are we doing in order to try and ensure equity in the delivery of HIV/AIDS health care services?
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    Dr. O'NEILL. Just to give you the statistics that we have from the Title I and Title II programs on this, using a definition of minority provider that reads defined as which the majority of the board or the staff are members of a minority population with reference to the U.S. population, using that definition, as Earl mentioned, 50 percent of the Title I EMAs reported—let me rephrase this. Fifty percent of providers by that definition in Title I would be classified as minority and 28 percent in Title II. I would not go through what I have said before. I am not complacent about that. I think we have to—now, you asked the question of what are we doing to help bolster that.

    This really turns on a number of issues. Number one, I think, is the adequacy and quality of the technical assistance that we can provide and target to these types of organizations. We are particularly concerned about the issue of managed care and the impact of managed care.

    We can supply additional details on this, but we have a fairly aggressive managed care strategy, technical assistance strategy where we actually go out into these centers and work with them to help them prepare for managed care activities. We are ready, willing, and able, and have done it, to provide a range of other technical assistance services when requested.


    The third area that we are very concerned about—and it is a challenge, I think, over the next year, and I would like to be able to come back next year and give you a more detailed report—how to do a good job of supporting the actual clinical provision of care in these centers. We are looking at our AIDS Educational Training Center program which has been a very key provider and, again, has good statistics in terms of numbers of minority professionals who have been served by the program. But we are really taking a good, hard look to see how we can do a better job with that.
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    We are starting a small fellowship program with the Historically Black Colleges and Universities where we are going to be able to bring in—we have had one with the schools of public health, and we are now moving to—we expanded that to include the HBCUs so that we can be bringing interns in to work with us. But I think we have a long ways to go in this area, and I would be pleased to give you information in a more detailed way of what we are doing now and also to invite more information as we go along.

    Mr. STOKES. I appreciate that, and at some point, I would like to take you up on that offer to spend more time talking with you on the aspects of that.

    Dr. O'NEILL. I would very much appreciate that.

    Mr. STOKES. Mr. Chairman, you have been very generous with my time, and I really appreciate it.


    Mr. PORTER. Thank you, Mr. Stokes.

    Mr. Stokes referred to this and you have referred to it several times, but we have a very changing health care delivery system in America. I wonder if you have looked at all the programs under your jurisdiction and made an assessment as to how they fit within this changing system and what you should be doing to restructure them to the extent that they do not. We talked about community health services and Medicaid access. Can you address that, Dr. Fox?
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    Dr. FOX. Yes, sir. The short answer is yes, we have. I will give you a little detail.

    Since I came to HRSA, we have backed up and really tried to rethink our strategic plan. And I have said I never met a strategic plan that I liked. I think most of them are put on the shelf and are never used. But we have really tried to come back and we have involved the leadership at this table and other upper-level leadership in the agency, and myself, and we have actually gone off—for instance, let me take as an example Dr. O'Neill's area. We went off for a day, took Joe, his upper-level staff, and every one of the other bureau directors that you see here, and their leadership, their upper-level staff as well, to talk about what was going on in the Ryan White program and how does it impact every one of the other programs. And then we did that same thing with each one of these other areas, so that when we took Marilyn Gaston's area of Primary Care, the Rural Health, Maternal and Child Health, Health Professions. So we tried to, one, sit back up and say where do we think we need to be based on the demography, on the change in the system, managed care, 5 years from now, 10 years from now, what do we need to be doing. And so we are trying to basically construct that scenario.

    The issues of change in the Child Health Program and Maternal and Child Health are significant, and the fact that we may end up 5 years or 10 years from now with all children insured, raises questions about what we should be doing in Maternal and Child Health? Well, there are a number of things we're looking at. These include: having the information that allows us to know we have gotten there; the need for Medicaid and State Maternal and Child Health to pool databases to give States the information to know what is happening; the issue of doing outreach and the fact that these children are not going to come in to the system; the issue of systems of care around genetic services and kids that are screened for sickle cell, for glycemia and for PKU, and who makes sure that they get into treatment once they are identified. We also worry bout underinsured children. So those are all things that MCH could do.
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    We looked at every one of the areas in the agency and tried to think not only where should be we be in 5 years in light of what is happening within the system, but how do they interface. And what we are trying to do is think strategically to get outside of our stovepipe, categorical mindset and think across agencies in the areas that if we—for instance, telemedicine. We have telemedicine activities in health professions, in rural health. We also support them in other ways through other funding sources. But how can we make sure that in the community, our AHECs and our rural health telemedicine activities are coming together?

    So we really have tried a lot of strategic thinking. We are not there yet, Mr. Chairman. I think that we are working on it. We have a strategic plan that we think begins to reflect that. What we are doing now is trying to actually make sure that our operations, our business plan for the agency reflects strategically where we want to go and that the performance measures that we then provide to you and to the rest of this Congress then will tell us when we get there and that they track. And I don't think it has ever tracked before, but our plan is for it to track from the strategic goals to the business plan, to the performance measures, and then to the budget request and the budget expenditures.

    So that is a long answer to say that we really are trying to think through this. We have spent a lot of time. It has not been delegated to lower-level staff. And I hope that as we move forward—and I think we have something better now than we had a year ago, and a year from now I think we will have something even better. And in the process, we are trying to think what type of information do we not have that can better tell us.

    Health professions, we are trying to do some things. We know there is some need for additional information there. So I think we are moving in this area, and I am very pleased with where we have gone in the last year, and I think a year from now we will have even more information for you.
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    Mr. PORTER. Dr. Fox, I like the way that you think.

    When we talked to the Secretary yesterday, we talked about the 21st Century Fund for Research and about how to integrate research, delivery, and evaluation. The Secretary used the example of NIH, CDC, and ACHPR. You also have an interest in moving research into the delivery system. Have you looked more broadly as to how you can integrate your work in that same way?

    Dr. FOX. Well, a couple comments. One, as you know, we have some discretionary money, and two programs come to mind, although we have a little bit everywhere. But in Maternal and Child Health, with the SPRANS, we have a set-aside of dollars that fund training and various demonstration projects. And we have in HIV/AIDS, SPNS, which does some analogous activities.

    One of the things we are trying to do is think through in an applied research way how can we spend that money to help us better direct services for mothers and children. How can we spend part of that 15 percent set-aside to tell us what we ought to be doing with the 85 percent state funds.

    The SPNS money, which is $25 million of a billion-plus dollars in HIV/AIDS. What can we be doing with the SPNS money that helps Joe O'Neill and the people that are under him figure out where we should better be targeting and spending the $1 billion. And so that is one thing we can do.
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    The second thing we can do is work with other groups, like ACHPR. We have had some conversations since I arrived about joint efforts to try to, again, think through, for instance, in the child health area, when this Congress—when the money that you have provided is spent in child health insurance, how do we know what we have done? And what are our tools to do that? And I think that we are trying to think through that with ACHPR.

    Then the final thing in the area of what the—the example of the treatment guidelines, for instance, that are coming out of NIH, work very closely there. Dr. O'Neill is working right now on what kind of things we can do within the primary health care system and within our other providers, rural health, to make sure that we get out to the community as quickly as possible the—as things come out of the research community and they tell us we ought to be doing X, Y, Z, whether it is an AIDS treatment or hypertension or whatever, that we get that out to the practice community and to the providers so that they can actually translate it into what they are doing in providing care.

    We have some specific things we are working on in that area. We had a teleconference last week, in fact, where we actually did that. We have had a live hookup for people to call in and to ask questions. We are looking at some online computer-based mechanisms where we can actually have infectious disease fellows who can actually be on a computer and provide real-time counseling to people out in the community, if you have an AIDS patient who wants to know what to do.

    So there is a lot going on, and we want to continue to push that way, and I think it is a very appropriate part of what we do.
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    Mr. PORTER. Thank you very much.

    Either Friday or Monday—I can't remember which—Secretary Shalala issued a regulation that will revamp the system for allocating livers to people awaiting transplants. And if I understand the regulation, what it attempts to do is to give livers to those who are most in need of them and to circumvent the regional allocation that we have had in the past, so that someone who is going to die if they don't get a liver and doesn't live in a region where there is one available can receive one.

    Is there likely to be a lawsuit over this by the organization that has done the organ distributions and had apparently complete responsibility for it? Secondly, if this makes sense in reference to livers, would it also make sense in reference to other organs? Was this limited to livers simply because it is politically difficult to do all organs at the same time?

    Dr. FOX. Mr. Chairman, out of respect to this body, the Secretary has delayed the release or the implementation of the regs, so they have actually not gone out. At the request of many of the Members, we were asked not to do that, and we have withheld those.

    Mr. PORTER. That may be a mistake, but all right.

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    Dr. FOX. Well, I think the plan is for them to go out. But to have the opportunity to have dialogue, I think there was a concern that we would release them while many of the Members were on recess previously, and we want to give the Congress a chance to basically have a dialogue with the Department around that. I think that they will be released.

    Let me just say that the regs do not specify a specific allocation policy. In fact, what they do is—the language actually provides specifically that the allocation policy in this country around all organs, not just livers, will be the responsibility of the Board of Directors of the OPTN, the organ agency, basically UNOS right now. And so that that policy still will rest with the transplant community to formulate.

    Now, the Secretary will maintain oversight over that, and I think that what we want to do is continue to rely on the transplant community to come up with a more equitable transplant policy. It may be national allocation. It may be regional allocation. I think the bottom line of what we want to see is equity in people's ability to get a transplant in this country. And the fact that if you live in one place in the United States, you may have a 5- to 10-fold waiting time in the time it takes you to get an organ if you are in need of transplant. We want to see that equal.

    And so the intent of the regulation is going to be to try to equalize that and to introduce what we think will be some fairness. We don't want to put transplant centers out of business. That is not our goal. Our goal is to try to have equity in the system. And, again, we are not specifying a specific allocation policy either for livers, kidneys, or anything else. What we are doing is laying out a framework and a set of performance goals for the system to say that how somebody gets on a list, where they sit on the list, ought to be based on objective medical criteria, and that should be the same across this country. It is not right now. That the allocation policy should take into account a variety of things, waiting times and other things.
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    And so what we have tried to do is lay out some parameters, because I think that with the change in technology and the change in the way transplantation is going in this country, it would be inadvisable for us to put specific allocation policies in regs. So what we have done is lay a framework to charge UNOS, the OPTN board, to do that but within some general performance parameters.

    Mr. PORTER. Well, it seems to me that there is something inherently immoral about allowing someone to die in Las Vegas, Nevada, while there is an abundant supply of organs in Chicago but people do not need them as badly.

    I think the Secretary should proceed. The Congress is obviously trying to protect its own base, which means its nearest center. We are always going to say, well, we are going to look out for our own supplies but, it seems to me that this is at least a national matter where lives can be saved and to allow someone to die is just not acceptable, and I think the Secretary is aiming in the right direction.

    Should not you do this with all organs?

    Dr. FOX. We are proposing with all organs.

    Mr. PORTER. It is all organs?

    Dr. FOX. Yes, sir.

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    Mr. PORTER. So, I first heard it was all organs and then I read the press and it only referred to livers.

    Dr. FOX. There is actual little difference in the timing but it is basically all organs.

    Mr. PORTER. All organs.

    Dr. FOX. Yes, sir.


    Mr. PORTER. Good. The Bureau of Health Professions, within your agency, has been working for years on the development of a comprehensive performance monitoring system to be used to measure the outcomes of the health professions and nursing education programs. What is the status of this initiative and when will you have a system in place to do it?

    Dr. FOX. Well, we are working on that. As I understand it, it is within the clearance process within the Department. I believe it is actually being reviewed by OMB, right now. We think if you give us more information, I think actually we have more information than we had a year ago, and some of the things that we portrayed up here we want to build on.

    What we have got to do is make sure we can actually track the people that graduate from these programs and have some idea of what communities they are going into. And we think this will help us do this.
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    So, we are working on it. It is within OMB now being reviewed and we are trying to make sure that we can get what information is going to be out there in order to report back to this committee. It is on track and, as soon as it is cleared through OMB, we will proceed with it.


    Mr. PORTER. On performance measures under the Results Act, many of the measurements are dependent on data gathered from grantees at the State and local level. In order for goals and outcomes to be meaningful it seems all entities involved must be using the same set of terms, standards, and benchmarks. What are you doing to address this problem and will additional funding be required to implement these standards? If so, is there an estimate for it?

    Dr. FOX. Well, you have to—obviously we are trying to start at the actual ground level and I will give you an example. One of the things that Dr. O'Neill is addressing with the Ryan White Program right now is to make sure that we are using the same definitions and the same reporting methods that go across all the Ryan White titles, four titles.

    And, so, we are starting there and we are trying to also look across the agency. We have an internal—Mr. Morford chairs, something we started back a month or two ago, an internal data subcommittee, it sounds like a boring subject.

    But the bottom line is that we are trying to look across agencies at what data we are collecting, how we are collecting it, and are we collecting it in ways that it is duplicative, or we collecting it in ways that we can pool the data and have a better idea of what is going on out there?
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    We have several other projects that I think interface on this, one being in the maternal, child health area. Dr. Nora and her staff have initiated, and piloted with the States, an electronic disc, with a reporting form for block grant monies that provides some consistency across all of the States, and it does it in a way that is very user-friendly.

    We have asked the States what works and what does not work. In the past, we would have had up to a three year lag time to get our reports and information in, and now it is going to be six months.

    And we actually are in the process—this again has been cleared by OMB—we are in the process of getting it off the ground. So, a lot more needs to be done, Mr. Chairman, as you might suspect, but I think we are working within HRSA to try to—we are doing this on several fronts. It is a data issue that we are specifically looking at now by having a weekly meeting of data of our folks within the agency trying to look across data. We are doing the same thing in distance-based learning and in some other areas as well trying to, again, bring everything together that we are working on.

    So, there is a lot going on in this area.


    Mr. PORTER. The mission of the health centers is to increase access to comprehensive primary and preventive health care and to improve the health status of underserved and vulnerable populations.
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    Is not the Secretary's new initiative on race and health disparities duplicative of this?

    Dr. FOX. We actually think it is complementary. I, for one think, and I suspect most people here sitting with me would agree, that most of what we do at HRSA is really targeted at racial disparities.

    And most of the groups that we serve through any program that is represented at this table is having, I hope, and I think we can show in many ways a disproportionate positive effect on health disparities. But the problem is that in many instances our health disparities continue.

    Infant mortality being a prime example, where the low birth rate and the infant mortality rate among our African-American infants is, in most places, twice that of whites and, in some places, three times that of whites.

    And in many communities we are not narrowing the gap, it is widening. The stroke incidence among African-Americans is much higher, the deaths from cardiovascular disease is much higher. And, so, we, I think, particularly for HRSA, because of the role and charge we have, it is very complementary to what we do and fits in very well.

    And, again, we see this as part of what we do anyway and I think it will help us in our mission.

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    Mr. PORTER. I was not questioning the need for it. I was simply saying is it not already being done?

    Dr. FOX. Well, again, I think that you will see a whole variety of agencies, and HRSA is not alone in this, that address issues that you would say are giving attention to racial disparities. But there is not enough effort there.

    And again if you think about the disparities in virtually—in fact, NCHS has their Healthy People 2000 data unit, actually publishes an annual report that lays some of this out in fairly graphic terms—and we think that there is certainly a need for additional effort in virtually any health condition that you could take in this country because the disparities are so great.


    Mr. PORTER. A total of $160 million was provided in fiscal years 1997 and 1998 for guaranteed loans for community health centers. Loans could be used either for construction or for developing managed care networks. How many requests for these funds have you received and how many loans have you actually made?

    Dr. FOX. This is a very, very difficult situation and one of the problems we have with the community health centers is they do not have generally a lot of assets. And Dr. Gaston and I, in fact, will talk about talking about this earlier and I am going to ask her to comment on it. But it is an area we are very concerned about.

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    We are working hard through a variety of strategies to make sure that loans are available to community health centers but this has been a very problematic area for us. And maybe I will ask her to detail that.

    Dr. GASTON. As Dr. Fox is saying, it is very difficult for our programs that have no assets and no cash reserves to convince banks that they are a good credit risk.

    And, so, that is one major barrier. It takes about two to three years to really move a project that is a new capital investment, a new facility. There are a lot of issues around it that relate to just the architectural and, again, getting back to needing to get a loan. We have received 12 requests for the loan guarantee. At this point in time, we have definitely approved two and three more are very close to being approved.

    But that is why there is not a request this year because we can make it through 1999 with funds appropriated in fiscal years 1997 and 1988.

    But it is a very complex area and it has required review and compliance with complicated laws and regulations. There is only one other program in HRSA that does loan guarantees. So, this was a challenging project for all of us in the department.

    Dr. FOX. And, in fact, Mr. Chairman, if I could—we can provide you—there is a fairly detailed set of things that we have done to try to move this issue that we would be glad to provide you.

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    Mr. PORTER. It is both new to the Department and new to the community health centers. You mentioned credit risk, but this is a guarantee program and the Federal government guarantees the loans, so I do not think it is a credit problem. It seems to be a problem of not having done this before and something new to both the provider and those applying for the loan.

    Dr. GASTON. You are absolutely right. If I may, the facility loan is not a 100 percent guaranteed. There is a 20 percent risk that the bank would take and for the networks and the plans there is a 15 percent risk. So, there is some concern in that arena.

    Mr. PORTER. We think banks ought to take a little risk from time to time.

    Dr. GASTON. We agree with you. [Laughter.]


    Mr. PORTER. Can you tell me the status of transferring the Hansen's Disease Center in Carville, Louisiana to the State?

    Dr. FOX. Yes, sir. We are moving along with that. As you know, there was some money provided in the 1998 budget to prepare the facility for the transfer. The individuals who will be retiring, there has been a provision made for that and then the patients that are actually at the facility that really fall into two groups. The ones that want to stay in some type of residential care and those arrangements are being made. And then for those patients that do not want to stay there they will get a stipend to basically support them. That is being done.
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    We will have and are in the process of working up a plan, Mr. Chairman, that will provide for this body what we will need from this point on. Right now, the slight decrease in the Hansen's money that is requested for 1999, again, reflects the one-time money last year for the facilities.

    There may be some other funding that is needed. Right now, we are not in a position to delineate that. We will have the report. At this point, we anticipate having it by June and we could provide it to this body. And I think it will give you fairly explicit comments as far as what is needed from this point on. But it is on track.


    Mr. PORTER. The House report included language regarding its concerns with the Centers of Excellence program. The committee recommended this program refocus on providing support to the historically Minority Health Professions institutions and report back to the committee on the progress of this effort by February 1, 1998. It is now March 4th and the committee has not received the report. When will we get it and can you summarize its findings for us?

    Dr. FOX. I prefer to tell you when the report will be available. But let me just tell you that I have spent a fair amount of time, as hopefully Mr. Stokes and all of us know since my arrival at HRSA, to look at this issue.

    And, again, we have, I think, ensured and done everything we can to ensure that we are making the expenditures that this body provided and, in fact, we have increased the funding for both—and in the COE and HCOP—for both the historical black colleges and the Hispanic-serving institutions in the HRSA budget. I think we have gone beyond what we had to do. And, again, if there is any concern, at this point, I certainly would love to have the details on it.
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    But we feel like we have complied with both the letter and the spirit of the law in this area and will continue to do so. And as far as the actual written report, I will defer to Tony for when we will have that. But, again, we have the numbers and I can give you the breakdown for the numbers in the various programs and what we have done and I do know that we have that that we could provide this committee right away.

    Mr. PORTER. The date of the report?

    Dr. HOLLINS. I will have to get back to you. I do not have a specific date but, as Dr. Fox said, we have numbers that will detail what monies have gone where. And we can make that available to you.

    Dr. FOX. We can actually get that to you within 24 hours and I will get the date for the report, as well.


    Mr. PORTER. How are the Centers of Excellence and the Health Careers Opportunity programs different?

    Dr. FOX. The COE really targets faculty and a lot of the, what I guess you might consider infrastructure support. The HCOP is more an issue of what we do with the students now trying to make sure that there is a pipeline of minority students into the programs. Obviously, both of these programs deal with, in many instances, the same institution and in some instances, not. But, that I guess if I had to draw the main distinction between the two, that would be it.
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    Mr. PORTER. Funding was provided for the first time in fiscal year 1998 for the Abstinence Education programs. Since States are required to match every four Federal dollars with three State dollars, how many States have applied to receive this funding?

    Dr. FOX. Mr. Chairman, all the States have applied. We have had a few territories that have not. And all States were funded.

    We did have grant conditions on all the States and we are working with them. Again, we feel that we have worked hard to comply, not only with the letter of the law but with the spirit of the law, and follow the guidance that the law provided for what these grants should do.

    So, every State applied and every State was funded.

    Mr. PORTER. Let me recognize Mr. Stokes right now. He has a few more questions.


    Mr. STOKES. I have just a couple of more questions. I see we have a vote on, Mr. Chairman. I will submit the others for the record.

    But I was particularly interested in your mention of infant mortality, Dr. Fox. I have, I guess for more than two decades, sat on this committee talking to health officials about infant mortality which I think is a major problem for the United States.
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    How do we now compare with our global counterparts in terms of the rate of infant mortality?

    Dr. FOX. Overall, we are still high as far as an industrialized country. If you break it down, however Mr. Stokes, as I am sure you know, the infant mortality rate for groups like our African-American babies is still quite high.

    Part of the problem is the low birth weight rate. And the major contributor to infant mortality in this country—I mean there are obviously a lot—but the major contributor is the problem of low birth weight. And quite frankly, it is an area that we really do not have the key to turn that lock yet. We know there are things like smoking and nutrition and access to prenatal care that will impact, however, the low birth weight rates in this country for the most part for the last 10 or 20 years have remained static.

    We have made improvements in increasing the survival of low birth weight infants and of infants in the post-neonatal period. We have made improvements there with SIDS, major improvements in SIDS.

    We have made improvements by making sure, again through maternal and child health and others, that mothers and infants will get into care and that they get the care in the right place based on the risk.

    So, we have made progress but the infant mortality, the low birth weight rate in this country is still an enigma, and it is an issue, in my opinion, that we do not know the answer to and there is more research that is going to be required in that area. And because it is the major chunk of infant mortality, until we deal with that, we are, I mean we continue to make progress, but it is a major problem.
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    Mr. STOKES. I notice that your budget proposal flat-funds Healthy Start program. Wouldn't more funding help in this particular area?

    Dr. FOX. Again, we are in the process of funding some new grants. What we have done is actually transitioned the initial Healthy Start grants that were demonstrations and are now, 20 of the 22, are going to be mentoring sites and take those lessons that they have developed and learned and will provide them then to 41 new grantees that we are funding. We are also assisting 14 other communities with planning grants.

    And what we are trying to do right now, we are working with Mathematica and others who are helping us massage the data to really tease out those things within Healthy Start that we have the most impact on. We know that we have improved access to prenatal care. We know we have changed, improved the issue of substance abuse among many of the communities we serve. We know that we have increased visibility around infant mortality in the community and there are things that are very positive that I think we have done.

    So, what we are trying to do right now is to make sure that those lessons get disseminated and working with various communities in planning grants. And I think it is not inconceivable that we may want to look at other options down the road. But the bottom line is I think we have taken and actually broadened a number of communities. What has happened is we have gone to a smaller number of grants for more communities.

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    Dr. GASTON. If I can brag about the community health centers in terms of what we are doing with low birth weight. As you know and as Dr. Fox said, that nationally the rate for African-American babies is twice that of the majority population.

    In the health centers population we have brought the rate to the level of the majority population. It is not twice for African-Americans that of white babies. And, so, it goes to show that with aggressive programs that are community based, doing outreach, keeping mothers in care make a difference.

    Mr. STOKES. Thank you very much.

    Mr. Chairman, I appreciate the time. I will submit the balance of my questions for the record. But I do want to say to Dr. Fox and his colleagues how much I appreciate the responsiveness and the attention that you are paying to these type of programs that I am particularly concerned about and where, I think, the whole nation should be concerned about.

    Dr. FOX. We agree.

    Mr. STOKES. Thank you.


    Mr. PORTER. Thank you, Mr. Stokes.
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    A final question, Dr. Fox. This is in the context of pages 133 and 134 of the budget justification, which is the supporting documentation of the budget request for the Health Administration program. The programs is used to help subsidize the tuition burden of financially needy health administrator students and the average per student cost per year is $392.

    We would ask how cost-effective can this program be because that has got to be way short of what the costs for a student are? In other words, how can $392 help a graduate student? And the broader question is, how often do you evaluate programs you administer? Do you look at them to determine how effective they are every year, every three years, or every 10 years? What do you do to marry the facts out there with the facts of the program?

    Dr. FOX. Let me just say that part of the problem is that many of the stipends that we provide are below what, I think if they were optimum money available, we would like to see done. We try to again spread the limited dollars we have as far as we can and hope that we can provide enough to make the opportunities available.

    The Health Administration area, as the public health area, as preventive medicine area, are those areas that I think for the most part the market is not going to take care of. These are areas that really provide an infrastructure for this country around what we do in prevention and in public health. And for that reason, I think it is important that we can support that.

    We do look at these programs. I know we have reports that are required annually. I will have to get the details on this particular area. I cannot tell you right off the top of my head.
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    Mr. PORTER. Dr. Fox, my point though is that it is almost useless to give $400 a year to a number of students. It does not do anything for them or almost nothing considering the costs that they have to bear and maybe the program ought to be completely changed so that we target it better, give it to the most needy, give them substantial monies rather than spreading it around. It just does not make any sense at all to me. It is just money out the window basically.

    Dr. FOX. Well, we will be glad to look at that, Mr. Chairman, and I think that these areas, like I said, particularly in those particular categories are areas that, you know, the market is not going to take care of. So, I think there is, in my mind, there is no question about the need. There may be a question about how we target the dollars. And we will be glad to look at that and reevaluate that as part of what we normally do.

    Mr. PORTER. Dr. Fox, let me thank you and your team for the fine job you are doing. Thank you.

    Dr. FOX. Thank you so much, Mr. Chairman, thank you.

    Mr. PORTER. Thank you.

    The subcommittee will stand in recess until 2:00 p.m.

    [The following questions were submitted to be answered for the record:]
    "The Official Committee record contains additional material here."
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Tuesday, March 3, 1998.










    Mr. PORTER. The subcommittee will come to order. We began our hearings of the Department of Health and Human Services this morning with Secretary Shalala, and our hearings for the Department continue this afternoon with the Substance Abuse and Mental Health Services Administration. We are very pleased to welcome Dr. Nelba Chavez, the Administrator. Dr. Chavez, will you introduce the people who are with you and then to proceed with your statement.
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Opening Statement

    Ms. CHAVEZ. Thank you, Mr. Porter. To my far left is Dr. Goldstone, who is the Director for the Office of Applied Studies; Dr. Karol Kumpfer, the new Director for the Center for Substance Abuse Prevention. I might add this is her second week.

    Mr. PORTER. We will be nice to her.

    Ms. CHAVEZ. I feel very good that she is with us. She comes to us with a great deal of experience and very well known in the field of prevention. Also we have Dr. Bernie Arons, who is the Director for the Center for Mental Health Services. To my far right, we have Dennis Williams from the Department.

    We also have Dr. Camille Barry, who is the Acting Director for the Center for Substance Abuse Treatment and Daryl Kade, who is the Director of Budget.

    Mr. Chairman, we have submitted SAMSHA's full testimony for the record. Mr. Chairman and members of the subcommittee, I am pleased to present the President's 1999 budget for SAMSHA. We are proposing $2.3 billion, a $132 million increase over our 1998 level. As on previous occasions, we will highlight for you some of the remarkable accomplishments, some exciting paths we are taking, and the challenges we must face in the 21st Century.

    In his State of the Union address, the President spoke of ''an America where every citizen can live in a safe community, where families are strong, schools are good.'' As we look to the new century, two threats to the promise of a healthier, better future are clear. Mental and addictive disorders are among the most prevalent and most often ignored health problems in our Nation. In fact, by 2020, the World Health Organization projects that depression will become the second leading cause of disability in the world, exceeded only by heart disease, and nothing threatens the health and productivity of the United States more than our appetite for drugs and alcohol.
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    Drug and alcohol abuse ravages the lives of millions and fuels crime, domestic violence, disease and death. In a recent survey of adults, 52 percent listed drugs as the top problem facing American children today and tomorrow. SAMSHA has repeatedly demonstrated the effectiveness of federally supported mental health services and drug and alcohol prevention and treatment programs. For example, children receiving services through our Comprehensive Community Mental Health Services for Children and Their Families programs have made substantial mental health gains and improvements in school performance and school attendance. Yet, two-thirds of the young people in this country. who suffer from a mental disorder, are not receiving the help they need.

    Likewise, our treatment programs have shown that a 50 percent reduction can occur in drug use. As a result, people have better job prospects, better incomes and better physical and mental health. They are less likely to be homeless and less likely to be involved in criminal activity and risky sexual behaviors.

    The tragedy is that 63 percent of those who would benefit from treatment, which is approximately 3.3 million people, did not receive it in 1996 and the gap is growing.

    To help stem the tide, the President has proposed a $1.5 billion investment, which is a 15 percent increase in SAMSHA's Substance Abuse Block Grant. This $200 million increase will support and maintain State efforts to fund treatment and prevention programs. However, block grants are not enough. A strategic approach also requires a Federal investment in service research and development and in cultivating a system that is responsive to current and emerging needs.
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    First, wise investments in service research and development, through our KDA Program can speed findings from the laboratory to community health centers. We give it life. It can stimulate the discovery of new, more efficient and more cost-effective ways to deliver services paid for by block grants, Medicaid and Medicare. For example, getting homeless people who have multiple diagnoses, such as mental illness, substance abuse and chronic health conditions like HIV/AIDS appropriate care and off the streets is a serious challenge.

    Our Center for Mental Health Services Access program found new service approaches that reduced homelessness by 76 percent and increased independent housing by 43 percent. With these findings, we are embarking on a redesign of homeless services in five communities, in Alaska, California, Louisiana, Alabama and right here in Maryland.

    The progress we have made during the last few years in understanding the brain and psychological responses to drugs is extraordinary. I have no doubt that within the next decade, we will develop medicines to treat addiction just as we have medicines available to treat epilepsy and some forms of mental illness. However, medicines alone will not eliminate the problem.

    As we have learned from our experience with Naltrexone, even when we have effective medicines, there is no assurance people will use them. We must continue to study why people abuse drugs or develop mental illness, how to prevent their causes, what treatments work for people in their homes and communities, as compared to the experimental setting and why people fail to take advantage of treatment.

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    Many times, people fail to take advantage of treatment because the treatment is inappropriate, the treatment is not available, or they don't have the access, access not only in relation to the accessibility but, more importantly, access in ensuring that it meets the cultural and racial differences.

    We are very concerned, about the critical questions that we have not yet been able to answer but are in the process of addressing through many of our KDA programs. What we are finding is that many of our KDA funds are increasingly being used to leverage State and local resources and Block Grant funds in order to address the most urgent and emerging issues.

    For example, with KDA dollars our State Incentive Grant Program, is working with Governors in Vermont, Connecticut, Illinois, Kansas and Oregon to develop statewide strategies and deliver science-based prevention services developed by SAMSHA and others. We are very excited about this because of what is happening in these five States that we were able to fund this year, and we will submit for the record some information that I think you will find very exciting about how governors are now coordinating all of these funding streams for prevention that are coming into the States and are developing prevention strategies that are based on science.

    In addition to adapting science-based prevention programs to local needs, one of the requirements of the State Incentive Grant is for governors to account for coordinate and strategically manage the many funding streams in their State, including the 20 percent Substance Abuse Block Grant prevention set-aside and the dollars that they get through the Department of Education, and their Safe and Drug Free School programs.

    This July, we expect to fund an additional 15 to 18 new States, and an additional two states in 1999. To cultivate a treatment system that is responsive to current and emerging needs, we are initiating our new Targeted Capacity Expansion program. It would be used to help fund States, cities, counties, or others that identify an emerging need in a geographic area and can rapidly put into place an effective treatment approach to stop or slow deadly drug epidemics. These are regional problems that we are dealing with, and we will talk later about what we mean by that.
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    Some of the examples include the outbreak of methamphetamine use that has spread throughout the Southwest, or heroin use, which can be localized as it is in a small town in Texas. This new use of our KDA funds directly supports Goal 3, Objective 1 of the President's National Drug Control Strategy.

    Finally, our 1999 budget incorporates our first annual performance plan. The goals and measures are both linked to our budget and the HHS GPRA Strategic Plan. We look forward to Congress' feedback on the usefulness of our plan, as well as to working with Congress on achieving the goals described.

    Mr. Chairman, we have a three-part strategy—for closing the treatment gap, which includes investing in services research and development through our knowledge, development and application grants;

    Second, cultivating a system that is responsive to the current and emerging needs through targeted capacity development; and

    Third, supporting and maintaining State systems through the Block Grants. We feel this strategy provides the balanced approach needed to seriously address the gap between people in need and services available.

    Our budget is a down payment on closing the gap that exists. It strengthens the bridge between laboratory research and everyday health care delivery, and it supports the President's vision for the 21st century.
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    We will be pleased to answer any questions you may have. Thank you.

    [The prepared statement follows:]
    "The Official Committee record contains additional material here."


    Mr. PORTER. Dr. Chavez, thank you for your fine opening statement. I am afraid I have to subject you to my very brief sermonette, which goes something like this:

    The President's budget was fine, but the revenues, the new revenues that the President suggests in his budget that support a good deal of the discretionary spending increases are very, very problematical. It is very unlikely that they are going to be adopted this year; and that means we probably are not going to have the resources that otherwise we might have to work with. This is going to make it difficult to meet the spending targets, obviously, that every agency and department coming before us is suggesting.

    We will do the best that we can, and your area of responsibility is obviously a very important one. Your agency spends about a billion and a half dollars a year on substance abuse, both prevention and treatment activities, and yet, after years of decline, we are now seeing drug use in our country on the rise, especially among young people. I would add that your agency is just one of many Federal agencies that spends money on the fight against illegal drug use. How do you explain the increase in drug use at this point in time?
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    Ms. CHAVEZ. Mr. Chairman, there have been some dramatic changes that we have seen in the past 10 years, and one is that drug use, has become very glamorous. We see that often through the media, through our movies, through our videos, through other media.

    We also have seen a change in the attitudes that young people have toward drugs, especially when it comes to the use of marijuana, in that many youth feel that it is not wrong to use marijuana.

    In addition to that, the glamorization, or how drug use is viewed, we have another issue that we have been dealing with that many parents grew up in the 1960's and the drug use at that time was somewhat different. Marijuana was not as strong as it is today, and many of these parents find it very difficult to talk to their children because of their own past use.

    I would like to have Dr. Kumpfer expand on this answer a little bit more in terms of these uses. SAMSHA is taking some very strong measures but it is not just SAMSHA. We are working with General McCaffrey and the Office of National Drug Control Policy.

    Dr. Kumpfer.

    Dr. KUMPFER. Dr. Chavez, that was a very good answer. I have done research on the factors related to drug use in youth across the country. The causes of drug use are complex and involve many different aspects of the youth's environment, including the family, the school, the community, the cultural community, the media, a number of the factors that Dr. Chavez has already mentioned.
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    I think one of the other major factors that we need to take into consideration is the breakdown of families. I had predicted at least 10 years ago that we would have this upswing in drug use, because of changes in family statistics. If you look at the amount of time that parents are spending with their kids, over time, through Child Trends, you could see that it was predictable that parents were not spending as much time with their children; hence they were not going to have as much positive socialization influence on their children. They were not going to be talking with their children as much, and helping to ensure that those children would not use drugs.

    Youth who like their parents are less likely to use drugs. Research such as the Pride survey and the NIMH Resnick study suggest that the primary reason for youth not to use drugs in this country is the family. If the family is opposed to drug use and children are attached to their parents, they are not going to use drugs, even though the primary influence to use drugs is the peer group. So we have got to, through our prevention efforts, keep the family strong; and that is what I have dedicated my life to.


    Mr. PORTER. Well, Dr. Kumpfer, can we assume then that since we have had, in the near term, a much greater emphasis on family, that this is going to give us some optimism about future drug use?

    And the second question would be, if the effort for prevention is the one that is going to keep us—or help us get away from having increased drug use in the future, why aren't we spending more money there and less money on treatment, since preventing a case of illicit drug use probably will not save individuals, but it will save a great deal of resources in the long term if we don't have the incidence in the first place?
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    Dr. KUMPFER. Thank you, Chairman Porter. I certainly agree with you. This has been a very exciting time for the prevention field. I have been in this field for over 20 years, and what we are seeing now is really a confluence. It is like the stars are coming together. We are finding that across many different Federal agencies and research agencies that we now know, after so many years, what works in prevention and what doesn't work in prevention. Family strategies really have become much more popular.

    Actually, I published an article about 10 years ago called the ''Cinderellas of Prevention, Want to Come to the Ball, Too.'' It was about a need for more family-based approaches and environmental approaches. And what we have found is that finally, over the years, we now know the strategies that work. The most effective approach is a comprehensive, coordinated strategy. It involves strengthening the family, strengthening our schools, strengthening our communities and also working with the larger environment, such as the media, and policies. To create a consistent no-use message and a caring place where kids are successful and happy.

    And what you are saying is right, that a number of Federal Research agencies like NIMH, NIDA and, now—NIAAA, have gotten much more involved and in testing family-based approaches. In fact, I have been working with OJJDP for the last 10 years to locate best practices through the research literature and to disseminate information on the top parenting and family strengthening programs, to the field.

    And that is the critical job that I envision for CSAP. We are the needed bridge between research and practice. We now know what works in research, and we can serve as the bridge to get that information out to the States and to the local communities through the State block grants, through the the State Incentive Grants (SIGs), et cetera, and support them to do the prevention programs that work.
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    So in terms of your question, yes, there is a great deal of optimism. We can now do that very effectively. After 25 years, we have gotten out of our infancy in prevention, and we are now mature. And, yes, we are seeing a little bit of hope, because states and communities, with our help are starting to do more effective prevention programs.

    We are seeing that the eighth graders for the first time are not using drugs as much and—I hope we are going to start seeing a reverse trend if we continue with good prevention programs.

    Ms. CHAVEZ. Chairman Porter, may I comment on that, please?

    One of the things that I don't think we have done very well as a country and in our society is really focus our prevention and interventions in children at a much younger age. In the past few years, more and more research findings have been coming out about how important it is to focus on children at a very young age. One of the programs that we introduced last year, Starting Early/Starting Smart, includes 12 projects, Chairman Porter, is to examine children zero to 7—not just from a prevention perspective, but also in terms of their mental health and substance abuse.

    Where do you find these populations? You may find them in primary care settings or you may find them in child development centers.

    We have been able to support 12 of these projects throughout the country; and the beauty of this strategy is that we are going to be examining integrated services, a very holistic approach. The question of which interventions are appropriate by the child's developmental age is number one.
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    We are not undertaking this effort alone. The Department of Education is investing resources for the evaluation component, and other Federal agencies are doing the same.

    But I think the most critical aspect in terms of ultimate goal, is the fact that we have the Casey Family Program involved. Their role has been key from the outset. Not only they are putting money in; but after the Federal dollars are gone, they will continue to support some of these communities that have demonstrated that, yes, we can make a difference.

    One of the reasons that the Casey Program became involved in this endeavor is because they have been very much involved in foster care, and from that perspective they have begun to notice that many children needing services are coming in too late. So we believe very strongly that prevention is very important.

    For example, our idea of prevention 15 years ago was to go in a class and do a 1-hour presentation, and then we had done our job. We have learned a lot since then, as noted by Dr. Kumpfer.

    But it is not just SAMSHA. We are beginning to coordinate more and more with ONDCP. But SAMSHA has a very important and very unique role to play. I mean this not only with respect to prevention—we cannot treat prevention in isolation. We must also consider treatment, needs and not forget that we have many individuals that suffer from co-morbidity. Many young children have mental problems in this country as well, and many later develop substance abuse problems.

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    Mr. PORTER. I certainly agree with what you are saying, and I also would add that mass media often can address the glamour part of this equation.

    I think you have to go where kids are and where their attention is. I know that this doesn't necessarily apply to drugs, although it certainly is a relevant tangent, but when my kids were young, for example, they picked up from television that cigarettes were not good for you. That was about the time that I had quit smoking, but their mother had continued to smoke and those kids used to go into her purse, steal the cigarettes and flush them down the toilet because they knew that it was bad for her and they wanted her not to do it. Today, while she continues to smoke, none of our kids has ever even thought of smoking. So, if you reach them at the right age with the right message through the right medium, you can change their conduct and make a difference in their lives, I think even in a broader sense.

    Let me ask either you, Dr. Chavez or Dr. Kumpfer, when the Secretary testified this morning, she was talking about the 21st Century Research Fund. Her example was the use of NIH working together with AHCPR and CDC, jointly, to address infectious diseases. Has the Secretary gotten you in the same mode of working with other relevant agencies that can combine research and outreach and evaluation efforts? In other words, are you part of this concept as well?

    Ms. CHAVEZ. Chairman Porter, we are not exactly part of that one concept. However, SAMSHA and its three centers work very closely not only with all of the NIH, but with CDC, HRSA, ACF, all of the HHS programs.
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    But we also go beyond that. We work with the Department of Education; we work with HUD; we have partnered with Justice on many things. One of the best programs that we support is our GAINS program. The Center for Mental Health Services through Dr. Arons' leadership, and the Center for Substance Abuse Treatment, through Dr. Barry's leadership, are working very closely with Justice in the area of the dually diagnosed. As you well know, many individuals that are incarcerated have not only a substance abuse problem, but also have serious mental problems. So we are doing a lot of partnering in that area as well.

    In terms of our evaluations, Dr. Goldstone's Office of Applied Studies and Dr. Arons have been working closely in the areas of data collection and evaluation.

    I think it is very important to highlight once again that SAMHSA serves a very important role in this country. SAMSHA is the only agency that can take a large segment of the research that has been done in these areas and give it life in the community.

    Earlier, I spoke about some medications. Other effected medications have been developed, and we have spent billions of dollars of taxpayers' money to do so, for example, methadone, LAAM, et cetera. Yet we still have in this country 600,000 addicts, and these individuals are still addicted to heroin.

    There is treatment available and that is methadone, and also LAAM. And guess what? Only 115,000 of these people that are taking these medication, which are very effective. The question is, why? A variety of reasons.

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    Examining such questions represents a very important niche for SAMSHA, because it doesn't do the taxpayer any good for the Federal Government to continue to spend money on treatment if we cannot apply that knowledge at the community level where people need it the most.

    Mr. PORTER. Well that is why I asked about the 21st Century Research Fund because it seems to me that if the model of NIH, CDC, and AHCPR is a good one, then why isn't the model of NIDA, or NIMH, SAMSHA and AHCPR also a good one? In other words, why wouldn't you put all the agencies that work in the same areas together in coordination with one another doing the research, applying it and then analyzing the results to see whether you have gotten a good result and what works and what doesn't work?

    Dr. ARONS. Yes, Mr. Chairman. I would like to take a moment to try to address some of those issues; and for me, I try to remember back to the direct recipients of care that we are really improving the systems for, whether it is an individual who is homeless and on the streets of our cities with a severe mental illness, or a child in school where the teacher is concerned because this child isn't functioning as well as they might because of a serious emotional disturbance; or individuals who, unfortunately, these days are sometimes put in jail, sometimes even without a charge, because of a mental illness and inadequate services.

    In all of these areas, I think the notion of partnerships is critical, but the process of building appropriate partnerships varies somewhat depending on the different concerns and populations involved. This is really very much a focus of what we at CMHS are all about. Let me give just a couple of examples.

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    In the homeless area, wherever possible we try to build upon NIMH findings and with the help of HUD and with other agencies, serving, and that of individuals who need our help.

    In the criminal justice area, we work with a slightly different array of partners in developing our programs. We are working very closely with the Department of Justice as well as other agencies on our, Criminal Justice Diversion Program which is looking at models of identifying individuals with mental illness in the criminal Justice System and getting them into appropriate treatment settings.

    In each of these situations, we are looking to communities to identify what the needs are in those communities, and then respond to those needs with the appropriate partners.

    Mr. PORTER. Thank you, Dr. Arons.

    Ms. Pelosi.

    Ms. PELOSI. Thank you very much, Mr. Chairman. Mr. Chairman, before I ask my questions, I want to say how proud I am of Dr. Chavez. As you know, she was in San Francisco before she was assigned here. She served as Director for Juvenile Probation Service for the City and County of San Francisco.

    Our colleague, Mr. Hoyer, mentioned this morning, Secretary Shalala had made history by being the longest serving HHS Secretary. And I want you to know that Dr. Chavez made history because when she was appointed by President Clinton and was confirmed by the U.S. Senate, Dr. Chavez was the first Hispanic women to head an agency of the U.S. Public Health Services since its inception in 1798—in 200 years. This, I think, is a tribute to the Clinton administration.
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    This is my favorite time of the year, when we have such excellent representatives of the Clinton administration who come in and provide background on their programs.

    So I want to get back to what you asked, Mr. Chairman, about why kids still use drugs. I think that young people believe they are invincible, Dr. Kumpfer talked about the media, family, school, & other influences on drug use. But I think that one way we could curtail the young people from starting the use of drugs is to include them all in the health care system.

    We say to them that their health is important, and yet we don't give them guaranteed access to quality health care. And using drugs is harmful and perhaps even fatal to their health. I see many of the drug users in my community as being outside the loop of any access to quality health care. I think if we are saying that your physical well-being is important, so don't use drugs, we should also say, your physical well-being is important, we place a value on it, and so you will have access to quality health care. To me, they are connected in the same way as when we say to kids: education is important, so you should go to school.

    We should have some integrity about what we are saying to children regarding the importance of these issues.

    So I think if we had universal access to quality health care for all Americans, including all young people, the importance of their physical well-being would be driven home to them more clearly and they wouldn't hear two messages about their invincibility or lack thereof.
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    Now, I will ask my first question, unless someone would like to comment on that.

    Ms. CHAVEZ. Congresswoman, may I comment?

    Ms. PELOSI. Yes.

    Ms. CHAVEZ. It is wonderful to see you again, and I bring you greetings from Dr. Lee, who is back there with you now.

    I think it is important to develop a comprehensive system of health care for children and adolescents as well. That system, in my opinion, would be a system that is focused on children and adolescents; that it is not an adult system that has been dropped on our children. And in saying that, any part of a health system must include mental health, as well as substance abuse treatment and prevention. Thank you.


    Ms. PELOSI. I would completely agree with you. That was by no means meant to minimize the importance of the other or influences on young people. And I will just follow up with a question on mental health.

    Is there an estimate of the number of children in the United States with serious mental and emotional disorders? In addition, is it your opinion that the children's mental health service program is responding to the needs of these youngsters, and if so, how? Particularly, I am interested in whether the program improves their educational progress and reduces their involvement with the juvenile justice system.
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    Ms. CHAVEZ. Congresswoman Pelosi, let me just start out, and because I know that Dr. Arons would not talk to me for the rest of the day if I did not allow him to talk about some of the great programs that they support at the Center for Mental Health Services.

    In the area of mental illness, I think the projection is close to 7 million children between the ages of 9 and 17 who are so impaired—with serious mental problems—that it affects their school performance, their attendance, et cetera.

    One of the most interesting things is that we have information on children. Age nine and over, however, we don't have the research or the numbers on children that are under 9 years of age. What we are finding, as understood by other experts throughout the country, is that the number of children under age 9, who have serious mental problems and/or other emotional problems is much higher than the 9 and over what.

    Let me ask Dr. Arons to respond to the question in terms of the small investment that we are making, the payoff, and the real need to sustain this investment in the future.

    Dr. ARONS. Congresswoman Pelosi, let me start first by saying a little bit about our estimates on the numbers of children and adolescents with serious emotional disturbances.

    It is actually quite difficult to make an accurate projection. We don't have the kind of national surveys, national statistics, that can do the job. What we have been working on for the past couple of years is taking smaller studies that have been done and analyzing them and come up with the best estimates. It is now estimated that between 9 and 13 percent of young people have serious emotional disturbances with some impact on their functioning in school or their communities.
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    Ms. PELOSI. This is 9 and over?

    Dr. ARONS. Yes, and in about half of them we find the most serious emotional disturbances, where you clearly see a profound effect impact on school, community, their functioning and their families.

    We have a number of ways that we approach these issues, and they are clearly very important issues. Certainly a part of the block grant funds that go to States are serving children, adolescents. You have heard before about our Starting Early/Starting Smart program. We also have some specialized studies as part of our knowledge development and application, looking at the impact of managed care on children's services.

    Another very important approach to this is our comprehensive systems of care for children, the program that helps communities develop and put into place comprehensive systems of care in which the education system, the juvenile justice, child welfare—all the different systems that serve children—come together and serve those young people in a coordinated way. This program is just in its early years; it was first funded in 1992. We are finding, in looking at some of the preliminary evaluation data, that we are achieving some important successes.

    We are looking at a number of aspects of success, such as reducing the number of shifting family arrangements, and we are finding that after 6 months, more of the children are in one living arrangement, not shifting around to others. They are attending school more often, fewer contacts with the juvenile justice system; and we look forward to tracking this and other data and hopefully seeing further indications of the success of this program.
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    Ms. PELOSI. It sounds like one of the most important things that can be done. Thank you for your answer and for your work.

    Last year, the subcommittee commended your work on the AIDS mental health demonstration program. The House report strongly encourages the Center for Mental Health Services to use the findings of the demonstration in formulating new knowledge development grants, or KDAs, for programs directed to people with HIV. What is the status of the follow-up on this?

    Ms. CHAVEZ. Dr. Arons.

    Dr. ARONS. Yes. As I mentioned before, we are very concerned about people who have problems with mental illness, and children with serious emotional disturbances in a variety of settings. One of those groups of concern is those individuals who become HIV positive or are living with AIDS, we are doing a number of things in that area.

    We are continuing our effort to educate the mental health providers so that they will become the leaders in the society who can educate others about the psychosocial and neuropsychiatric aspects of HIV/AIDS.

    We are just completing the studies that were done around models of intervention for delivering mental health services to people with HIV/AIDS. One of the important things we learned through that program was the need to study further the impact on outcomes, on health outcomes, the impact on the cost of services to individuals, and in particular individuals with an addictive disorder who become HIV positive and need of mental health services.
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    And even as we speak, we are receiving applications for the next series of grants in that area, which will look at those individuals and try to develop information so we can better serve those individuals.

    Ms. PELOSI. Thank you, Dr. Arons.

    Thank you, Dr. Chavez.

    Mr. Chairman, thank you very much. I know my time is up, and I have to run to the floor. If I don't get back in time for more questions are we able to submit questions?

    Mr. PORTER. Oh, absolutely. And we will continue on this hearing until about 2:30.

    Ms. PELOSI. 3:30.

    Mr. PORTER. Sorry, 3:30 and then we will take up the IG.

    Ms. PELOSI. Thank you, Mr. Chairman. I will probably be back in time for that.

    Mr. PORTER. Mrs. Northup.

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    Mrs. NORTHUP. Yes. Dr. Chavez, thank you so much for passing on to my office a copy of the Synar amendment and for the progress you all have made in enforcement. I would like to ask you a couple of questions about your involvement in creating a national strategy.

    In fact, as I reviewed the information that took place in your testimony, I think you specifically spoke about the importance of a national strategy and about what the components of the national strategy might be. I am concerned about our focus or lack of focus on a national strategy when it comes to drugs and smoking. I mean, I happen to be one of the believers that believe that smoking is a gateway drugs, that kids go from smoking to drinking to illegal drugs. And I appreciate the grants that are given through CDC and SAMSHA, and some of them, through CDC, the Impacts grants—there are two different ones—for State-based tobacco reduction policy.

    Ms. CHAVEZ. We have, Congresswoman, the block grants that go to the States which require compliance with the Synar amendment, and are part of our treatment and the prevention activities.

    In addition to that, we have knowledge development and public education and prevention programs, which all require that there be some component in terms of nonsmoking, and reduction of tobacco use by young people.

    Mrs. NORTHUP. I think I was talking actually about a different set of grants.
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    Ms. KADE. CDC and NCI.

    Mrs. NORTHUP. Right. CDC and NCI. Every State has one or the other, as I remember.

    Ms. CHAVEZ. Yes.


    Mrs. NORTHUP. But the point is that they are basically State-based, grass-roots efforts. And that is an important component to tobacco control, and there is an important component that has to do with what State and Federal laws are—in terms of whether kids can buy, whether we are going to have vending machines.

    But in addition to that, we have to appeal to their minds and hearts not to smoke, and there have been some very successful campaigns, television ads, States that have initiated these. It is very expensive, especially for a small state like Kentucky, to put on their own ad program. And not only that, but for Kentucky to design education programs, a curriculum, along with a mass media program, that would be effective takes a lot of effort, expertise and money. I don't think it is particularly good strategy to think that 50 States would be able design their own.

    And I have been surprised that SAMHSA, which has the experience of setting sort of national preventive policy, hasn't been proposed to get some of the money from the tobacco settlement to actually design and at least make available—especially to small States, information on—the efforts that would coordinate all the research; all your past practices; all the efforts that have been effective; and ways that states should avoid that aren't effective.
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    Any thoughts on that? Or am I putting you too much on the spot?

    Ms. CHAVEZ. I will answer part of it, and then ask the Department to respond to the other component of your question.

    Mrs. NORTHUP. Well, actually I did ask the Secretary this morning about it, and she said you had been at the table, but there isn't an extra penny in the settlement that goes to the effectiveness of anything you might develop.

    Ms. CHAVEZ. Congresswoman, I will address a couple of issues that you brought up. For example, one involves the media campaign in your State, Kentucky. CDC has a media campaign resource center which provides support for local campaigns for every State. But there is another such campaign, the current ONDCP media campaign, where, as you know, the Congress allocated $195 million. That amount would be matched by the private sector to reduce drug use in this country. That campaign includes tobacco, marijuana and drugs, alcohol, et cetera. So we do have those campaigns, which I really believe are necessary in order for us to deal with the issue of smoking among young people. It is like the Chairman noted earlier, when his children were very young and they saw anti-smoking programs on TV, this was very helpful in teaching them not to smoke. But every generation changes, so our approaches have to change.

    One of the most important things that we have to consider in addressing this massive problem is that there are many people engaged in trying to deal with teenage smoking and the availability and appeal of tobacco for young people—and the President, the Secretary, and SAMHSA are all very committed to reducing youth tobacco use and we believe that it requires a very comprehensive plan.
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    Part of that plan is addressing access, addressing the availability and addressing the appeal. The other aspect has to do with pricing, and studies have indicated over and over that the higher the price, the less likely that kids are going to buy tobacco.

    We are at the table and have been involved in the discussions. We work very closely with FDA; we are working very closely with CDC; we are working very closely with NIH and many other agencies in trying to address the issue of tobacco among young people.

    Dennis, do you want to comment?

    Mr. WILLIAMS. I think the only other thing I would say is that the Food and Drug Administration clearly does have the lead regulatory responsibility in this area, but in the Department, in terms of trying to organize and coordinate a program that is aimed at youth smoking prevention, everyone—all of the agencies mentioned so far are at the table, and it is being coordinated at the very top levels of the Department, because of its importance and because of the range of issues involved.

    But on counteradvertising, community prevention programs, enforcement, all aspects are being—are assigned to the various agencies, and SAMHSA is involved in that, as well as the other agencies. But there is some regulatory leadership with FDA that I think one needs to remember.

    Mrs. NORTHUP. Well, I guess that my concern is that we haven't seen the use by children go down yet. And if we don't give one penny of the proposed tobacco settlement to lead agencies that are making public policy—it is nice that they are all at the table, but it is sort of hard for me to understand how we are going to make a difference.
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    We have spent the proposed settlement on all of these new ideas. We have not spent it on the prevention side of it, not in funding a specific message for kids at a certain age, nor to have all the strategies coordinate. I would challenge you to tell me what agencies besides FDA are to get any of it? Who does get it? You just said everybody gets it, it is a coordinated effort. Well, where is the money going?

    Mr. WILLIAMS. Well, if you—the 1999 budget request, there is a $100 million increase for tobacco in the Food and Drug Administration. That is on top of existing resources there. The Centers for Disease Control also has additional resources in the budget, about $50-some-odd-million in their budget for increased efforts in this area.

    Mrs. NORTHUP. Targeted for tobacco?

    Mr. WILLIAMS. Yes, targeted at tobacco as part of the administration's overall youth prevention.

    Mrs. NORTHUP. It won't go far. Like I said, last year we were talking about how important it is that we have a mass-media-based program. It would be hard to think that level would fund it.

    You know, you can't advertise marijuana right now, but we know that kids know where to get it. What that tells us is that we have to go beyond having a policeman stand and watch what kids buy and go to approach them on why it is bad for them, why they should not want to smoke it, and sort of help rebuild the sense of why a child would say no from within, in addition to making it a threat that they might get arrested if you use it.
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    Now, tobacco, we know we don't have public policies that slow down kids from purchasing it, but even if you do, I would daresay that you are not going to be any more successful than you are with marijuana, unless you help children, from within, decide that they are not going to smoke. And I don't see the resources going to that. That is what my point is.

    Mr. WILLIAMS. And we——

    Ms. CHAVEZ. Congresswoman—go ahead.

    Mr. WILLIAMS. Let me just say, we certainly agree with you with respect to the need for media campaigns and affecting youth and the way they think about tobacco; and as part of the President's budget, we have indicated support for comprehensive tobacco legislation.

    Part of that legislation—that legislation would generate a lot more revenues than are currently in our budget request. There are bills in the Congress now on tobacco, comprehensive tobacco legislation, like the Conrad bill. Those would, if enacted, would produce revenues in the neighborhood of $60–$65 billion over the next 5 years. Those bills and others talk about various aspects of trying to deal with this problem in making money available through that legislation for media campaigns, local community prevention programs and other aspects of trying to reduce tobacco use by youth in the country.

    Ms. CHAVEZ. Congresswoman, may I respond, to one thing?

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    Mrs. NORTHUP. Yes.

    Ms. CHAVEZ. What I hear you saying is that one of the most important things to consider within a successful media campaign is that progress will be achieved through prevention and treatment, and where the money is going to come from to support of this continuum becomes very critical.

    Mrs. NORTHUP. Well, that is what I am talking about.

    Ms. CHAVEZ. That is what I hear you saying.

    Mrs. NORTHUP. We know in California that money was used pretty effectively for reduced use of tobacco, and we have a possible new funding stream, but I don't want to get into a partisan fight here, but I haven't seen anybody suggest from the administration side that we would use it in some of these strategies for reducing tobacco use.

    We all have new teacher programs. We have new day care programs. We have a lot of other research, which I am very much for, but I do not see it being used to fund the things that are pretty strategic in reducing youth use.

    Thank you.

    Thank you, Mr. Chairman.

    Mr. PORTER. The Chair would like to interject one thing here that may not sound mainstream Republican. It seems to me that our users of the airwaves, both television and radio, have a responsibility to the public to spend a little bit of their resources and allow public service announcements to be aired. Rather than having the government pay for every single penny of air time, I think we ought to change FCC rules and require them to do some of these things. Now I realize there is a limit to it, obviously, but it seems to me that the media do virtually next to nothing. The only public service announcements that really get aired have to be paid at high rates, and that doesn't seem to me to be the appropriate use of public facilities.
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    Ms. DeLauro.


    Ms. DELAURO. Thank you, Mr. Chairman. And just to follow up on this effort, I will be happy to sit down with SAMHSA or with the FDA and try to do a campaign to prevent kids from using tobacco. We have started, in the Third Congressional District, something called the Kick Butts Connecticut campaign. We started this about a year ago with middle school children, because that is the age range at which kids are beginning to be pressured to smoke.

    We have created an army of about 80 or 90 kids who, with information from the appropriate agencies about skits and all kinds of role playing, this army of kids is going into the middle schools. They go into all the grades up to middle school and particularly the younger grades, and talk about not smoking to their peers.

    I want to just build on that, because we get to what the Chairman was talking about in terms of the broadcast industry.

    We have now done this, as I say, for a year and a half. The kids have been into almost every middle school in the district.

    We just did a poster contest with these kids because—I think my colleague from Kentucky is right. What we try to portray to the kids is that they have the power, that if they are not going to start smoking it has got to come from within. They have got to not want to smoke. They have got to understand the pitfalls of this. They can be helpful to themselves, to their families and to their friends, and we designed a poster contest so all the kids participated, It was on a voluntary basis. There were five winning posters selected, seven kids involved.
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    We now have cable TV—I have spoken to them. They are going to bring the kids on to deal with the public service announcements.

    The billboard companies have said that they are going to take the five winning posters, and they are doing a billboard which will be put up free of charge. I mean, they are donating the space, the time, the painting, and the kids will come in and paint these things to put them up in the community. One of them is a particularly great one. It is a frog and it says, ''If you smoke, you croak.'' I mean, the kids did this in an unbelievable way.

    We have also the the big movie houses who are going to put the posters up.

    We were working with the attorney general's office in our State to do something that gets done with local resources and community resources and private resources, in an effort to get maybe a book cover so that you have got all of our kids every single day with their book covers looking at this stuff that says what will happen to you if you smoke.

    The radio stations were going to—to get the kids on. This is not a partisan effort. This is to get our young people engaged in the anti-smoking effort.

    I want to talk to you about a model for that, because I think it is worthwhile. I have been talking to my colleagues about it, and it is a package and easily put together, which engages kids and their families in the process of taking on the issue of not smoking.

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    When I talk to young kids, I talk to them about the fact that I believe that we can have a big turnaround, like we did with the environment. We have a clean environment now in this country, because of what young people did and the effect that they have had on their parents. So I think that we can get some of the major corporations, some of the major institutes and so forth, without the Federal Government having to be the trough all of the time to get the money to do these things.

    I might also add that the settlement, as I understand it, deals partially with restrictions of advertising and so forth and so on in a national way in some of these efforts.

    It is not what I wanted to ask you about, and I am going to get to my question here, Mr. Chairman. But I would love to at some point talk to you about this model.

    Ms. CHAVEZ. We look forward to that and thank you so much, Congresswoman.


    Ms. DELAURO. Yes. I was pleased to receive the information on the Synar amendment.

    I would like to ask you to summarize some of the findings for us. I have had lots of conversations about this, what you did about it. Are you satisfied with the States' efforts to enforce existing laws regarding tobacco use by minors?
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    Ms. CHAVEZ. Thank you, Congresswoman, and let me go ahead and summarize very quickly and then ask Dr. Kumpfer to address this issue in more detail.

    Yes, we are satisfied with the progress and I want to thank Chairman Porter and the members of the subcommittee for your input in pushing us to get this done. We have worked very hard. I want to commend the SAMHSA staff, because they have done an outstanding job.

    We have worked very closely with the States in helping them understand that we mean business with the Synar amendment and have been able to establish very specific performance measures.

    All of the States now have laws prohibiting outlets to sell tobacco to youth. So we are now focusing on compliance monitoring. But the aspect that I think is really important is that there are dollars attached to compliance, and basically what that means is if you don't comply and meet the percent that we have set as a goal, then the state will lose part of its Block Grant money in the area of substance abuse.

    Karol, do you want to just briefly outline some of the major areas in this report?

    I am sure everybody has a copy, and it does give you, State by State, their current status.

    Dr. KUMPFER. I also want to commend my staff and especially Lee Wilson, who coordinated CSAP's efforts on synar. I want to commend them for the really good job that they did in putting together this report to Congress and working collaboratively with the States, FDA, and CDC in establishing the baseline rates for this report to Congress. This report was just released last Friday, on February 27th.
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    The goal of this, of course, is to reduce access of tobacco products to youth, to a goal of 20 percent of outlets that are selling to minors. In our report we have established the baseline rates for all of the States at this point. Actually at this point, we also have 40 of the second-year reports from the States, and about 15 of them have now been checked, approved, and validated. All of the States are now in compliance and things are looking very good.

    In fact, the overall state median is 40 percent of the outlets selling to minors, compared to 60 to 90 percent last year according to the studies that were done previous to Synar.

    So we are quite excited about the preliminary results, and all the States are in compliance. In fact, four of them already have met their 20 percent goal at this point.

    Ms. DELAURO. Mr. Chairman, my time has run out, I am sure.

    Mr. PORTER. No, it has not. You have two more minutes.


    Ms. DELAURO. Thank you very much, Mr. Chairman.

    Dr. Chavez, in your testimony, you mentioned that in 1996 about 63 of those who have problems with substance abuse did not receive treatment. If you wouldn't mind, just take us through a little bit about what type of barriers keep these people from treatment.
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    Do we have difficulty letting them know treatment is available? Do we have funds to serve everyone? And what funding level do you think we would need if we were to try to serve 100 percent of the need?

    Ms. CHAVEZ. Congresswoman, let me start by focusing on two points, and then I am going to turn it over to Dr. Barry, because I know that she wants to participate in this treatment discussion.

    The treatment gap is very interesting, because there is some geographic variety there. If we are serious about closing the treatment gap in this country for individuals who suffer from an addiction to—alcohol, drugs, and other substances, it will cost approximately $8 billion.

    Now, we don't have those resources, and I am talking about just the treatment gap for individuals that have a substance abuse problem. Our investments must increase in the area of prevention and early intervention, because the gap appears to be growing.

    Between, 1993 and 1996, there has been approximately a 34 percent increase in the treatment gap. It is not getting smaller. It is getting a little bit wider.

    You asked whether people get into treatment. Yes, some people get into treatment. Do some people not get into treatment? Yes, some people still cannot get into treatment.

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    And it becomes more interesting when you start looking at it by region. In some regions, for example, you may not have the high utilization rates of services as in other areas. Let me just give you one example that ties in with some of the drug trends that we are seeing.

    An article that I just read this weekend, has to do with a small town in Iowa. It is called Marshalltown, Iowa, with a population of about 25,000 people. One of the things that they have experienced is a tremendous increase in the use of methamphetamine. If you look at the methamphetamine increase throughout the State, it becomes more shocking—in 1993 there were approximately 252 people that sought treatment for abusing methamphetamine; in 1995, it is over 3,000 people.

    Now, is that community prepared to deal with this? No. One of SAMHSA's proposed responses is what we call our ''Targeted Capacity Expansion Program'' which helps communities, cities, and States cluster together to deal with issues that are specific to those areas addressing problems as viewed on a continuum that is going to help solve some of these emerging issues and problems that we are beginning to see are more regional in scope.

    Dr. Barry, do you want to comment?

    Ms. BARRY. Yes. It is a very complex question, and it doesn't have a very easy answer.

    What are the barriers? Surely funding is one. There is a treatment gap, and that translates to the local level or to the city level in that there is not enough treatment to provide treatment on demand. There is not enough access, there is not enough availability. And that goes back to funding; there is a shortfall in funding.
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    But it also has—

    Ms. BARRY. Pardon me?

    Ms. DELAURO. In other words, we don't have the resources to deal with people who make the decision to get treatment and who need help, and go in to do that?

    Ms. BARRY. Right. We do have waiting lists. We have waiting lists out there. That has been verified; they have been validated. There are waiting lists out there. But the answer not only lies in the amount of funding and the treatment capacity; it has to do with the improvement of the services that are out there, too.

    If we are looking at heroin addicts, we know they stay out on the street probably 7 years before they enter into treatment. We know that it is very difficult to treat methamphetamine users. We don't know enough about the neurocognitive and neurophysiological effects of methamphetamine to keep these people in treatment. It is a retention problem. Methamphetamine addicts experience severe depression after we withdraw them from the methamphetamine. This is another phenomenon for which we don't have adequate treatment approaches and interventions.

    And so it is a balance between providing the treatment services, but also improving existing services and making sure we have adequate knowledge, development and application in the field.

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    In our 1999 budget we identified several initiatives in the pharmacologic area where we have effective medications including methadone, as well as antagonist drugs such as Naltrexone or Naloxone or LAAM. We find that there are barriers in the treatment field to using the medications that have been developed.

    Ms. BARRY. We have to dispel the myth that we cannot treat drug addiction with drugs. That is another barrier that must be overcome. So it is a very complex question and requires a very complex answer. It is a combination of things that need to be addressed.

    Ms. DELAURO. Thank you, Mr. Chairman.


    Mr. PORTER. Thank you, Ms. DeLauro.

    Dr. Chavez, earlier we had talked about KDAs and their application in a number of instances. Your budget proposes to cut the program by almost 20 percent, and in your budget justification it states that SAMHSA will be developing a plan for fiscal year 1999 to identify programs for termination and/or reduced funding. On what basis are you proposing this 20 percent reduction and how did you determine the figure of $74 million?

    Ms. KADE. Overall, our budget is increasing. But, obviously, our funding for the KDAs and, in particular, substance abuse is decreased. The priority this year is focused on the block grant and in expanding capacity. Since we are part of the overall department budget, it really is a balancing of resources. We didn't choose to be cut by $74 million. We didn't develop that number. But we are very supportive of the approach of focusing on the block grant in conjunction with the KDA. What we are doing in 1998 is starting what Dr. Chavez was talking about in terms of targeted capacity expansion to prime the States for the increase in 1999 in the block grant.
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    We feel that this will be cyclical, and at this point, the focus is on closing the gap with the knowledge that has been developed in the KDA program, but that knowledge cannot be stagnant.

    As we shift, as we go through the cycle, even as the knowledge is generated by NIH, there are funding increases for the Institutes for 1999 as well. It will not happen unless you funnel those research findings into the KDAs and then funnel, with the technical assistance and targeted capacity, expansion to the States and augment—leverage, the block grant resources. This is not an instance where one program is being sacrificed for another as much as one being prioritized for this year.

    What we have been talking about has been the linkage between the KDAs and the block grant. This committee has been extremely influential in defining the KDAs. It was your language in the 1996 budget that basically started the program. And what we have done is to develop the linkage between the KDAs and the block grant through the targeted capacity expansion not only in prevention, which is the State incentive grants, but also in treatment. We have been talking with the Department, as well as OMB, in terms of how this fits within the overall range of funding.

    Certainly, we are not pleased with the reduction in KDAs, but we see it as part of an overall strategy, not in terms of phasing out the program, but in terms of this linkage, this cyclical nature in our funding.

    So with a $74 million decrease we will have a net increase of $82 million. That is how the numbers worked out. The emphasis is in block grants this year. We still have new programs that we are funding in the KDAs for 1998, additional State incentive grants for CSAP, additional capacity expansion and pharmacological interventions for CSAP, and of course we have level funding for CMHS.
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    Mr. PORTER. Dr. Kumpfer, do you see any unwillingness on the part of the States to take evaluations that show which programs are most effective and ignore those, or are States very likely to zero in on what really works and has shown itself to be evaluated as working well?

    Dr. KUMPFER. Thank you, Chairman Porter. In my experience, the States and the local community agencies are very, very hungry to know what works in prevention. The more effectively we get that information out through our five regional Centers for the Application of Prevention Technologies, the more science based approaches to preventing will be implemented and provided to youth in this country.

    I can give you just an example that—with my own Strengthening Families Program (SFP). It was tested originally through a NIDA grant and then States and local communities started calling me saying;, Can we field-test this now with diverse populations? We used CSAP funds to test it with African-Americans in Alabama and in Detroit; Hispanics in Denver, Asian Pacific Islanders in Hawaii and diverse ethnic population in Utah. It was CSAPS funds that supports the field trials and we found that it was robust and worked with diverse populations in different areas of the country.

    What is interesting now is that a State like Texas is now using SFP as one of their model projects to disseminate with their own State funds.

    Ms. CHAVEZ. Chairman, may I respond to that, because I think it is really important in terms of what we did last year and what we are going to do this year. We mentioned earlier the State Incentive Grants, which are part of our Youth Initiative to reduce alcohol, to reduce tobacco use, and to reduce marijuana and other drugs.
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    One of the things that we did last year is initiate five State Incentive Grants, that I mentioned earlier we were able to fund. Let me tell you briefly a little bit about the five States that have received funding, because I think what they are doing is very important.

    The States were Illinois, Kentucky, Vermont, Kansas and Oregon. One of the most interesting aspects of the program is requiring governors of each State to look at all the prevention funding streams and then develop a comprehensive plan to deal with prevention needs in their State. Let me just read from a publication that I just picked up, which I thought was very interesting.

    In Illinois, which received a $3.2 million grant to implement their Prevention 2000, The State's Council on Prevention ''will coordinate the State's prevention funding and use local collaboratives to implement research-based prevention programs.''

    The same thing is occuring in Vermont, implementing research-based prevention programs. This goes back to what we talked about earlier, and that is we have come a long way. But, we must continue to work with communities and with States in moving more towards programs that work. For example, Dr. Barry was talking about the many treatment barriers, earlier.

    One of the barriers I don't think we were really prepared for, and which are now addressing in SAMHSA, the impact of managed care on treatment systems, especially for vulnerable populations, i.e., people that have addictions and people that have mental illness. So we have a lot of concerns about this issue.

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    The other issues that are of great concern have been the dramatic changes in America's demographics in terms of diversity, especially shifts in our population, individuals getting older on average and, some groups that are very young and are becoming more diverse.

    These issues are going to impact not only the research, but also interventions in communities that are diverse not only in prevention, but also in treatment needs. This is an element, of the big equation that we are trying to deal with; and that is one of the many aspects of our knowledge application efforts.

    Mr. PORTER. Thank you, Dr. Chavez.

    Ms. Pelosi.


    Ms. PELOSI. Thank you, Mr. Chairman. Mr. Chairman, I have a question not only for myself but on behalf of a number of our colleagues, including representative Sam Farr. Dr. Chavez, we are all curious about managed behavioral health care in the local county authorities in the 20 or so States that have State mandates to provide managed pay for health care. How is managed pay for health care affecting local county authorities in those States where there is mandated behavioral health care?

    Ms. CHAVEZ. Let me go ahead and ask Dr. Arons to answer that, and then I will respond.

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    Dr. ARONS. As you know, managed care is becoming much more important across the country. It seems like each week another study comes out that shows the increasing numbers of people covered by these programs.

    We are beginning to study and to look at States and communities where there is mandated coverage for behavioral health. We have taken a look at five States in which there is mandated parity for behavioral health, including mental health and addictive disorders; and we are just beginning to put together the results of those studies. I am not sure that we have solid research-based findings about those areas.

    However, we do know that there is a tremendous change going on in the system as a whole. The usual community behavioral health providers are finding that they either have to become part of a network of providers, changing the nature of their relationships in their communities to provide services, or they are in jeopardy of losing the opportunity to remain a provider. So we are trying to track that very carefully through some of our managed care studies, and in next couple of months we hope to come out with some of those findings.

    Ms. PELOSI. We would be interested in seeing that. As you know, these are hard fights, to be able to have behavioral health care mandated, and we hope it can serve as a model to all the country.

    I wanted to follow up on some of the questions—and I know the Chairman will let me know when my time is up—about substance abuse. As you know, drug use and substance abuse in general contribute to the HIV epidemic. Demand for substance treatment far outweighs the current available services, and I just wondered if you could tell me how many people on any given day are trying to get into drug treatment.
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    And then, following up on that, some local governments, including in my own City of San Francisco, are looking at providing substance abuse treatment on demand. As you know, this approach could have significant implications for public health service, for public health care system and for the primary.

    What is SAMHSA doing to assist in developing, implementing, and evaluating programs to provide substance abuse treatments on demand?

    Ms. BARRY. I will take the second part of that question and then turn to Dr. Goldstone to talk about how many people are trying to enter into treatment or are in treatment on any given day.

    We are working with the San Francisco area, and I commend the leadership that you have taken in treatment on demand. First of all, when we look at treatment on demand, we don't have that concept well defined yet. Are we talking about no waiting time whatsoever? Are we talking about a 24-hour wait? So we have to define that.

    Second, we also have to define what ''demand'' is, what the demand in the San Francisco area is. I don't think that the concept of demand is well-defined at this point in time. It is something very different to talk about demand and need. Those people who perhaps would benefit from treatment versus those people who are actually seeking entrance into treatment are two very different things.

    You are talking about treatment on demand, and we have to get at what your ''demand'' is.
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    We are also working in the San Francisco area at this point in time in terms of your management information systems. You have got two systems out there, one which we fund through our KDA program, which is through the target cities grants. It is a management information system and it is connected to your public health system.

    And right now the only thing that we can get out is the billing of the particular patients. And what we want to do is track patients through the system, and I think we can get a better idea of how people are moving through the system and what your demand actually is.

    We are going to be working with San Francisco to develop the access and get over the hurdle of getting the information out of your computer system. In April, we are going to be meeting with city officials, together with CDC, HRSA, and different Federal agencies to talk about implementation and evaluation. We will address issues such as implementing treatment on demand and answering some of the questions that I just described to you that are very difficult?

    And we are going to be able, hopefully, in our 1999 budget and I say that because of the cuts that we have sustained, $41 million to the Center for Substance Abuse Treatment's budget—hopefully be able to assist you with the implementation and evaluation of treatment on demand.

    The person who is spearheading this initiative, as you probably know, is Barbara Garcia. We are working closely with her right now. I think that she is in the emergency shelters, helping out in the San Francisco area. But as soon as she gets back to her regular duties and responsibilities, we are going to be meeting with her and mapping out a blueprint of where you are right now with treatment on demand and where you need to be.
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    Ms. PELOSI. Thank you. I appreciate that.

    Mr. GOLDSTONE. I wish I could give you a precise answer.

    I can tell you approximately how many people are admitted in the course of a year to a facility that receives any kind of public funding. Assuming patients are admitted on any day of the week, we know there are 3,300 admissions each day for the 37 states providing complete admission data. This estimate leaves out the for-profit facilities that receive no public funding. We would estimate 41,000 admission for all 50 states and we may not have an entire universe of even those that are receiving public funding. However, we believe the estimate is reasonably valid.

    Ms. PELOSI. Thank you.


    Mr. Chairman, I think it is important because we believe that treatment is one way to reduce drug abuse. So treatment on demand helps us reduce our drug problem. And I hope that our experience in San Francisco is successful and will serve as a model to the rest of the country.

    Thank you, Mr. Chairman.

    Mr. PORTER. Thank you, Ms. Pelosi.
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    Mrs. Northup.

    Mrs. NORTHUP. Mr. Chairman, I just have one question.

    Last year I raised questions at this hearing about the differences of alcoholism occurring, depending on the onset of drinking. And I appreciated that there was a follow-up and that NIH concluded their study and concluded specifically that children who begin drinking before the age of 15 were four times more likely to develop alcohol dependence and the risk of developing alcohol abuse more than doubled.

    I just wondered if your agencies have been able to put that information to use in terms of educating our young people about not only the dangers of drinking, but the increased likelihood that they will actually become alcohol dependent?

    Ms. CHAVEZ. Thank you, Congresswoman. I have Camille looking at me with a smile, because she wants to respond, I have Carol also wanting to respond. So I think I will respond.

    That is very important information and very true. And, yes, we are working with NIH. I will ask Dr. Barry and Dr. Kumpfer to talk a little bit about what we are doing with NIAAA. What is very important in terms of that finding is what we have been talking about, the continuum of early prevention, intervention and treatment.

    We also have studies that clearly indicate many of these young people have mental problems that often go undetected, and we have a wonderful window of opportunity to be able to work with many of them. If we don't get them before age 15, many of them will end up being dually diagnosed with either an alcohol-mental problem or an addiction of some other sort.
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    Camille, why don't you describe what we are doing with NIAAA in relation to adolescents?

    Ms. BARRY. We started working with NIAAA even before their findings came out, and I attended that press conference, and it provided important information and gave us some direction. And what Dr. Chavez said is that we—and I think that this crept up on us—we saw the age at which people start drinking or the age at which people start taking drugs going back to the earlier years, and the treatment system wasn't ready for that. A lot of work needs to be done with adolescents in identifying effective treatment approaches and effective treatment interventions. We started working with NIAAA even before they released their results from that particular study, and we have subsequently developed a grant program and are collaborating with them.

    They are going to be working on the instrumentation and the methodology. We are going to be putting that information, as it is developed, out in the field. And of course, that is the beauty of the KDA program, implementing those models in the field so they can be replicated, thereby providing effective treatment for adolescents when they are suffering or have problems with alcohol.

    Dr. KUMPFER. First of all, I would like to mention that age of early onset is also an indicator of genetic and environmental vulnerability usually having to do with being a child of an alcoholic or drug abuse.

    We know that alcoholism is a family disease that runs in families through generations. In order to help combat this problem, one of the things that CSAP is doing this year is developing a initiative for children of substance abuseing parents (COSAPs). This COSAPs an initiative will dedicate $8 million to field test research-based models that work for children of alcohol and drug abusers. We believe that this will also be a significant way of getting information back out to the field on what works, to help with this very high risk group of youth.
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    I might also mention, as Dr. Chavez has discussed, that we are starting this month a collaborative effort with the National Institute on Alcoholism and Alcohol Abuse (NIAAA) to do a research project looking at the effects of alcohol advertising on underage drinking. That effort will support a longitudinal study that will determine whether alcohol advertising affects initiation of drinking among youth and whether it affects consumption patterns. And we anticipate that we will have four or five projects that will be funded for a 3-to-5-year period, so this should also help address that issue.


    Mr. NORTHUP. Well, I met with Dr. Gordis after the result was finished because, of course, I had asked the original questions and had a few additional questions that I think are fairly important. It sounds like you all almost have decided what the interests are, but I think it is important to have science-based evidence, on questions including whether or not a child who starts at 14 is already inclined to drink and at whatever age they started they would then become a person that abused alcohol. In other words, was there already that tendency—or whether there is in the immature cells, sort of pleasure-seeking cells, a sort of untracked, unlearned resistance, and whether there is a window of vulnerability that exists for very young children that maybe when you are 21, when you begin drinking, that you are beyond that window of vulnerability and that there would in fact be people who, if they waited, could be social drinkers, healthy drinkers.

    We all know that alcohol is not a problem to even most drinkers; it is a problem to some drinkers. And it is very important that we either establish that there is sort of already a group of people that tend to have that problem or whether it is the years of vulnerability that add to it.
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    It is probably some of both.

    Dr. KUMPFER. Congresswoman Northup, it is both. That is a very, very good question, and I really hope that NIAAA is willing to dedicate more research to that effort because we need to know that.

    One of the things that we do know, though, is that there is a research program called the Caspar Program that was able to significantly decrease substance use in highly vulnerable children of alcoholics by doing prevention programs through the schools with the children of alcoholics. The results were so strong that it is clear that many of them just choose, through that risk education and information, not to drink at all. So it is possible either way. But basically, environment overall is the number one factor.

    Mr. PORTER. Thank you, Mrs. Northup.

    Well, Dr. Chavez, we have all managed to filibuster away our Results Act questions, but I know that you are so well prepared in that area that you can answer those for the record for us, if you will. There are also a number of other questions that we have for the record that we would ask you to answer.

    What I am encouraged about is that you and your team—and you have assembled a very fine and excellent team—are all focused on results, looking at what works and putting the resources where they can do the most good. That is exactly what we have been focused on. We will not always agree, but we are going to find a way to give you the resources so that you can place them where they do the most good for people and get results. On behalf of the subcommittee, I'd like to thank you for the fine job you are doing and tell you that we will look forward to continuing to work closely with you on these very important problems.
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    Ms. CHAVEZ. Thank you, Mr. Chairman. I never thought I would be in a position to filibuster on a subject with a subcommittee, but I love it.

    Mr. PORTER. That is what I am worried about.

    Ms. CHAVEZ. I do want to thank you and the other members of the committee, and thank your staff and staff of all the committee members, for their support and help. I would also thank the SAMHSA staff, because they have done an incredible job and continue to work what are sometimes difficult conditions. So thank you so much.

    Mr. PORTER. Thank you.

    The subcommittee will stand in recess for 5 minutes.

    [The following questions were submitted to be answered for the record:]

    "The Official Committee record contains additional material here."